Deductibles

You pay the first portion of contracted or recognized charges for most covered expenses incurred by you and each covered dependent during the plan year before the plan begins paying benefits.

Each PPO Option has separate network and out-of-network medical coverage plan year deductibles. These deductibles are exclusive of each other. This means your covered network expenses count only toward meeting the network medical deductible. Network expenses do not count toward meeting the out-of-network medical deductible.

Similarly, covered out-of-network expenses count toward meeting the out-of-network medical coverage deductible, but do not count toward meeting the network medical deductible.

In addition, the Health+Savings PPO Option has two separate deductibles for network expenses, and two more for out-of-network expenses. Under the Health+Savings option, the lower deductibles apply only if you have You Only coverage. The higher deductibles apply if you have You + Spouse, You + Child(ren) or You + Family coverage, even if only one family member incurs medical expenses during the year. Under the Health+Savings option, the lower You Only deductibles would not apply to any covered individual in your family if you have You + Spouse, You + Child(ren) or You + Family coverage.

If you participate in the HealthPlus and Standard PPO options, any medical expense that counts toward an individual's deductible automatically counts toward the family deductible. This means that once you meet the family network or out-of-network deductible for the plan year, no other covered family member is required to meet his/her individual network or out-of-network medical deductible (as applicable) for that plan year before benefits are paid.

If you participate in the HealthPlus PPO Option, there is no separate plan year deductible for prescription drugs. Prescription drug expenses do not apply to the medical plan deductible.

If you participate in the Standard PPO Option, you pay a separate plan year deductible under the Prescription Drug Program. Medical expenses do not apply to the deductibles under the Prescription Drug Program and vice versa.

If you participate in the Health+Savings PPO Option, there is no separate plan year deductible for prescription drugs. Prescription drug expenses do apply to the medical plan deductible. You must meet the plan year deductible before the plan starts to pay most expenses, including those for formulary brand preventive and non-preventive prescription drugs.

Expenses excluded from the deductibles

The following expenses do not apply to the medical coverage plan year deductibles under the various PPO Options as indicated:

Under the HealthPlus and Standard PPO Options
Under the Health+Savings PPO Option
  • Office visit copays.
  • Emergency room/urgent care facility copays.
  • Prescription drug expenses.
  • Expenses for diabetic insulin pumps and tubing.
  • Penalties for noncompliance with precertification provisions.
  • Expenses not covered by the PPO Option.
  • Charges above recognized charge limits.
  • Expenses for diabetic insulin pumps and tubing.
  • Penalties for noncompliance with precertification provisions.
  • Expenses not covered by the PPO Option.
  • Charges above recognized charge limits.

 

Publication date: April 2019

 

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