This document provides an overview of deductibles, caps, and out-of-pocket maximums (DCO) in health insurance plans. It defines these terms and explains how they work, including how they can be applied at the individual and family level. It also discusses different options for setting DCO benefits based on claim type, accumulation periods, and specific drugs. Plan administrators can leverage DCO functionality to steer member behavior through penalties and exclusions.

1. Deductibles, CAPs, Out-of-Pocket (OOP)

4. DCO Plan Phase Examples Basic DED, CAP and OOP only Complex DED, CAP, OOP, Life Time Cap and Rx Specific CAP

6. Individual with Family Example Claims are applied to each member with a family total or limit. This is also knows as embedded benefits. No member will pay more than the individual limit and no family will pay more then the family limit. $50 Dollar Individual Limit $75 Family Limit No member will pay more than the individual limit and no family will pay more then the family limit.

7. Individual Only Each claim applied to each member’s individual accumulation. Each member must meet their individual accumulation before moving to next phase.

8. Family Only Claims are applied to a family limit only. Once the family limit is meet every member will move into the next benefit phase .

9. Individual or Family (Non Embedded) Members in the same group either have a individual or family limit based on eligibility coverage code. Individual Coverage Code Family Coverage Code

11. Channel Example Retail Only. Retail claims would apply to accumulation. Mail Claims would bypass phase. Mail Only. Mail claims would apply to accumulation. Retail Claims would bypass phase. Retail Mail Combined. Retail and Mail claims would apply to same accumulation. Retail Mail Separate. Retail apply to retail accumulation and Mail apply to mail accumulation.