Note: Amounts applied to the annual deductible and to member coinsurance are not used to calculate benefit limitations that are based on a dollar amount (e.g., $1,500 per calendar year). Such limits are based on amounts actually paid out by the Pool. However, when a limitation is based on a maximum number of days, visits, or benefit periods (e.g., 30 days per calendar year), the maximum benefit may be reached even if all covered charges were applied to the deductible.


Plan Deductible
See your ID card for your individual deductible amount.

Deductible — The deductible you chose is indicated on your ID card (see table, above). You must pay your deductible amount before the Pool will begin paying its share of your covered charges. Only covered charges are applied toward the deductible. Covered charges may be less than the billed amount. If you receive services from a nonparticipating provider, you will be responsible for paying the provider any amounts over the covered charge, in addition to your deductible.

Prescription Drugs and “Preventive Services” – There is no deductible to meet for prescription drugs; nor do prescription drug co-payments apply to the out-of-pocket limit. There is also no deductible requirement for the Preventive Services benefit.  (See Policy Handbook for details on this benefit.)

Family Deductible — An entire family meets an annual deductible when the total deductible amount for all family members reaches two times the Individual deductible amount chosen (see table, above). Note: If a member’s Individual deductible is met, no more charges incurred by that member may be used to satisfy
the Family deductible.

Change in Deductible Plan — Pool members can change from a lower to a higher deductible plan at any time upon written notice to the Administrator. The effective date of the change is the next premium due date following the request date.

If you increase your deductible amount, the new deductible amount must be met for all services received as of the change effective date. This means that if you had met your lower deductible and then change to a higher deductible, for services received as of the change effective date, you do not receive benefit payments until the increase in deductible is met.

Pool members can change from a higher to a lower deductible plan on or before October 1 each year. The effective date will be January 1 the following year. Requests for such changes must be made in writing to the Administrator. If you decrease your deductible amount you do not receive a refund for any deductible
amounts applied for services before the change effective date.