Deductible

The amount of money you must pay out of your own pocket before your insurance will start paying/covering for other healthcare expenses. This can be a very small amount or thousands of dollars.

Your deductible can apply to one part of your insurance or all covered benefits depending on your coverage. Call your insurance to get the specifics on if your deductible applies to the following benefits:

  • Prescription benefit – For qualifying prescription drugs
  • Medical benefits – For doctor visits or other procedures
  • DME (Durable Medical Equipment) – For medical supplies that are not drugs like pump supplies, syringes, etc.

A deductible of $3000 means that you must pay $3000 out-of-your-own-pocket before your insurance will start to pay anything. Some or all parts of your insurance (prescriptions, procedures, medical visits, etc.) may require you to meet the deductible first. After the deductible is met then your insurance agrees to pay a percentage of your medical expenses.

A Real World Example of how it Worx

I have a deductible of $3000. My deductible applies to some parts of my insurance, but not other parts. See chart below.

Insurance CoverageDeductible
Medications – Acute (like antibiotic)Deductible applies. 20% after paying deductible
Medications – Chronic (like Insulin)No deductible. 20% co-pay
Medical Office Visits – Acute (for a problem like an infection)Deductible applies. 20% after paying deductible
Medical Office Visits – Preventative (Diabetes check-up)No deductible. 20% co-pay
Durable Medical SuppliesDeductible applies. 20% after paying deductible

Given the explanation above I will pay either all of the cost (where deductible applies) or only 20% of the cost after the deductible is met.

Return to Insurance Primer

Take 10 minutes to understand your insurance. Your own insurance may require that you have to pay a deductible for all covered benefits before they start covering any medical costs. Don’t be surprised: Now that you understand the terminology—Call and ask your insurance provider about your coverage. You should have a help line number on the back of your insurance card or on their list of medical expenses labeled EOB- Explanations of benefits.

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