Overnight, or inpatient, admittance to an acute care general hospital, skilled nursing facility, birth center or mental health facility.

Covered services for an adult (age 17 or older) that include annual physicals or gynecological exams and related wellness services. Adult wellness does not include routine vision and hearing examinations.

A licensed facility (pursuant to Chapter 395 of the Florida Statutes or a similar applicable law of another state) that primarily provides elective outpatient (one day) surgical care.

Includes transfusion of blood or blood components at a hospital or skilled nursing facility.

The maximum amount paid by an insurance company for covered services during a calendar year. Also known as Out-of-Pocket Maximum.

Proof of prior insurance that is sometimes required when you change your insurance carrier. It proves uninterrupted coverage. Without a Certificate of Creditable Coverage, you might have a waiting period or may not be covered for a pre-existing condition. For Medical Eligible products, you may be assessed a late enrollment penalty without a Certificate of Creditable Coverage

The doctor or hospital you choose to visit.

A formulary list that categorizes covered prescription medications based on two cost tiers: Tier 1 includes lower-cost generic medications and Tier 2 includes more expensive brand name medications. Most generic medications are covered, so even if your medication is not listed in the closed formulary, it may still be covered unless specifically excluded in your benefits. However, brand name medications not listed in the closed formulary will not be covered and you will be responsible for the entire cost of the medication.

The percentage you pay for covered services. Also referred to as cost sharing, it’s part of the total cost of medical or hospital services you receive. If your plan has a deductible, you pay your coinsurance for covered services once the deductible is met.

Refers to the dollar amount of an insurance policy.

A prescription drug included on BCBSF’s Formulary (list of covered drugs) that has the same active ingredients found in brand name prescription drugs. After the patent on a brand name drug has expired, other manufacturers may duplicate the drug and sell it as a generic equivalent. Generic prescription drugs are approved by the Federal Drug Administration and usually cost less than the brand name drug.

Refers to a spouse, domestic partner if applicable, or eligible child (by birth, adoption or legal guardianship) of the contract holder.

An endorsement is an amendment made to your Certificate of Insurance that can either add or exclude coverage for certain benefits. This may also be referred to as a rider.

A laboratory, properly licensed pursuant to Chapter 483 of the Florida Statutes, or a similar applicable law of another state, which is not part of a hospital or physician facility, that performs procedures such as urinalysis, blood chemistry tests, blood cell counts, Pap tests, HIV tests and more, to help diagnose and/or treat medical conditions.

The amount you must pay annually (January 1st to December 31st) for covered dental services before insurance begins to pay for covered dental services. A dental deductible is separate from a plan’s individual or family calendar year deductible for covered health care services.

The fixed dollar amount you pay a hospital, psychiatric facility or substance abuse facility (as applicable) for each overnight (inpatient) admission.

Refers to the optional coverage for prenatal care and delivery of a newborn.

A list of Preferred Generic Prescription Drugs, Preferred Brand Name Prescription Drugs and Non-Preferred Prescription Drugs covered under the prescription drug benefit of your health plan.

Medical care or treatment received in a physician's office or other outpatient facility (does not include overnight hospital stay).

Refers to the services and treatment provided by a licensed physician, whether at a doctor’s office, hospital or other medical facility.

A condition that is determined to exist prior to your insurance effective date. It’s often a limitation in your coverage, meaning you may not be covered for medical care related to this condition. In some cases, the pre-existing limitation can be lessened or waived if you can prove uninterrupted insurance coverage by providing a Certificate of Credible Coverage.
BCBSF generally defines a pre-existing condition as one that manifests itself in such a manner to cause an ordinarily prudent person to seek medical advice, diagnosis, care or treatment or for which medical advice, diagnosis, care or treatment was recommended or received during the 24-month period immediately preceding your effective date of coverage under the contract. For specific information regarding pre-existing condition and how a condition is determined to be pre-existing, please refer to your Certificate of Insurance or discuss with your agent.

PPO stands for Preferred Provider Organization. This type of health insurance plan provides comprehensive medical coverage to members and gives them the flexibility to see any health care provider they choose, whether in the “preferred” network or not. There is no requirement for a member to select a primary care physician (PCP) and out-of-pocket costs are the lowest when seeking care from providers in the “preferred” network. Though PPOs provide coverage for out-of-network services, members generally pay more in out-of-pocket costs.

Any medicinal substance, remedy, vaccine, biological product, Drug, pharmaceutical or chemical compound which can only be dispensed pursuant to a Prescription and/or which is required by state law to bear the following statement or similar statement on the label: "Caution: Federal law prohibits dispensing without a Prescription".

Medical care that focuses on preventing health problems from occurring and diagnosing health conditions early for greater chances of recovery. Care can include vaccines, routine health screenings and more.

An individual who consistently meets all applicable eligibility requirements and who is actually enrolled under the contract other than as a dependent. This can also be referred to as contract holder or member.