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Understanding 7 Health Insurance Concepts

billing statement with stethoscope

It can be difficult to keep up with what’s going on in the world of health insurance and understand how your health coverage works. Here are 7 concepts that may help you better understand your health insurance benefits.

  1. Benefit Summary: Reading your Benefit Summary is probably the best way to understand your health coverage. This is usually a one-page document that quickly sums up how your health plan coverage works.
  2. Deductibles: Some healthcare services require you to meet your deductible before your insurance plan will begin to pay. This means you must pay a certain amount out of pocket, first. Once your deductible is met, then your plan will kick in and cover the service according to your benefits. Some services, such as preventive care, are covered without you needing to first meet your deductible. Your Benefit Summary will explain which services require deductibles and which don’t.
  3. Out-of-pocket limit: The out-of-pocket limit is the most you’ll pay for healthcare services within your plan year. (Oftentimes, your plan year is the same as a calendar year, but not always.) Note that your in-network and out-of-network limits may be different. Your benefit summary will include more information about the out-of-pocket limit for your plan.
  4. Formulary: Health insurers are able to offer better prices on some drugs than others. They maintain a list of “preferred” drugs that will cost you less. This list is called a formulary. The preferred drugs found on the formulary usually include both generic and brand-name medications, and you can save money by using drugs on the list. You’ll find the PacificSource formulary list at
  5. Using the formulary: Sometimes your doctor prescribes a medication that is not covered by your plan, or is not covered as well as preferred (formulary) drugs. Show your doctor the formulary for your health plan, and ask if there is another drug that may be prescribed that will cost you less.
  6. Providers: Providers are healthcare professionals such as medical doctors, nurse practitioners, dentists, chiropractors, and more. Health insurers contract with providers to make sure you get quality care at a discounted price. Providers who are contracted with PacificSource are our “participating” providers or “in-network” providers. When you get care from a participating provider, you’re getting the best value from your health insurance coverage. It’s your responsibility to make sure your providers are in your plan’s network. You can find participating providers at
  7. Appointments: As much as we’d like to, we’re not always able to get appointment times exactly when we need or want them. Providers are often scheduled out in advance, and it can take some time and advance planning to get care. Providers will often try to fit you into their schedule as soon as they can when you’re sick, but if you’re scheduling preventive care appointments, it could take a few weeks. Talk with scheduling staff at your provider’s office for information about average wait times for scheduling appointments.