HDHP: deductibles, copays, copayments, and out-of-pocket maximums

​​To better understand the coverage provided under the HDHP option, it’s important to understand these key terms.​

​To better understand the coverage provided under the HDHP, it's important to know these key terms.

Deductible

The deductible is a specified annual dollar amount you must pay for covered medical services before the plan begins to pay benefits. The HDHP has a much higher deductible than the PPO or EPO.

  • HDHP deductibles are flat amounts, as shown on the Key Provisions chart
  • If you enroll any family members, you are responsible for paying the entire family deductible before the plan pays benefits for care that is not preventive. There is no individual deductible amount that applies when one or more eligible family members are enrolled in the HDHP. 
  • You can reduce your deductibles by completing Call to Health, a well-being initiative that focuses on the four dimensions of wholeness: spiritual, health, financial, and vocational. 
  • Under the HDHP, the deductible applies to all your covered medical expenses — including doctor's office visits — except for 
    • preventive care, which is covered 100 percent when network providers are used; and 
    • certain preventive prescription drugs (see the preventive drug list), for which you pay a flat-dollar copay (see Copay below). 
  • When you enroll in the HDHP, you may set up and contribute to a health savings account (HSA), and use your HSA funds to pay for your deductible and other eligible medical expenses. See the Health Savings Account overview for more details. Your employer may offer an HSA in which you can participate, or you may set up an HSA individually.

Copay 

A copay is a flat dollar amount that you pay upfront for certain services when using network providers. 

Copayment

A copayment is the percentage of the plan allowance for covered services that you pay after meeting the deductible: 

  • Your copayment for network medical services is 20 percent. 
  • Your copayment is 30 percent for non-preventive formulary prescription drugs. 
  • The HDHP does not cover out-of-network care or non-formulary prescription drugs.

Combined maximum out-of-pocket 

The combined maximum out-of-pocket is a specified annual dollar amount you pay for covered medical and prescription services, after which the plan pays 100 percent of allowable costs for the rest of the year. 

  • The HDHP combined maximum out-of-pocket amounts, shown on the Key Provisions chart, reflect the Affordable Care Act maximums. 
  • Unlike the deductible, if any one covered family member's expenses reach the Member-only copayment maximum before the family copayment maximum is reached, the plan will pay 100 percent of allowable charges for that family member for the rest of the year.
  • Expenses that count toward the HDHP combined maximum out-of-pocket include your deductibles, copayments, and preventive prescription drug copays.