Deductibles, Copayments and Coinsurance

Depending on your benefit plan, your out-of-pocket costs may include copayments, deductibles and coinsurance.
Note: Your benefits may vary in the following examples.


A deductible is a fixed dollar amount you must pay.
Charges that are not covered don’t count toward the deductible.
Example: Individual and family deductible limits ranging from $500 to $5,000 are common. Note: There may be separate deductibles for services received from in-network providers and services received from non-network providers. If you use both in-network and out-of-network services, you must pay both deductibles.


A copayment is the fixed dollar amount you pay up front when you receive a health care service or pick up a prescription. Different services often have different copays.
Example: $50 for an emergency room visit, $25 for an office visit and $15 for a prescription.
If the charge is less than the copay, you pay the smaller of the two.


Coinsurance is the percentage of the covered amount that you pay.
Example: You have 80/20 coverage for outpatient surgery.
The health plan pays 80% of covered charges. Your coinsurance is 20%.

Out-of-pocket maximum

This is the total amount you may have to pay in deductibles, copays and coinsurance during the contract year or calendar year covered by your health plan.*
There are individual and family out-of-pocket maximums. The out-of-pocket maximum may be calculated on a calendar year or a contract year, depending on your health plan.
* To tell whether you are on a contract-year or calendar-year plan, check your Member materials or call Customer Service.
Out-of-pocket maximums are calculated separately for covered in-network/out-of-network services. Once the maximum is met, your health plan pays 100% of covered charges up to the maximum.
Note: If you use in-network and out-of-network services, you are responsible for paying the in-network out-of-pocket maximum and an additional out-of-pocket maximum for out-of-network services. Out-of-network services not covered by your health plan do not count toward the out-of-network, out-of-pocket maximum.
Out-of-network charges that are above the non-network provider reimbursement amount do not count toward the out-of-network out-of-pocket maximum.

If you pay more than the out-of-pocket maximum

Call Valley Benefits.

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