Calendar year deductibles and maximum coinsurance amounts
Services from all providers (Preferred, Participating and non-contracted) accumulate to individual and family calendar year deductibles.

There are not separate in- and out-of-network deductibles.

The family calendar year deductible is three times the individual deductible amount, regardless of the number of family members. It is possible for a family to reach the family deductible before the individual deductibles are met.

For example, if each individual deductible is $250, the family deductible would be $750. If three family members met $200 of their individual deductibles (3 x $200 = $600) and one family member met $150 of his or her individual deductible, the family deductible would be met: $600 + $150 = $750.

The same concept applies for maximum coinsurance.

Immunizations

• Childhood immunizations are covered at 100 percent of the allowed amount and are not subject to deductible or coinsurance, even when billed by non-contracted providers.
• Adult immunizations are covered under medical benefits and subject to deductible and coinsurance.
• Travel immunizations are excluded.

Emergency room (ER) services

• $100 copayment, after which member’s deductible and coinsurance apply
• Copayment waived if member admitted as an inpatient
• ER services processed at member’s highest benefit level

Built-in benefits and programs

• Pharmacy benefits
• Wellness programs

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