The Plan will never pay 100% for those expenses that do not apply toward satisfying the coinsurance/co-payment maximum.
Deductible and Coinsurance/Co-payment Maximum - Family Coverage
Calendar Year Deductible Coinsurance/Co-payment Maximum
Out-of-Network $2,100 $7,900
Calendar Year Deductible – Family Coverage Family coverage is when an enrollee has one or more covered dependents. If an enrollee has family coverage, there is no separate deductible for each covered individual in the family. Benefits will not be paid until the family deductible for all participants under that ID number has been satisfied. The family deductible also applies when both husband and wife are covered separately as enrollees, one of the enrollees has dependent coverage, and both are enrolled in Base Coverage.
If both husband and wife are covered employees, one carries dependent coverage, and only one of them elects Base Coverage, calendar year deductibles and coinsurance/co-payment amounts are not shared.
If both husband and wife are covered employees with employee only coverage, and both elect Base Coverage, the calendar year deductible and coinsurance/co-payment amounts are not shared.
The following expenses do not count towards the calendar year deductible for Individual or Family Base Coverage:
Expenses in excess of the allowable charge Utilization review penalties Expenses in excess of Plan maximum limits Services not covered by the Plan including all those found in the Medical Limitations and Exclusions section Services not considered medically necessary
Coinsurance/Co-payment Maximum – Family Coverage The coinsurance/co-payment maximum is the maximum amount that an enrollee with family coverage has to pay in coinsurance and co-payments for covered expenses in a calendar year before benefits will be paid at 100%. If an enrollee has family coverage, there is no separate coinsurance/co-payment maximum for each individual. The family coinsurance/co-payment maximum also applies when both husband and wife are covered separately as enrollees, one of the enrollees has family coverage, and both are enrolled in Base Coverage. The amount paid toward meeting the calendar year deductible does not count toward satisfying the coinsurance/co-payment maximum.