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Glossary Terms


Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe.


A fixed amount (for example, $15) you pay to the healthcare provider for a covered health care service, usually paid at the time of service.


This is how much you will pay out-of-pocket per calendar year before your coverage will apply.

Emergency Care

Covered services that are: 1) rendered by a provider qualified to furnish emergency services; and 2) needed to treat, evaluate or stabilize an emergency medical condition.

Emergency Room (ER) copay

This is the amount you will pay for a visit to the Emergency Room for any Medicare approved facility. This fee is waived if you are admitted to the hospital. If traveling outside of the SCMedicare network, emergency care will be covered at the in-network level.

Hospital Stay copay

This is the amount you will pay per day based on your plan selection. If additional hospital days are needed for the same admission once you reach your maximum payment amount, the additional days are covered at a $0 copay.


Physicians, hospitals and other providers in our service area that have contracted with SummaCare to provide health care services to plan members. Your network of providers is called the SCMedicare network.

Inpatient Hospital Coverage

A hospital stay when you have been formally admitted to the hospital for skilled medical services. Even if you stay in the hospital overnight, you might still be considered an “outpatient.”

Maximum Allowable Charge

The amount billed for covered services for which benefits are available under the contract.

Monthly Plan Premium

This is how much you will pay for plan coverage each month. To know your annual premium costs, multiply the monthly premium by 12.


A provider or facility with which we have not arranged to coordinate or provide covered services to members of our plan. Out-of-network providers are providers that are not employed, owned or operated by our plan or are not under contract to deliver covered services to you.

Out-of-Pocket Maximum

This amount is the MOST that you will pay out-of-pocket for in-network medical expenses during the calendar year for your care. This is not a deductible. This does not include payments for monthly premiums and prescription drug costs.

Outpatient Hospital Coverage

You’re an outpatient if you’re getting emergency department services, observation services, outpatient surgery, lab tests, X-rays, or any other hospital services, and the doctor hasn’t written an order to admit you to a hospital as an inpatient. In these cases, you’re an outpatient even if you spend the night at the hospital.

Part D

Drugs that can be covered under Part D. We may or may not offer all Part D drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs were specifically excluded by Congress from being covered as Part D drugs.


The periodic payment to Medicare, an insurance company or a health care plan for health or prescription drug coverage.

Primary Care Physician (PCP)

This is your main health care provider in non-emergency situations.

Star Rating

SummaCare's Medicare plan has been recognized with a 4-Star (out of 5) overall rating for 2021 by the Centers for Medicare and Medicaid Services (CMS).

Tier 1

Preferred Generic

Tier 2


Tier 3

Preferred Brand Name

Tier 4


Tier 5


Tier 6


Urgent Care Center copay

This is the amount you will pay for a visit to any Medicare-approved Urgent Care facility. If traveling outside of the SCMedicare network, urgent care will be covered at the in-network level.

Urgently Needed Services

Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible.