A deductible is the amount you pay out-of-pocket before your plan pays for any benefits. Your deductible is satisfied by both medical and prescription drug expenses. A plan's deductible must be satisfied before benefits are paid.
The Health Saver 2800, Health Saver 3000 and Health Saver 5000 plans have a non-embedded deductible, which means the employee and their dependents must meet the plan's family deductible before any claims will be paid. The only time an individual deductible is applied is for members without dependent coverage.
- The family deductible may be met by one individual or by the combined claims of multiple family members. However, one individual cannot contribute more than the ACA individual limit.
- Payments toward the penalty for choosing a brand prescription drug when a generic is available and/or the penalty for not per-certifying an inpatient hospital admission do not count toward the deductible or maximum out-of-pocket.
- Once the family in-network deductible has been satisfied, the plan pays eligible in-network claims at the plan's co-insurance level until an out-of-pocket limit is satisfied.
- Once the annual maximum out-of-pocket has been satisfied, the plan pays 100% of eligible in-network health care expenses. Some plans have embedded maximum out-of-pocket limits that may differ from individual maximum out-of-pocket limits since they have to facilitate ACA limits. Please review the Schedule of Benefits for your plan for more information.
- In-network, preventive care services are not subject to the deductible and are covered at 100%. Please review the Preventive Care Schedule for more information.