Insurance words, defined by the government
The terms you meet when a plan decides whether to pay for a GLP-1. Each definition is quoted, not rewritten.
Read Sep 27, 2026. HealthCare.gov has no entry for “exception” or “specialty drug”, so those come from Medicare.gov.
- Appeal
A request for your health insurance company or the Health Insurance Marketplace® to review a decision that denies a benefit or payment.
healthcare.gov, Sep 29, 2026If your health plan refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party.
healthcare.gov, Sep 29, 2026- Brand name drug
A drug sold by a drug company under a specific name or trademark and that is protected by a patent. Brand name drugs may be available by prescription or over the counter.
healthcare.gov, Sep 29, 2026- Coinsurance
The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.
healthcare.gov, Sep 29, 2026- Compounded drug
However, compounded drugs are not FDA approved. This means the agency does not review compounded drugs for safety, effectiveness or quality before they are marketed.
fda.gov, Sep 29, 2026- Copayment (copay)
A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.
healthcare.gov, Sep 29, 2026Copayments (sometimes called "copays") can vary for different services within the same plan, like drugs, lab tests, and visits to specialists.
healthcare.gov, Sep 29, 2026- Deductible
The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.
healthcare.gov, Sep 29, 2026Some plans have separate deductibles for certain services, like prescription drugs.
healthcare.gov, Sep 29, 2026- Exception
An exception is when a drug plan decides to cover a drug that's not on its drug list, or to waive a coverage rule. A tiering exception is when a drug plan decides to charge a lower amount for a drug that's on its non-preferred drug tier (“Tiers” are described below.).
medicare.gov, Sep 29, 2026- External review
A review of a plan's decision to deny coverage for or payment of a service by an independent third-party not related to the plan. If the plan denies an appeal, an external review can be requested.
healthcare.gov, Sep 29, 2026- Flexible spending account (FSA)
An arrangement through your employer that lets you pay for many out-of-pocket medical expenses with tax-free dollars. Allowed expenses include insurance copayments and deductibles, qualified prescription drugs, insulin, and medical devices.
healthcare.gov, Sep 29, 2026- Formulary (drug list)
A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.
healthcare.gov, Sep 29, 2026- Generic drug
A prescription drug that has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs. The Food and Drug Administration (FDA) rates these drugs to be as safe and effective as brand-name drugs.
healthcare.gov, Sep 29, 2026- Health savings account (HSA)
A type of savings account that lets you set aside money on a pre-tax basis to pay for qualified medical expenses.
healthcare.gov, Sep 29, 2026- Out-of-pocket maximum
The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.
healthcare.gov, Sep 29, 20262026: No more than $10,600 for an individual or $21,200 for a family
healthcare.gov, Sep 29, 20262027: No more than $12,000 for an individual or $24,000 for a family
healthcare.gov, Sep 29, 2026- Preauthorization
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.
healthcare.gov, Sep 29, 2026- Prescription drug coverage
Health insurance or plan that helps pay for prescription drugs and medications. All Marketplace plans cover prescription drugs.
healthcare.gov, Sep 29, 2026- Prescription drugs
Drugs and medications that, by law, require a prescription.
healthcare.gov, Sep 29, 2026- Prior authorization
Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.
healthcare.gov, Sep 29, 2026- Tiers
To lower costs, many plans place drugs into different “tiers" or levels on their drug lists. Each plan can divide its tiers in different ways. Generally, a drug in a lower tier will cost you less than a drug in a higher tier.
medicare.gov, Sep 29, 2026Tier 2—medium copayment: preferred, brand-name prescription drugs
medicare.gov, Sep 29, 2026Tier 3—higher copayment: non-preferred, brand-name prescription drugs
medicare.gov, Sep 29, 2026Specialty tier—highest copayment: very high-cost prescription drugs
medicare.gov, Sep 29, 2026
Putting these to use: prior authorization letters and savings cards with insurance.