These documents are provided by your private insurance carrier. They are typically provided when you sign up. Call or check your online account if you can't find the copy that was mailed to you.
- Summary of Benefits: Roughly 6-page standardized format includes cost coverage details for about a dozen categories of benefits, for drug coverage, general info about networks, some sample scenario costs and other plan benefit coverage & exclusions.
- Plan brochure: Contains insurance company marketing and general company info, lengthy chart comparing all the company’s plans on a number of elements.
- Provider directory: May be updated during year. Use search feature to search by provider type, location, name or other terms.
- Formulary: May be updated during year. Takes you to the company’s website. Search alphabetically using control F command by type of drug to see if a drug is covered and at what level.
- Certificate of Coverage or Member Benefit Agreement: Very lengthy contractual, legal document detailing how to use the plan, what is and isn’t covered, cost sharing details, coordination of benefits stipulating which plan pays first if there are two plans, how to appeal and other information.
- Explanation of Benefits (EOB): This is a document the carrier sends you after you have utilized health care services. It will tell you for each kind of care you received (examination, imaging, lab work, etc.), how much the insurance company agreed to pay and how much you need to pay. Depending on your carrier an EOB might be called a "Health Care Summary", "Summary of Payment", or "Activity Summary". If they did not pay a claim you think they should have, you can appeal that denial of payment.
- Medical Guidelines: May be updated during year. Specific document with clinical utilization management medical guidelines for specific medical situations.
- Clinical UM Guidelines: May be updated during year. Specific document with clinical utilization management medical guidelines for specific medical situations.
