The Annual Deductible
Under Options 1 and 2, there is no in-network annual deductible, however, if you go out-of-network, certain expenses are subject to an annual deductible. The annual deductible is the amount you must pay "up front" each calendar year before the Plan begins to pay benefits for most covered expenses.
Amounts in excess of reasonable and customary (R&C) charges do not count toward the out-of-network deductible.
The annual deductible you are subject to depends on your coverage level. The following table shows the annual deductibles for the different coverage levels under each option.
* For out-of-network deductibles, the "per person" rule allows the employee or any covered dependent(s) [e.g., spouse/domestic partner or child] to reach an individual deductible, after which the deductible is satisfied for the year for that person. Covered individuals who have not met the deductible may combine to meet the remainder of the deductible for that particular coverage level. If no one person has met the individual deductible, the expenses of all covered individuals can combine to meet the deductible for that coverage level.
If you elect coverage for yourself and go out-of-network for care, you must pay up front for all eligible out-of-network expenses until you meet the per-person deductible. After you meet the annual per-person deductible, you will then pay the applicable out-of-network copay.
If you cover dependents, all eligible out-of-network expenses paid by you and/or your covered dependents combine to meet the out-of-network deductible amount for the coverage level.
However, no individual must satisfy more than the per-person deductible amount. This means that once an individual's expenses meet the per-person deductible, your maximum cost will be the in-network copay amount, even if the family has not yet met the full deductible for the coverage level.