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HOW DO PLANS
CALCULATE BENEFITS?
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The plan that pays first will calculate benefits as though duplicate coverage does not
exist. In other words, it will process the claim as it would any other claim.
The plan that pays second calculates benefits for each individual item on the claim,
based on the lowest of:
• The amount that would have been payable had it been the first plan, or
• 100% of the eligible expenses minus the benefits paid by the first plan.
The combined payment from all plans cannot exceed 100% of the eligible medical or
dental expenses. In some cases, the combined payment from all plans may be less
than what you have paid out of your pocket.
Some plans limit the number of visits per year to a health/dental practitioner (e.g.,
once per nine months) and some plans have an annual dollar maximum. In these
cases, when a plan (first and/or second) pays out any benefit for the visit, it will
count as a visit and towards any maximums under both plans.
