Glossary of Terms

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Online Provider Directory (DocFind®)

The online provider directory lists doctors, hospitals and other health care providers who belong to the plan’s network (including Aexcel-designated providers). You can use this tool to search for a particular provider or find all in-network providers within a certain geographical area.

Out-of-network Provider

A non-network or out-of-network provider is one that has not contracted with the LM HealthWorks Plan to provide members with services based on pre-agreed fee structures and other criteria. Out-of-network providers can apply to become in-network providers.

Out-of-pocket Maximum

The out-of-pocket maximum is the plan’s limit on what you must pay in coinsurance each calendar year. Once you reach the out-of-pocket maximum, the plan pays 100% of covered expenses for the rest of the calendar year. If you have family coverage, each family member must meet the individual out-of-pocket maximum before the 100% coverage begins. Once family expenses reach the family out-of-pocket maximum, expenses for all family members are paid at 100% for the rest of the year.

Beginning January 1, 2015, prescription drugs have their own out-of-pocket maximum.

Note that prescription drug and preventive care expenses do not count toward the out-of-pocket maximum. In addition, amounts over the recognized charges as well as non-covered services do not accumulate to the out-of-pocket maximum. There are separate in-network and out-of-network out-of-pocket maximums.

Over-the-counter Medication

An over-the-counter medication is one you can purchase without a prescription from your doctor.

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