All Non-Preventive Expenses Apply to the Deductible

All benefits in an HDHP plan are subject to the deductible—except for preventive care expenses. This means that the insurance policy only pays after the deductible is met. With that said, you will still get the benefit of negotiated discounts when using in-network providers.

Going Out-of-Network: “Allowed Amount” Defined

The “allowed amount” is the amount that the carrier will allow for a participating provider, even when the services rendered are out-of-network. Out-of-network charges can be significantly greater than the allowed amount, and you will be responsible for the difference between what the out-of-network provider charges and what the insurance carrier reimbursed. These balanced billed charges (charges in excess of what the insurance carrier recognizes in their reimbursement calculation) do not accumulate towards your out-of-network deductible or out-of-pocket maximum. You will be responsible for paying any balance billed amount that your provider charges, but that is not recognized by the insurance carrier. 

Utilization Review

All hospital confinements and surgeries must be preauthorized by your insurance carrier. You or your physician must call your insurance carrier prior to hospital admission for non-emergency treatment. If you do not obtain this mandatory authorization, your benefits will be reduced or a penalty payment will apply. Please refer to your ID card for the utilization review phone number and required time frame for reporting.

Claims

In-network providers will submit claims directly to your insurance carrier. If you see an out-of-network provider, you may be required to personally submit the claim to the insurance carrier for reimbursement.

Brand Name Prescription Drug Benefit

Under some contracts, if you choose to receive a brand name drug when a generic equivalent is available, you will be responsible for the generic drug cost plus the difference in cost between the generic and the brand name negotiated rate. Check the details of your contract to confirm how your prescription benefits work.