Out-of-pocket Limit Premium Tax Credits The most you could pay Financial help that lowers your taxes to help you and during a coverage period your family pay for private health insurance. You can get (usually one year) for this help if you get health insurance through the your share of the costs Marketplace and your income is below a certain level. of covered services. Advance payments of the tax credit can be used right After you meet this away to lower your monthly premium costs. limit the plan will Jane pays Her plan pays usually pay 100% of the 0% 100% Prescription Drug Coverage allowed amount. This (See page 6 for a detailed example.) Coverage under a plan that helps pay for prescription limit helps you plan for drugs. If the plan’s formulary uses “tiers” (levels), health care costs. This limit never includes your prescription drugs are grouped together by type or cost. premium, balance-billed charges or health care your plan The amount you'll pay in cost sharing will be different doesn’t cover. Some plans don’t count all of your for each “tier” of covered prescription drugs. copayments, deductibles, coinsurance payments, out-of- network payments, or other expenses toward this limit. Prescription Drugs Physician Services Drugs and medications that by law require a prescription. Health care services a licensed medical physician, Preventive Care (Preventive Service) including an M.D. (Medical Doctor) or D.O. (Doctor of Routine health care, including screenings, check-ups, and Osteopathic Medicine), provides or coordinates. patient counseling, to prevent or discover illness, disease, Plan or other health problems. Health coverage issued to you directly (individual plan) Primary Care Physician or through an employer, union or other group sponsor A physician, including an M.D. (Medical Doctor) or (employer group plan) that provides coverage for certain D.O. (Doctor of Osteopathic Medicine), who provides health care costs. Also called “health insurance plan,” or coordinates a range of health care services for you. “policy,” “health insurance policy,” or “health insurance.” Preauthorization Primary Care Provider A physician, including an M.D. (Medical Doctor) or A decision by your health insurer or plan that a health D.O. (Doctor of Osteopathic Medicine), nurse care service, treatment plan, prescription drug or durable practitioner, clinical nurse specialist, or physician medical equipment (DME) is medically necessary. assistant, as allowed under state law and the terms of the Sometimes called “prior authorization,” “prior approval,” plan, who provides, coordinates, or helps you access a or “precertification.” Your health insurance or plan may range of health care services. require preauthorization for certain services before you receive them, except in an emergency. Preauthorization Provider isn’t a promise your health insurance or plan will cover An individual or facility that provides health care services. the cost. Some examples of a provider include a doctor, nurse, Premium chiropractor, physician assistant, hospital, surgical center, skilled nursing facility, and rehabilitation center. The The amount that must be paid for your health insurance plan may require the provider to be licensed, certified, or or plan. You andor your employer usually pay it accredited as required by state law. monthly, quarterly, or yearly. Reconstructive Surgery Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries, or medical conditions. Glossary of Health Coverage and Medical Terms Page 4 of 6