Terms to Know

Allowable amount

The amount allowed by the plan for a given service, supply or procedure.

Annual dollar maximum

Each person can receive plan reimbursements up to a calendar-year limit. Annual dollar maximums apply as a single amount to in-network and out-of-network services combined.

Balance billing

When the allowable amount is less than a health care provider usually charges, a provider can bill the patient for the amount not paid by the plan. If this occurs with a network provider, you are not responsible for the additional amount. With a non-network provider, you are responsible for payment, and the amount of the balance bill does not apply to your out-of-pocket maximum.

Benefit Claim

A benefit claim is a request for a particular benefit under an option (for example, a claim for a certain type of surgery under the medical plans). A benefit claim typically includes your initial request for benefits.


The portion of covered expenses the plan pays after the deductible is met. Coinsurance is expressed as a percentage.

Copayment (copay)

The dollar amount you must pay for specific supplies or services.


The portion of covered expenses you pay each calendar year before the plan begins to reimburse you for all eligible expenses.

Drug Preferred

A list of prescription drugs, both generic and brand name, that are approved by the health plan.

Eligibility Claim

An eligibility claim is a request to enroll, disenroll or change your participation in a specific option or coverage category outside of the enrollment guidelines stated in this guide. Eligibility claims are filed by calling Your Benefits Resources at 1-877-BMC-4849 between 7 a.m. and 6 p.m. weekdays.

Generic Drug

A chemical copy of a brand-name drug.

Health Savings Account (HSA)

A before-tax account feature of a high-deductible medical plan (BCBSTX HSA Plan) that you use to pay your health-related expenses each year. BMC contributes to the account, and you may also make voluntary before-tax contributions each year.

High-Deductible Health Plan (HDHP)

An option that provides comprehensive health care coverage for you and your family along with a tax-advantaged Health Savings Account that lets you save to pay for your current and future out-of-pocket health care expenses. The HDHP/HSA gives you greater flexibility and discretion over how you use your health care benefits.

Network Provider

A doctor, hospital or other health care provider who is an active member of a particular plan’s provider network.

Non-network Provider

A doctor, hospital or other health care provider who is not an active member of a particular plan’s provider network.

Out-of-Pocket Maximum

When the amount of coinsurance you pay for expenses has reached a stated annual maximum, the plan will reimburse 100% of covered expenses for the rest of the calendar year. You must still pay all required copayments (if any).

Preferred Provider Organization (PPO)

A PPO is a managed care organization of medical doctors, hospitals and other health care providers who have contracted with an insurer or a third-party administrator to provide health care at reduced rates to the insurer’s or administrator’s clients.

Preventive Prescription Drug

Medications prescribed for disease prevention. To view medications that are considered preventive under the BCBSTX HSA Plan, please see the list on My BMC Compensation & Benefits website. Select Your Benefits Resources, then Plan Information.

Specialty Pharmacy

A specialty pharmacy is a pharmacy that provides specialty medications. Specialty medications often require special storage and handling that most retail pharmacies cannot manage. These medications include injectable, infused and selected oral therapies. A specialty pharmacy offers these medications, and an in-house compounding pharmacy lets pharmacists create forms of medication that are not available in stores. Patients may have trouble sticking to their therapy schedule and often have side effects from their medications. This is why specialty medications require a pharmacist or registered nurse to monitor the treatment. BMC strongly recommends that all specialty medications be obtained through either the Express Scripts or Kaiser Specialty Pharmacy services.

Step Therapy

A process where Express Scripts works with you and your doctor to see if you should first take a less expensive generic or brand drug before trying a non-preferred higher cost medication.

Usual and Customary (U&C) (allowable charges)

Charges that fall within an acceptable range based on the most common fees for similar services in a given local area, as determined by BCBSTX using Health Insurance Association of America (HIAA) rates. Additional factors such as the complexity and complications of a procedure may also be considered. If your expenses exceed the U&C charge, you will pay the excess amount. Usual and customary charges for services within the PPO network are predetermined—you should not be billed for the excess amount.