Print this page| Following are copays you will be responsible for: | |
|---|---|
| Office visit: | $15 |
| Prescription drugs | |
| Tier 1: | $10 |
| Tier 2: | 50% of the drug cost |
| Emergency room visit: | $100 |
Example of how a COPAY works
Sally takes her son, Charlie, to the pediatrician for a bad cough. Sally pays the $15 office visit copay at the doctor's office.
Example of how a DEDUCTIBLE works
John falls off his roof and is taken to the hospital by ambulance. The ambulance service is subject to his annual deductible. John has not paid anything toward his deductible, so he is responsible for the first $150 of the $500 cost. He also is responsible for paying 20% coinsurance of the remaining bill.
| Ambulance services: | $ 500 |
|---|---|
| John's deductible: | $ 150 |
| Remaining bill: | $ 350 |
| John pays 20% of remaining bill: | $ 70 |
| Health plan pays 80% of remaining bill: | $ 280 |
| John's total cost: | $ 220 |
Because John has met his $150 deductible, he will only pay copayments and the 20% coinsurance for the rest of the year until he reaches his out-of-pocket maximum.
Example of how a COINSURANCE works
Sally is hospitalized for an injury. The hospital stay costs $1,000. The hospital stay is subject to her annual deductible. Sally has already paid her annual deductible, so she pays 20% coinsurance for the hospital stay and her health plan pays the remaining 80%.
| Hospital Stay | $1,000 |
|---|---|
| Sally pays 20% | $ 200 |
| Health plan pays 80%: | $ 800 |
Example of how an OUT-OF-POCKET MAXIMUM works
When John fell off the roof, he seriously damaged his knee. He will need three surgeries to repair the damage. Each surgery will cost $5,000 and his coinsurance is 20%. The surgeries are subject to his annual deductible, which he has already met with the ambulance service.
| FIRST SURGERY: | $5,000 |
|---|---|
| John pays 20%: | $1,000 |
| Health plan pays 80%: | $4,000 |
For the second surgery, John will not have to pay the full 20% coinsurance, because he has already paid $70 for the ambulance service and the $1,000 for the first surgery, that go toward his annual out-of-pocket maximum of $1,500.
| SECOND SURGERY: | $5,000 |
|---|---|
| John pays (the remainder of his $1,500 out-of-pocket maximum): | $ 430 |
| Health plan pays: | $4,570 |
As long as the third surgery occurs in the same calendar year, John will not have to pay any deductible or coinsurance because he has already paid his out-of-pocket maximum with the ambulance service and the first two surgeries.
| THIRD SURGERY: | $5,000 |
|---|---|
| John pays: | $ 0 |
| Health plan pays: | $5,000 |
John will still be responsible for paying his copays for follow-up office visits, prescription drugs, and for non-covered services.
