MMC Benefits Handbook
Deductibles
The deductible is the amount that must be paid before the Plan will reimburse any benefits.
The deductibles vary under each of the medical plan options available to you (as shown in the table below.
1 These plans are named for the deductible applicable to the "individual" for in-network service providers. The deductibles applicable to any other coverage level (for example, "Family coverage") or for services provided by out-of-network service providers will be significantly higher than (in many instances, double) the amounts captured in the names of the plans.
2 "Family" applies to all coverage levels except Employee-Only.
3 Not "True" Family: For the $3,200 Deductible Plan, if more than one person in a family is covered under this plan, there are two ways the plan will begin to pay benefits for a covered family member. When a covered family member meets his or her individual deductible, benefits begin for only that covered family member, and not for the other covered family members. When the family deductible is met, benefits begin for all covered family members whether or not each has met the individual deductible. The family deductible can only be met by a combination of covered family members, as amounts counted toward individual deductibles count toward the larger family deductible. The out-of-pocket maximum functions in the same way. When a covered family member meets his or her individual out-of-pocket maximum, the out-of-pocket maximum is satisfied for only that covered family member. When the family out-of-pocket maximum is met, the out-of-pocket maximum is satisfied for all covered family members, whether or not each has met the individual out-of-pocket maximum. The family out-of-pocket maximum can only be met by a combination of covered family members, as amounts counted toward individual out-of-pocket maximums count toward the larger family out-of-pocket maximum.
4 "True" Family: For the $1,600 Deductible Plan, if more than one person in a family is covered under this plan, benefits begin for any one covered family member only after the family deductible is met by one covered family member or a combination of family members. This plan does not require that you or a covered family member must meet the "individual" deductible to meet the family deductible. The out-of-pocket maximum functions in the same way. If more than one person in a family is covered under this plan, the out-of-pocket maximum is met for any one covered family member only when the family out-of-pocket maximum is met by one covered family member or a combination of covered family members.
Do in-network medical claims apply toward the out-of-network deductible?
Yes. In-network claims apply toward the out-of-network deductible. Also, out-of-network claims apply toward the out-of-network deductible.
Do out-of-network medical claims apply toward the in-network deductible?
Yes. Out-of-network claims apply toward the in-network deductible. Also, in-network claims apply toward the in-network deductible.
How do deductibles work?
Under the $1,600 Deductible Plan
If the "employee" coverage level is elected, the Plan will begin reimbursing benefits for the one covered individual once he or she has met the individual deductible. For any other coverage level (employee + spouse, employee + child(ren) or family, the Plan will begin reimbursing benefits for a covered family member (including a newborn) once the family deductible is met. In meeting your family deductible, each covered family member's (including a newborn's) covered expenses (medical and prescription drug expenses) count toward the family deductible. Once this family deductible is met, the Plan will pay benefits for all covered family members.
Under the $3,200 Deductible Plan
The Plan will begin reimbursing benefits for a covered family member once he or she has met the individual deductible (even if the entire family deductible has not been met). (Note that newborns have their own separate deductible.) The family deductible is the maximum amount you have to pay before the Plan will reimburse any benefits. Newborn expenses, including nursery charges in the hospital, will apply to newborn's individual deductible.
Do I have to meet a new deductible every year?
You and your family members will have to meet a new deductible each year.
What expenses apply toward the deductible?
Most of your medical expenses apply toward the deductible.
Under the $1,600 Deductible Plan and the $3,200 Deductible Plan, prescription drug expenses (other than preventive drug expenses) apply toward the deductible.
Refer to "Do preventive drug expenses apply toward the deductible?" for further details.
Your payments for the following don't apply toward the Plan deductible:
- Amounts in excess of a reasonable and customary charge
- Preauthorization penalties
- Services not covered by the Plan
Under the $1,600 Deductible Plan
- Amounts exceeding the network negotiated price for prescription drugs (other than preventive drugs)
Under the $3,200 Deductible Plan
Do preventive drug expenses apply toward the deductible?
Preventive drugs as defined by the Patient Protection Affordable Care Act for the $1,600 Deductible Plan and $3,200 Deductible Plan are covered with no cost sharing (i.e. deductible, coinsurance, copay). Certain examples include: aspirin products, fluoride products, folic acid products, immunizations, contraceptive methods, smoking cessation products, bowel preps, primary prevention of breast cancer and statins. The list of preventive medications covered with no cost sharing, called the CVS Caremark ACA Drug List, is subject to periodic review and may change.
If you enrolled in the $1,600 Deductible Plan or the $3,200 Deductible Plan, there are certain preventive medications that are not subject to the deductible. Certain examples include: hypertension, diabetes, asthma, and cholesterol lowering drugs. This list of preventive medications, the CVS Caremark Preventive Drug List, is covered at the standard coinsurance and the list of medications is subject to periodic review and change.
Call CVS Caremark® at +1 844 449 0362 for more information about preventive drugs. You can access the preventive drug listing at www.caremark.com. To obtain information on the cost of preventive drugs, log on to the Drug Cost Tool at www.caremark.com. Follow the provided steps to access the Drug Cost Tool.
- Go to www.caremark.com.
- Login or create an account.
- Plan & Benefits.
- Check Drug Cost & Coverage.
- Enter drug name & dose and choose a pharmacy.