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Fiscal Year Medical and Prescription Deductible

All GIC employee/non-Medicare health plans include a deductible, a fixed dollar amount that applies to certain services.

Fiscal Year Medical Deductible

All GIC employee/non-Medicare health plans include a deductible, a fixed dollar amount that applies to certain services. Before the plan will pay for these services, you are responsible for paying your provider(s) up to the deductible maximum. This is a separate charge from any copays. The fiscal year deductible will increase effective July 1, 2017.

In-network fiscal year 2018 medical deductible

The in-network deductible will increase effective July 1, 2017 to $500 per individual and $1,000 per family.

Here is how it works for each coverage level:

  • Individual: The individual has a $500 deductible before benefits begin.
  • Two- or more person family: The family as a whole has a $1,000 maximum deductible before benefits begin, but no single family member will be liable for more than $500 per year.

If you are in Harvard Independence, Tufts Navigator, or UniCare PLUS, there is an additional out-of-network deductible.  This deductible is increasing effective July 1, 2017, to $500 per member, up to a maximum of $1,000 per family. This is a separate charge from the in-network deductible.

The effect of changing plans on your deductible

There is no effect on your deductible for changing plans during Annual Enrollment.  Whether you decide to stay in the same health plan, switch to a different option with the same health plan carrier, or switch to a different health plan carrier, a new deductible will begin July 1.

Health care services that are subject to the medical deductible

The lists below summarize expenses that generally are or are not subject to the annual deductible. These are not exhaustive lists. You should check with your health plan for details. As with all benefits, variations in these guidelines below may occur, depending upon individual patient circumstances and a plan’s schedule of benefits.

Examples of in-network expenses generally exempt from the medical deductible:

  • Prescription drugs Outpatient mental health/substance abuse benefits
  • Office visits (primary care physician, specialist, retail clinics, preventive care, maternity and well baby care, routine eye exam, occupational therapy, physical therapy, chiropractic care and speech therapy)
  • Medically necessary child and adult immunizations
  • Medically necessary wigs
  • Hearing aids
  • Mammograms
  • Pap smears
  • EKGs
  • Colonoscopies

Examples of in-network expenses generally subject to the medical deductible

  • Emergency room visits
  • Inpatient hospitalization
  • Surgery
  • Laboratory and blood tests
  • X-rays and radiology (including high-tech imaging, such as MRI, PET and CT scans)
  • Durable medical equipment

Out of pocket costs

Upon request, plans are required to tell you the amount you will be required to pay before you incur charges. Call your plan or visit their website to get this information.

When you visit a doctor or hospital, the provider should ask you for your copay upfront. After you receive services, your health plan may provide you with an Explanation of Benefits, or you can call your plan to find out which portion of the costs you will be responsible for. The provider will then bill you for any balance owed. Please contact your plan if you have any questions about what you owe.

Fiscal Year Prescription Deductible

All GIC employee/non-Medicare health plans except Fallon Health Direct and Select will include a new separate prescription drug deductible.

Fiscal year 2018 prescription drug deductible

The prescription drug deductible effective July 1, 2017, will be $100 per individual and $200 per family for all plans except Fallon Health Direct and Select. 

If the cost of a drug is less than $100, you will pay the cost of the drug, which will go towards satisfying the deductible.  Once an individual reaches his or her deductible, copays apply.  When the family deductible is reached, copay benefits apply to all family members, even those who have not met their individual deductible. 

Examples: 

Family Member 1 orders a 30-day supply of a brand drug that costs $80.  This family member will pay $80 to the pharmacist and will have a $20 deductible balance.

Family Member 2 orders a 30-day supply of a brand drug that costs $105.23.  The family member will pay the $100 deductible plus the balance of $5.23, because the remaining balance is less than the brand copay of $30.  This family member has satisfied his or her prescription drug deductible and will pay copays only for all future prescription drugs.

Family Member 3 orders a 30-day supply of a brand name drug that costs $200.  This family member will pay the remaining family deductible of $20 (see Family Member 1) plus the $30 copay.  The family’s deductible has been met and all family members will pay a copay for any prescription drugs ordered for the remainder of the fiscal year until they reach their out-of-pocket maximum.

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