A tiered medical network organizes its providers (doctors, hospitals, and others) based on cost and quality. Typically, they fall into three or four levels, each representing a different level or coverage and associated costs.
Tiers can vary based on providers, but generally include:
- Tier 1: In-network providers: These typically come with lower copays, coinsurance, and deductibles because the insurance company has negotiated lower rates with them.
- Tier 2: Higher-cost, in-network providers: This tier often includes in-network providers who have not negotiated the same rates of Tier 1 participants. While you could still receive some coverage, your out-of-pocket costs (deductibles, copays, and coinsurance) may be higher than Tier 1 providers.
- Tier 3: Out-of-network providers: This tier includes services from out-of-network providers, which generally have higher costs and may not be covered at all except in emergency circumstances. If coverage is provider, you will have higher deductible, copays, and coinsurance.
- Tier 4: Specialty services: In some plans, this tier may include specialty services, which may require pre-authorization, and higher costs.