An out-of-network provider or facility may bill you for charges – in addition to deductible and coinsurance, as applicable – which exceed the Plan’s reimbursement for a covered service. You may be responsible for these charges and receive an invoice from your provider or facility after your claim has been processed.
The family deductible limit is the most a family will pay in deductibles in a given calendar year for covered expenses. If you have family coverage, each family member must meet his or her individual annual deductible before benefits are paid for that family member until the family deductible limit has been met. Once the family deductible limit is reached, the deductible will be considered met by all family members for the rest of the calendar year.
The family out-of-pocket maximum is the most a family will pay in coinsurance before the plan pays 100% of covered expenses for the rest of the calendar year. If you have family coverage, each family member must reach the individual out-of-pocket maximum until the family out-of-pocket maximum is reached. Note that the annual deductible does not count toward the out-of-pocket maximum.
The formulary, or preferred drug list, is a list of brand-name and generic medications that are preferred by your prescription program. This formulary contains a very broad list of medications for most medical conditions that are treated on an outpatient basis. Because the medications on the formulary are preferred, you will usually pay a lower copayment than you would for non-preferred drugs.
