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?

The deductible is the amount paid by you before the insurance will pay for any eligible expenses. If you are enrolled in the $400 or $900 plan, office visits and prescription drugs do not require that the deductible is met before the plan begins to pay for benefits. Other services such as outpatient surgery or inpatient hospitalization requires that you meet the deductible before the plan will pay any applicable charges.

If you are enrolled in the $1,850* or $2,850 plan, you must meet your deductible before the plan will pay for any eligible expenses including office visits and prescription drug charges.

Individual Deductible

Once you meet your annual 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.