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Medical Benefits - Deductibles and Co-Payments

Most of the medical plans have deductibles that you must pay before the Plan will pay at the specified reimbursement percentage.  To determine your deductible, out-of-pocket limits, and reimbursement percentage (% payable by the Plan), you may review the following summary for your plan:

• Plan 500
• Plans 551 - 553
• Plans 554 - 556

Once deductibles have been met, payment will equal the reimbursement percentage multiplied by the covered charge (generally, the actual charge or the usual and customary charge for that service, whichever is lower), until the out-of-pocket limit is met.  Once the out-of-pocket limit is met, payment will equal the covered charge (or the usual and customary charge for that service, whichever is lower).

Please note that the following items are not applied towards your annual medical deductible or out-of-pocket limit: 

• $10 (or $25) fee paid at a Wellness and Minor Care clinic
• Out-of-network penalties
• Expenses in excess of the usual and customary
• Prescription drug co-payments
• Any expense not covered by the Plan

There are no annual or lifetime maximums for general medical benefits; however, reimbursement is limited for treatment for the following conditions:

• Alcohol and/or substance abuse
• Inpatient mental health
• Gastric bypass procedures and related complications
• Infertility
• Physical Exams
• Pre-existing conditions 

For details, see the Plan Documents or review your Plan Booklet.

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