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Health Plan Benefit Structure

Meaning

The Health Plan Benefit Structure is the comprehensive, contractual framework that meticulously defines the scope of healthcare services, medications, and treatments covered by a patient’s insurance policy, alongside the associated patient financial responsibilities. This structure precisely outlines copayments, deductibles, out-of-pocket maximums, and the specific administrative rules for coverage, such as prior authorization requirements or drug formulary tiers. A clear understanding of this structure is essential for clinicians and patients to accurately estimate costs and ensure access to covered care.