$60. If the member’s coverageincludes a $10 copaymentfor that particular prescription drug, the participating pharmacywill collect $10 from the memberat the time the prescription drugis dispensed. This copaymentis part of the allowable amountfor the benefitprovided under the member’s coverage. Since the participating pharmacyalready received $10 from the member, Capital, through its PBM, will reimburse the participating pharmacya maximum of $50 for the prescription drug. The participating pharmacystill receives the total
allowable amountof $60; it is just shared between the memberand Capital. In this example, payment for the claim is calculated as follows:
Subtract the copaymentpaid by the memberfrom the allowable amountto determine Capital’spayment to the
participating pharmacy($60 – $10 = $50).
The memberin this example would be responsible for paying the participating pharmacy$10, and Capital
would be responsible for paying the participating pharmacy$50. So, in the end, the participating pharmacy
receives a total of $60 (the allowable amount).
Membersshould refer to the Summary of Cost-Sharing and Benefitssection of this Certificate of Coverageto determine if any copaymentsapply to their coverage.
D
EDUCTIBLEA deductibleis a dollar amount that an individual memberor a subscriber’s entire family must incur before
benefitsare paid under this coverage. The allowable amountthat Capitalotherwise would have paid for benefits
is the amount applied to the deductible. Depending on the member’s coverage, there may be a deductibleamount applicable only to benefitsreceived for services provided by participating providers and a separate deductible
amount applicable only to benefitsreceived for services provided by non-participating providers.
For Example: The charge for a particular health care service provided by a participating provideris set by the
participating provider’scontract with Capitalto pay at anallowable amountof $60. If the subscriber’s coverageincludes a $500 single coverage deductiblefor participating provider benefits, and assuming a
copaymentis not applied, the memberis responsible for this $60. The participating providerwill collect this amount from the member. Capital will then apply this $60 towards the $500 single coverage deductible
applicable to the subscriber’s coverage. So, on the subscriber’s$500 single coverage deductible, the remaining
deductibleamount which must be met would be $440.
In this example, payment for the claim is calculated as follows:
Subtract the allowable amountfrom the subscriber’stotal deductible amount to determine the remaining
deductible amount the subscribermust meet ($500 - $60 = $440).
For Example: The allowable amount for a particular prescription drugprovided by a participating pharmacyis $60. If the subscriber’s coverageincludes a $500 single coverage deductiblefor participating pharmacy benefits, the subscriberis responsible for this $60. The participating pharmacy will collect this amount from the subscriberat the time the prescription drug is dispensed. Capital will then apply this $60 towards the $500 single coverage deductibleapplicable to the subscriber’s coverage. So, on the subscriber’s$500 single coverage deductible, the remaining deductibleamount which must be met would be $440.
In this example, payment for the claim is calculated as follows:
Subtract the allowable amountfrom the subscriber’stotal deductible amount to determine the remaining
deductible amount thesubscribermust meet ($500 - $60 = $440).
For each deductibleamount (participating and non-participating) that may apply to this coverage, one (1) of two (2) deductible amounts will apply: a single coverage deductibleor a family coverage deductible. If only the
subscriberis covered under the group contract, then the subscriber must satisfy the single coverage deductible
applicable to this coverageevery benefit periodbefore benefitsare paid. When the subscriber and one or more
coverage must be met every benefit periodbefore benefitsare paid. In calculating the family coverage deductible,
Capitalwill apply the amounts satisfied by each membertowards the family coverage deductible.
Membersshould refer to the Summary of Cost-Sharing and Benefitssection of this Certificate of Coverageto determine if any deductiblesapply to their coverage.
C
OINSURANCECoinsuranceis the percentage of the allowable amountpayable for a benefit that membersare obligated to pay. Depending on the member’s coverage, the coinsurancemay be calculated as two separate percentages: one for
benefits received for services provided by participating providers; and one for benefitsfor services provided by
non-participating providers.
For Example: The charge for a particular health care service provided by a participating provideris set by the
participating provider’scontract with Capitalto pay at anallowable amountof $60. Assuming no copayment
is applied, any applicable deductiblehas been met, and the member’s coverageincludes a 10% coinsurancefor
participating providerservices, the allowable amountof $60 will be multiplied by 10%, which equals $6. This $6 will then be subtracted from the allowable amountof $60, leaving $54, which Capitalwill reimburse the
participating provider. The participating provider will then collect the $6 from the member. In this example, payment for the claim is calculated as follows:
1. Multiply the allowable amountby the coinsurancepercentage to determine the member’sliability ($60 x 10% = $6).
2. Subtract the coinsurance amount from the allowable amountto determine Capital’spayment to the
participating provider($60 – $6 = $54).
The memberin this example would be responsible for paying the participating provider$6, and Capital would be responsible for paying the participating provider$54. So, in the end, the participating providerreceives a total of $60 (the allowable amount).
For Example: The allowable amount for a particular prescription drug provided by a participating pharmacyis $60. Assuming any applicable deductiblehas been met, and the member’s coverageincludes a 10%
coinsurance, the allowable amountof $60 will be multiplied by 10%, which equals $6. This $6 will then be subtracted from the allowable amountof $60, leaving $54, which will be reimbursed to the participating pharmacy. The participating pharmacy will then collect the $6 from the memberat the time the prescription drug is dispensed.
In this example, payment for the claim is calculated as follows:
1. Multiply the allowable amountby the coinsurancepercentage to determine the member’sliability ($60 x 10% = $6).
2. Subtract the coinsurance amount from the allowable amountto determine Capital’spayment to the
participating provider($60 – $6 = $54).
The memberin this example would be responsible for paying the participating provider$6, and Capital would be responsible for paying the participating provider$54. So, in the end, the participating providerreceives a total of $60 (the allowable amount).