Cost Sharing Made Clear

Tufts Health Direct has a cost-sharing structure, meaning you pay for a portion of your health care costs not covered by Tufts Health Plan. The amount or percentage you pay depends on your plan level.

Here are some key definitions and explanations to help you understand your health plan costs. See specific costs for your plan level.

Annual deductible
Your annual deductible is an amount you may need to pay each benefit year before we will pay for covered services. You may need to pay part or all of your medical bill(s) until you reach your total annual deductible. 

If you have a family plan, your family annual deductible is the combined amount individuals within your family must pay before we will pay for covered services. You need to reach your total family annual deductible before we will pay for covered services for all members enrolled under your family plan.

Annual medical out-of-pocket maximum
Your annual medical out-of-pocket maximum is a limit on the amount you need to pay for covered medical services within a benefit year. All Tufts Health Direct members have an annual out-of-pocket maximum. Your annual deductibles (if applicable), medical co-insurance, and medical co-payments all contribute to this maximum amount.

Once you reach your full annual medical out-of-pocket maximum, we will pay for covered services for the remainder of the benefit year and you no longer need to pay co-payments or co-insurance for covered medical services. Keep in mind, once you reach your full annual medical out-of-pocket maximum, you are still responsible for your monthly premiums.

If you have a family plan, and a medical out-of-pocket maximum, your family out-of-pocket maximum combines the annual deductibles, medical co-insurance, and medical co-payments paid by covered family members. For all members enrolled under a family plan, once the family reaches the full annual medical family out-of-pocket maximum, no one in your family plan will need to pay for covered medical services for the rest of the benefit year. Keep in mind, once you reach your full family annual medical out-of-pocket maximum, you are still responsible for your monthly premiums.

Annual pharmacy out-of-pocket maximum
Your annual pharmacy out-of-pocket maximum is a limit on the amount you need to pay for covered prescription drugs within a benefit year. All Tufts Health Direct members have an annual pharmacy out-of-pocket maximum. Your annual pharmacy deductibles (if applicable), pharmacy co-insurance, and pharmacy co-payments all contribute to this maximum amount. Your monthly premium, medical co-payments, and medical co-insurance do not apply toward this maximum amount.

Once you reach your annual pharmacy out-of-pocket maximum, you no longer need to pay pharmacy co-payments or pharmacy co-insurance for covered pharmacy services. We will pay for covered pharmacy services for the remainder of the benefit year. However, you will still need to pay your monthly premiums.

If you have a family plan, your family annual pharmacy out-of-pocket maximum combines the annual deductibles, pharmacy co-insurance, and pharmacy co-payments paid for pharmacy services by covered family members. For all members enrolled under a family plan, once your family reaches your total family annual pharmacy out-of-pocket maximum, no one in your family plan will need to pay for covered pharmacy services for the rest of the benefit year.

Benefit year
A benefit year is the consecutive 12-month period during which your health plan benefits are purchased and administered.

Note: In some cases, your first benefit year will not be a full 12 months.

Co-insurance
Co-insurance is a percentage of the cost of a service, which you may pay for covered services or prescriptions. For example, if you have 20% co-insurance for a $100 covered medical service, you will owe $20 at the time of the service.

Co-payment
A co-payment is a fixed amount you may pay for covered services or prescriptions. All plan levels have co-payments.

What is a medical co-payment?

A medical co-payment is a fixed amount you may have to pay for a covered service other than pharmacy. You may need to pay a co-payment for covered services, like doctors' visits and nonemergency hospital care.

What is a pharmacy co-payment?

A pharmacy co-payment is a fixed amount you may have to pay for covered prescription drugs.

Integrated annual deductible
A deductible is the amount that you must pay toward covered health care services before we will begin paying. An integrated annual deductible is when your payments for either medical or pharmacy services both apply toward your deductible. For example, if you have a $500 integrated annual deductible, and spend $400 for medical costs and $100 for pharmacy costs, you have met your $500 integrated annual deductible.

Once you've met your integrated annual deductible, you only have to pay pharmacy or medical co-insurance or pharmacy or medical co-payments until you reach your total integrated out-of-pocket maximum.

If you have a family plan, your family integrated annual deductible combines your annual medical and pharmacy deductibles by covered family members. For all members enrolled under a family plan, once your family reaches your total family integrated annual deductible, members of your family will only have to pay pharmacy or medical co-insurance or pharmacy or medical co-payments until you reach your total integrated out-of-pocket maximum.

Note: Your monthly premiums do not contribute toward your integrated deductible.

Integrated annual out-of-pocket maximum
An integrated annual out-of-pocket maximum is the maximum amount you pay in a benefit year for both medical and pharmacy covered services.

Once you reach your annual out-of-pocket maximum, you no longer need to pay co-payments or co-insurance for covered medical services. We will pay for covered medical services for the remainder of the benefit year. However, you will still need to pay your monthly premiums. Your monthly premiums do not contribute toward this maximum amount. If your plan level does not have an integrated annual out-of-pocket maximum, then your plan may have an annual medical out-of-pocket maximum and a separate pharmacy annual out-of-pocket maximum.

If you have a family plan, your family integrated annual out-of-pocket maximum combines any annual medical and pharmacy deductibles, co-insurance, and co-payments paid for services by covered family members. For all members enrolled under a family plan, once your family reaches your total family integrated annual out-of-pocket maximum, no one in your family plan will need to pay for covered services for the rest of the benefit year.

Premium
Your premium is your monthly contribution to pay for your health plan coverage.

If you are not part of a group:

  • Your premium is determined based on your age, residence, plan level, and type of coverage. Check your monthly invoice to see what your premium is.
  • You should receive a monthly invoice in the mail, unless you set up electronic billing at the time of your enrollment.

If you are part of a group:

  • Your premium is determined based on your employer's selected plan level, your type of coverage, and additional factors.
  • Your employer may pay part or all of your premium.
  • Your group may ask you to pay a portion of your monthly premium to them, in which case your group will pay the full premium to Tufts Health Plan.

Questions about this amount or your payment options? Please call the number listed on your invoice, or talk to your employer (if you are part of a group).

Find more information and definitions in your Tufts Health Direct Member Handbook 2018 (PDF). Or call us at 888.257.1985. We're happy to help.

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