A deductible is a fixed dollar amount you pay each calendar year before the plan begins paying most benefits. The medical deductible amount is $250 per person, with a maximum of $750 for a family of three or more people; see "How Does the Medical Deductible Work With Families?" below. When you first get services, you pay your provider the first $250 in charges. After you pay that first $250, the plan begins to pay benefits for your care. This applies to each covered family member, up to the $750 maximum.
You also pay a separate deductible for prescription drugs when you purchase Tier 2 and Tier 3 drugs. The prescription drug deductible is $100 per person, with a maximum of $300 for a family of three or more people, and does not apply to Value Tier or Tier 1 drugs.
If You Qualified for the SmartHealth Wellness Incentive
The subscriber is the only family member eligible to earn the SmartHealth wellness incentive. The 2017 incentive reduces the subscriber’s medical deductible by $125. See more about how the deductible reduction works.
What Doesn't Count Toward My Medical Deductible?
The following out-of-pocket expenses do not count toward your $250 medical deductible:
- Services you pay for that aren't covered by the plan.
- Services that are exempt from the medical deductible, even if you had out-of-pocket costs. For example, preventive care received from an out-of-network provider.
- Charges for services exceeding benefit maximums. For example, the maximum for adult vision hardware is $150 every two calendar years; charges over $150 do not count toward your medical deductible.
- Charges for services beyond benefit limits. For example, the annual benefit limit for acupuncture is 16 visits. Costs for more than 16 visits are not covered by the plan and do not count toward your medical deductible.
- Out-of-network provider charges that exceed the allowed amount.
- Your inpatient hospital copayment.
- Your $75 per visit emergency room copayment.
- Prescription drug costs.
Which Services Are Exempt From the Medical Deductible?
TIP: The plan pays the services (subject to cost share) listed below even if you have not met you deductible. This means that you do not have to pay the first $250 of covered services before the plan begins to pay.
You do not have to pay the medical deductible before the plan pays for these services:
How Does the Medical Deductible Work With Families?
If you have three members in your family enrolled in UMP Classic, each family member must pay the $250 medical deductible for a family maximum of $750. Once any one person spends $250 that applies toward the deductible, the plan will begin paying benefits for that person only. Because the plan is now paying for this person’s covered services, he or she is no longer contributing toward the family deductible.
If your family has four or more members, each person has an individual medical deductible of $250 and the maximum the family pays towards medical deductibles is $750. Once a particular individual pays his or her $250 deductible, the plan begins paying for covered services for that person. Because the plan is now paying for this person’s covered services, he or she is no longer contributing toward the family deductible. If the combined amount paid toward the deductible for everyone in the family reaches $750—even if no one reached $250 on their own—the plan begins paying for covered services for everyone in the family; no more deductible is owed.
Note: Only services that are covered and are subject to the medical deductible count; see above for a list of services that don’t count.
If the subscriber earned the SmartHealth wellness incentive, the subscriber’s medical deductible is reduced to $125. For details and examples of how the deductible reduction works for accounts with more than one member. See more about the SmarthHealth program.
ALERT! If you receive services with a benefit limit (such as spinal or extremity manipulation, massage therapy, or physical therapy) before meeting your medical deductible, those visits will count toward the benefit limit. For example, if you pay out of pocket for a massage therapy visit because you haven't met your deductible, that visit will count toward the maximum of 16 visits per calendar year. See definition of "Limited Benefit" for more information. Note: If you have other primary coverage, including Medicare, visits paid by your primary plan also count toward UMP Classic benefit limits.