Annual Deductible

The annual deductible is the amount of Allowable Charges you pay before the Plan pays any expenses for the calendar year. The amount of the annual deductible is:

  • In-Network Plus (INP): None
  • Preferred Provider Organizations (PPO): $400 per person/$800 per family
  • Out-of-Network (OON): $2,000 per person/$4,000 per family

Once you satisfy your deductible for the calendar year, you and the Plan share in the cost of PPO and OON medical services. The deductible is combined for PPO and OON; in other words, your PPO expenses apply to the OON deductible, and vice versa.


Example #1: Mike has a specialist office visit, including labs and radiology. If Mike sees an INP provider, the Allowable Charge for the visit is $800. If Mike sees a PPO provider, the Allowable Charge for the visit is $1,500. Here is what Mike will pay out of pocket if he goes to an INP provider, as compared with a PPO provider:

  INP: Total cost $800PPO: Total Cost $1,500

Mike pays:

$0 deductible
$0 coinsurance
Total = $0

Mike pays:

$400 deductible
+ $220 (20% of remaining $1,100)
Total = $620

The Plan pays the full $800.The Plan pays the remaining $880.

Example #2: On January 1, Susan has an ER visit at a PPO hospital with an Allowable Charge of $1,500. This is the first ER visit of the year for her family. Here is what Susan will pay out of pocket: 

  ER visit at a PPO Hospital: Total cost $1,500

Susan pays:

$400 deductible
+ $150 copay
Total = $550

The Plan pays the remaining $950.

On April 22, Susan has an office visit at a PPO doctor with an Allowable Charge of $150. Susan’s deductible for the year was already satisfied, so she only needs to pay the coinsurance. Here is what Susan will pay out of pocket:

  PPO Office Visit: Total cost $150

Susan pays:

$0 deductible (already satisfied)
+ 20% office visit coinsurance
Total = $30

The Plan pays the remaining $120.

The individual deductible applies to each covered person in your family. The family deductible applies collectively to all the covered people in your family. For example, after you pay a total of $800 in Allowable Charges toward the PPO deductibles for your family, no further PPO deductible will be required for any covered family member for the rest of the year. No one person in the family may contribute more than $400 toward the PPO family deductible.


Example #3: Carl covers himself, his wife Helen, and his daughter Julia under the Health Plan. As of March 5, Carl has paid the following Allowable Charges toward the PPO deductibles for his family members:

  • Carl: $300
  • Helen: $300
  • Julia: $200
Total = $800 (This satisfied the PPO family deductible for the year.)

As of March 5, although no one in Carl’s family has reached their $400 per person annual deductible, collectively they have satisfied the $800 family deductible. On March 10, Julia has an outpatient procedure at a PPO provider with an Allowable Charge of $1,500. Since the family has satisfied the family deductible for the year, here is what they pay:

  Julia's Outpatient Procedure with a PPO Provider: Total cost $1,500

Carl's family pays:

$0 deductible (already satisfied)
+ 20% office visit coinsurance
Total = $300

The Plan pays the remaining $1,200.

Example #4: Joe covers himself, his wife Mary, and their son Tom. Joe frequently gets sinus infections and has made four trips to his doctor’s office since the start of the year. He sees a PPO provider, so he must pay the full Allowable Charge for the office visit ($100) until he meets his $400 individual deductible. Here is what Joe has paid out of pocket since January 1:

  Joe's PPO Office Visits

First visit: $100 office visit
Second visit: $100 office visit
Third visit: $100 office visit
Fourth visit: $100 office visit
Total = $400 (Joe has now met his deductible, and no longer has to pay toward it.)

Even though Joe has met his individual deductible, Mary and Tom have not met theirs, nor has the family met their $800 family deductible. So later in the year, when the entire family caught the flu and each of them had to see the doctor, here are the Allowable Charges they had to pay individually:

Joe pays:

$0 deductible (already satisfied)
+ 20% coinsurance ($20)
Total = $20

Mary pays:

Total = $100 (full amount of office visit)

 

Tom pays:

Total = $100 (full amount of office visit)

 

The following expenses do not apply to deductibles:

  • Copays
  • Amounts you pay for prescription drugs
  • 25% benefit penalties (100% benefit penalties for transplants) you pay for preauthorization non-compliance (when required)
  • 40% benefit penalties for Care Coordination non-compliance (when required for your condition)
  • 40% benefit penalties for using a provider that is not a Plan-approved Center of Expertise for a designated procedure
  • Amounts paid above Allowable Charges
  • Medical or prescription drug services or expenses that exceed limits set by the Plan (see the Medical Plan “Benefit Summary” and the Prescription Drug Plan section)
  • Premiums (including premiums paid for COBRA continuation coverage)
  • Medical or prescription drug expenses that are not eligible for coverage under the Plan