Insurance cards have a lot of information and abbreviations packed into one small piece of paper (or plastic). Sometimes it can be challenging to figure out what it all means. While each insurance carrier and plan may have different information displayed on the card, most insurance cards have the following:
Name of insurance company
subscriber name
subscriber ID
the names of any dependents under your insurance
group ID
RxBIN number
out of pocket costs
prescription coverage
Terms and Abbreviations On Insurance Cards
The following are common terms and abbreviations used on most insurance cards. Knowing what they mean can help you understand more about your policy and be prepared to use it accordingly with your health provider:
Insurance Carrier: The company that provides your health insurance plan (e.g., Anthem, Kaiser, Blue Cross Blue Shield).
Member ID: A unique identifier assigned to you by your insurance company. It's used by healthcare providers to bill your insurance.
Group Number: Identifies the specific insurance plan offered by your employer or group. It helps the insurance company process claims according to the correct plan.
Plan Code: A code that represents the specific plan or coverage you have within the insurance company.
RxBIN (Prescription Bank Identification Number): A six-digit number that identifies the company that processes your prescription drug claims.
PCP (Primary Care Provider): The doctor or medical professional you choose to be your main healthcare provider. Some insurance plans require you to select a PCP.
Copay: A fixed amount you pay for a healthcare service at the time you receive it, such as $20 for a doctor’s visit.
Deductible: The amount you must pay out of pocket for healthcare services before your insurance starts to pay. For example, if your deductible is $500, you pay the first $500 of medical expenses.
Coinsurance: The percentage of costs you pay after you've met your deductible. For instance, if your coinsurance is 20%, you pay 20% of the cost of a service, and your insurance pays 80%.
In-Network: Providers or healthcare facilities that have a contract with your insurance company to provide services at a lower cost.
Out-of-Network: Providers or facilities that do not have a contract with your insurance company. Services from out-of-network providers may cost more or may not be covered at all.
Effective Date: The date when your insurance coverage begins.
Dependent: A family member (e.g., spouse, child) who is covered under your insurance plan.
Subscriber: The primary person who holds the insurance policy, often the employee in an employer-sponsored plan.
Out-of-Pocket Maximum (OOP Max): The maximum amount you pay for covered services in a plan year. After reaching this limit, your insurance covers 100% of the costs.
Rx: Refers to prescription medications.
HMO (Health Maintenance Organization): A type of insurance plan that typically requires you to use in-network providers and get referrals to see specialists.
PPO (Preferred Provider Organization): A type of insurance plan that offers more flexibility in choosing healthcare providers and doesn’t usually require referrals for specialists.
EPO (Exclusive Provider Organization): Similar to an HMO, but typically does not require a referral to see a specialist. You must use the plan’s network of providers for all non-emergency care.
POS (Point of Service): A type of plan that combines features of HMO and PPO plans. You pay less if you use providers in the plan’s network and need a referral from your primary care doctor to see a specialist.
ID: Refers to your Member ID number.
PCP: Primary Care Provider—your main healthcare provider.
DOB: Date of Birth—used to confirm your identity.
RxPCN (Processor Control Number): A secondary identifier used by pharmacies to route prescription claims.
RxGRP (Prescription Group Number): Identifies your prescription drug plan group.
COB (Coordination of Benefits): Refers to the process used to determine the order in which multiple insurance plans will pay benefits when you're covered by more than one plan.
What’s the difference between RxGRP and RxBIN?
RxGRP (Prescription Group Number) and RxBIN (Prescription Bank Identification Number) are both related to processing prescription drug claims, but with key differences and serve different purposes:
RxBIN routes the claim to the correct processor, ensuring the claim goes to the right place. When you go to a pharmacy to fill a prescription, the pharmacist uses the RxBIN to route the claim to the correct insurance or PBM, ensuring that your prescription is processed under the correct plan.
RxGRP identifies the specific plan or group coverage you belong to, which dictates the benefits and rules applied to your prescription claim. The RxGRP helps the PBM or insurance company determine the specific benefits and coverage rules that apply to your prescriptions based on the group plan you are enrolled in. This ensures that the right copays, deductibles, and coverage limits are applied according to your specific plan.
Figuring out the information on your insurance card can feel overwhelming, but understanding the key terms and details can make a big difference in how you use your coverage. By familiarizing yourself with these common abbreviations, phrases, and sections found on most insurance cards, you’ll be better prepared to manage your healthcare needs and avoid unexpected costs. Remember, each insurance plan is unique, so if you ever have questions about your specific coverage, don’t hesitate to reach out to your insurance provider for clarity. Being informed is the first step towards making the most of your health insurance.