Terms to Know
What you need to know
These are common terms used when talking about your Simplot benefits.
Cost Sharing (Coinsurance)
Cost sharing (also known as coinsurance) is your share of the cost of a covered health care service, calculated as a percent of the allowed amount for the service. You have to pay the deductible before you receive the cost sharing benefit. For example, after you pay $1,800 for individual in-network medical claims, Simplot will then pay 80 percent of your next in-network medical claim in most cases. You will only pay 20 percent. Your cost sharing is higher for out-of-network claims.
Copayment
A copayment, or copay, is a flat amount you pay.
Deductible
A deductible is a fixed amount you pay before the Simplot Medical Program begins to pay. For example, Simplot’s in-network medical deductible is $1,800 for individual coverage. You will pay the first $1,800 toward in-network claims. If you have family coverage, the in-network medical deductible is $3,300. When you or any covered members of your family have claims that together add up to $3,300, your deductible is met for your entire family. The deductible is higher for out-of-network claims.
Formulary
A formulary is a preferred medication list used by the Simplot Medical Program. These drugs are considered to be clinically appropriate and cost effective. This list of preferred generic and brand-name drugs usually offers favorable pricing.
Health Saving Account (HSA)
An HSA is a savings account available to eligible employees who enroll in our qualified high deductible health plan. You pay no taxes on the money contributed to the account in most states. HSA money is intended to be used to pay for eligible health care expenses. Funds accumulate year to year if you don’t spend them.
In-Network Provider
An in-network provider has agreed to contract with Simplot’s claims administrator, Blue Cross, to provide a negotiated discount off their regular fees.
Out-of-Pocket Maximum
The out-of-pocket maximum is your safety net in the Simplot Medical Program and protects you from catastrophic medical and prescription drug expenses. Once you pay the individual maximum ($4,300 in-network, $8,400 out-of-network) or family maximum ($6,850/$8,400 in-network, $16,400 out-of-network), your other covered medical and prescription claims for the year are paid by Simplot, and you pay nothing. Please refer to the Medical Program Document for more information.