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:
- Alliance Direct providers: None
- Non-Direct providers: $400 per person/$800 per family
Once you satisfy your deductible for the calendar year, you and the Plan share in the cost of Non-Direct medical services.
The individual deductible applies to each member 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 deductibles for your family, no further 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 family deductible.
Example #1: Mike has a specialist office visit, including labs and radiology. The Allowable Charge for these services is $800. Mike has not paid anything toward his annual deductible. Here are the deductible and coinsurance that Mike will pay if he goes to a Non-Direct provider, as compared with an Alliance Direct provider:
| Alliance Direct Allowable Charge $800 | Non-Direct Allowable Charge $800 | ||
Mike pays: $0 deductible | Mike pays: $400 deductible | ||
| The Plan pays the full $800. | The Plan pays the remaining $320. |
Example #2: On January 1, Susan has a minor procedure. The Allowable Charge is $1,500. Here are the deductible and coinsurance that Susan will pay if she goes to a Non-Direct provider, as compared with an Alliance Direct provider:
| Alliance Direct Allowable Charge $1,500 | Non-Direct Allowable Charge $1,500 | |||
Susan pays: $0 deductible | Susan pays: $400 deductible | |||
| The Plan pays the full $1,500. | The Plan pays the remaining $880. |
On April 22, Susan has an office visit. The Allowable Charge is $150. Susan’s deductible for the year was already satisfied, so she only needs to pay the coinsurance. Here is the coinsurance that Susan will pay out of pocket if she goes to a Non-Direct provider, as compared with an Alliance Direct provider:
| Alliance Direct Office Visit Allowable Charge $150 | Non-Direct Office Visit Allowable Charge $150 | ||
Susan pays: $0 deductible | Susan pays: $0 deductible (already satisfied) | ||
| The Plan pays the full $150. | The Plan pays the remaining $120. |
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 deductibles for his family members:
| |
| Total = $800 (This satisfied the 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 Non-Direct provider with an Allowable Charge of $1,500. Since the family has satisfied the family deductible for the year, here is the coinsurance they will pay:
| Julia's Outpatient Procedure with a Non-Direct Provider Allowable Charge $1,500 | |
Carl's family pays: $0 deductible (already satisfied) | |
| 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 Non-Direct 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 Non-Direct Office Visits | |
First visit: $100 office visit |
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 for a Non-Direct office visit with an Allowable Charge of $100:
Joe pays: $0 deductible (already satisfied) | Mary pays: Total = $100 (full amount of office visit)
| Tom pays: Total = $100 (full amount of office visit)
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The following expenses do not count toward satisfying the deductibles:
- Copays
- Amounts you pay for prescription drugs
- Benefit penalties
- Amounts paid above Allowable Charges (i.e., amounts that are "balance-billed" by a provider)
- 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)
- Any reduction in the amounts you are required to pay by a provider or manufacturer, such as through a coupon, rebate, credit, discount, or similar arrangement
- Medical or prescription drug expenses that are not eligible for coverage under the Plan
