Code | Display | Definition |
after-deductible |
After Deductible |
The consumer first pays the deductible, and after the deductible is met, the consumer is responsible only for the cost-share amount (this indicates that this benefit is subject to the deductible). |
before-deductible |
Before Deductible |
The consumer first pays the cost share amount, and any net remaining allowed charges accrue to the deductible (this indicates that this benefit is subject to the deductible). |
no-charge |
No Charge |
No cost sharing is charged (this indicates that this benefit is not subject to the deductible). |
no-charge-after-deductible |
No Charge After Deductible |
The consumer first pays the deductible, and after the deductible is met, no cost share amount is charged (this indicates that this benefit is subject to the deductible). |
charge |
Charge |
The consumer always pays just the cost share amount and the issuer pays the remainder of allowed charges (this indicates that this benefit is not subject to the deductible). |
coinsurance-not-applicable |
Coinsurance Not Applicable |
The consumer pays only a copay. Note: When using Not Applicable for coinsurance, Not Applicable cannot also be used for copay (unless the drug tier type is Medical Service Drugs). |
copay-not-applicable |
Copay Not Applicable |
Deductible is not applicable: Zero-deductible cost sharing represented by a co-pay value of 'Not applicable' and co-insurance value of 'No charge'. |
deductible-waived |
Deductible Waived |
The consumer pays the cost share amount with deductible requirement waived. |