Tufts Health Direct health care costs

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

If your employee has a family plan, their family annual medical deductible is the combined amount individuals within their family must pay before we will pay for covered services. Your employee needs to reach their total family annual medical deductible before we will pay for covered services for all members enrolled under their family plan.

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

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

If your employee has a family plan, and a medical out-of-pocket maximum, their 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 their family plan will need to pay for covered medical services for the rest of the benefit year. Keep in mind, once your employee reaches their full family annual medical out-of-pocket maximum, they are still responsible for their monthly premium.

Your employee's annual pharmacy out-of-pocket maximum is a limit on the amount they 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 employee's annual pharmacy deductibles (if applicable), pharmacy co-insurance, and pharmacy co-payments all contribute to this maximum amount. Your employee's monthly premium, medical co-payments, and medical co-insurance do not apply toward this maximum amount.

Once your employee reaches their annual pharmacy out-of-pocket maximum, they 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, they will still need to pay their monthly premiums.

If your employee has a family plan, their 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 their family reaches their total family annual pharmacy out-of-pocket maximum no one in their family plan will need to pay for covered pharmacy services for the rest of the benefit year.

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

Note: In some cases, their first benefit year will not be a full 12 months. Your Member Handbook explains situations that may shorten the length of your benefit year.

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

Copayments are set dollar amounts that your employees are responsible to pay for certain Covered Services

Your employee's premium is their monthly financial contribution to pay for their health plan coverage.

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