Costs In Which Members Share
Medical costs are shared on a per person, per incident basis, for illnesses or injuries incurring medical expenses when treated by physicians, urgent care facilities, clinics, emergency rooms, or hospitals (inpatient and outpatient).
Members share these kinds of costs:
- Bills incurred per incident over the Single, Couple, or Family Annual Unshared Amount*
- Inpatient or outpatient hospital treatment or surgery for a medically diagnosed condition
- Doctor’s visits related to each medical incident
- Tier 4 prescriptions used for acute illness for the 45 days following each related medical incident
- Physical therapy and home health care, as limited by the Sharing Guidelines
- Limited sharing for pre-existing conditions for the first 13-36 months of participation
Expenses in which members do not share, including but not limited to:
- Pre-existing conditions for the first 12 months of participation
- Dental/vision services or procedures
- Tier 1-3 prescriptions
- Medical costs that fall below the Single, Couple or Family Annual Unshared Amount*
- Expenses other than accidents, acute illness, or injury within the first 60 days of membership.
See Sharing Guidelines for a complete list of shared and unshared costs.
*A medical expense eligible for sharing must exceed an Annual cumulative Unshared Amount (AUA) of $500 for a single, $1,000 for a couple, $1,500 for a family and is calculated upon each member's enrollment date until their next annual renewal date.