Deductibles & Out-of-Pocket Maximums

Deductibles & Out-of-Pocket Maximums

For all Anthem and Cigna plans, out-of-network deductibles and out-of-pocket maximums apply to in-network deductibles and out-of-pocket maximums. However, in-network deductibles and out-of-pocket maximums do not apply to out-of-network deductibles and out-of-network maximums.

For all Aetna plans, out-of-network deductibles and out-of-network maximums apply to in-network deductibles and out-of-pocket maximums (and vice versa).

How do deductibles work?

Individual Deductible

Once you meet your deductible, the plan will begin paying benefits.

Family Deductible

Once you meet the family deductible (whether or not you each meet your individual deductible), the plan will begin paying benefits.

How do out-of-pocket (O-O-P) maximums work?

Your out-of-pocket expenses will be limited by an annual out-of-pocket maximum.

Individual O-O-P

Once you meet your out-of-pocket maximum, the plan will pay any additional eligible expenses at 100% in-network and 100% up to reasonable and customary charges out-network for the rest of the calendar year. Deductibles, copayments for office visits and coinsurance apply toward the out-of-pocket maximum.

Family O-O-P

Once you meet the family out-of-pocket maximum (whether or not you each meet your individual out-of-pocket maximum), the plan will begin paying benefits at 100% in-network and 100% up to reasonable and customary charges out-network for the remainder of the calendar year. Deductibles, copayments for office visits and coinsurance apply toward the out-of-pocket maximum.

A word about the $1,850 Deductible Plan

If you enroll in the $1,850 Deductible Plan and cover any dependents, the full family deductible must be met before the Plan pays benefits for any family member. Any covered family member can contribute to the family deductible. The individual deductible only applies if you elect the employee-only coverage tier. Please call the Pearson Benefits Marketplace at 855-237-6421 if you have any questions.