Family coverage applies when an enrollee (active employee, retiree, surviving spouse or COBRA participant) has one or more covered dependents. If an enrollee has family coverage, there is no separate high deductible for each covered individual in the family. Covered medical and prescription drug expenses apply toward the family calendar year deductible, unless otherwise indicated. Medical services and prescription drugs will not be paid for any participants in the family until the family deductible has been satisfied. However, in no event shall an individual's annual out-of-pocket costs exceed $6,500. The family deductible also applies when both husband and wife are covered separately as enrollees, one of the enrollees has dependent coverage, and both are enrolled in Base Coverage.
If both husband and wife are covered employees, one carries dependent coverage, and only one of them elects Base Coverage, calendar year deductibles and coinsurance amounts are not shared. If both husband and wife are covered employees with employee-only coverage, and both elect Base Coverage, the calendar year deductible and coinsurance amounts are not shared.
The following expenses do not count toward the individual or family calendar year deductible:
Telehealth provider visit copayments
Emergency room copayments
Prescription drug copayments
Utilization review penalties
Generic drug differential amounts
Expenses in excess of the allowable charge
Expenses in excess of Plan maximum limits
Services not covered by the Plan
Services not considered medically necessary