The deductible is the amount that members must pay before their plan starts sharing costs.The out-of-pocket maximum (OOPM) is the most a member will pay in a year for covered services; after that, the plan pays 100%.
To find what care costs are subject to your deductible & OOPM, refer to the Summary of Benefits and Coverages (SBC) and/or Summary Plan Description (SPD) in your Documents center.
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Pre-deductible benefits refer to services that are covered by the plan before you meet your deductible. These often include preventive services (like annual check-ups and certain screenings) that are covered at no cost, as well as copays for things like office visits or prescriptions, depending on your plan.
- Post-deductible benefits refers to the coinsurance benefits that may activate once a member reaches the plan deductible. Coinsurance amounts are determined by the plan a member is enrolled in.
To view your deductible and out-of-pocket maximum progress, log in to your Sana Portal and refer to the Medical Spend section on the Dashboard.
Family Deductibles and Out-of-Pocket Maximums
Family plans have both individual deductibles & out-of-pocket maximums, which apply to each person, and a family deductible & out-of-pocket maximum, which apply to all family members. Here is a further breakdown:
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Individual deductible: Each member has their own deductible. Once a member meets their individual deductible, their post-deductible benefits (coinsurance) begin, even if the family deductible has not yet been met.
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Individual Out-of-Pocket Maximum (OOPM): Each member also has their own out-of-pocket maximum. Once a member reaches their individual OOPM through their own spending (deductibles, coinsurance, copays), they no longer owe additional cost-sharing for covered services. The plan covers 100% of their eligible expenses for the rest of the year, even if the family OOPM has not yet been met.
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Family deductible: All family members’ expenses count toward the family deductible. Once the family deductible is met, all members on the plan can access post-deductible benefits, even if they haven’t met their own individual deductible.
- Family Out-of-Pocket Maximum (OOPM): Once the family out-of-pocket maximum is reached, no one on the plan owes additional cost-sharing for covered services, regardless of whether they’ve met their individual OOPM.
Embedded Cost-Sharing Example
Consider an E35 plan that covers a family of 4 (Employee + Spouse + 2 Children), with the following deductibles, OOPMs, and 30% coinsurance:
| Type | Amount | What Happens When Reached |
| Individual deductible | $3,500 | The member pays 30% of services (coinsurance) until their OOPM is reached. |
| Individual OOPM | $7,500 | The plan pays 100% of services for that member until the end of the policy year. |
| Family deductible | $7,000 | Once met, all members pay 30% of services until their OOPM or Family OOPM is reached. |
| Family OOPM | $15,000 | Once met, the plan pays 100% of services for all members until the end of the policy year. |
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