Embedded Deductible In a health plan with an embedded deductible, no single individual on a family plan will have to pay a deductible higher than the individual deductible amount. Once you meet the individual deductible, your plan’s coinsurance is applied. Embedded Out-of-Pocket Maximum In a health plan with an embedded out-of-pocket maximum, no single individual on a family plan will have to pay more than the individual out-of-pocket maximum amount. Once you meet the individual out-of-pocket maximum amount, your plan begins to pay 100% for the individual’s expenses for the remainder of the year. High-Deductible Health Plan (HDHP) HDHPs cover preventive care before the deductible - the Affordable Care Act (ACA) requires this of all plans - but under an HDHP, no other benefits are provided until the insured has met the deductible. That means HDHPs cannot cover office visits or prescriptions that do not qualify as preventive prior to the deductible being met (as opposed to a plan that has a high deductible but also requires only a copay for office visits). After you meet your deductible, you and the plan will pay the plan’s coinsurance. Preferred and Non-Preferred Medications A non-preferred medication is a brand name prescription drug that is not included in the insurance carrier’s formulary (list of preferred prescription drugs). Preferred medications, both generic and brand name, are chosen for their cost, effectiveness and their safety. Non-preferred medications will cost you more than preferred medications. Out-of-Pocket Maximum The out-of-pocket maximum is a specific limit for the total amount you will pay each year (includes amounts applied as copays, deductible and coinsurance) before the plan pays 100% of the covered services for the remainder of the year.
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