What Is the Medical Out-of-Pocket Limit?

The medical out-of-pocket limit is the maximum total amount of coinsurance and copayments you pay to your providers for medical services during a calendar year (see below for expenses not included). The limit is $2,000 per person or $4,000 per family (all family members combined under one subscriber’s account). Once you have reached this limit, the plan pays 100% of the allowed amount for covered medical services from network providers for the rest of the calendar year.

What Doesn’t Count Toward Your Medical Out-of-Pocket Limit

ALERT! Prescription drug costs do not count toward your medical out-of-pocket limit. The only limit to your drug cost is the prescription cost-limit at network retail pharmacies. There is no limit to your annual out-of-pocket cost for prescription drugs.

The following costs are not counted toward your medical out-of-pocket limit, and must be paid even after the limit has been met:

• Medical and prescription drug deductibles.
• Services and expenses that aren’t covered.
• Charges beyond benefit maximums, limits, and the allowed amount.
• Copayments for emergency room care.
• Prescription drug costs: coinsurance, copayments, and ancillary charges paid for prescription drugs.
• Coinsurance or copayments for services for non-network providers, except when the plan pays at the out-of-area rate.

ALERT! What you pay for non-network services does not count toward your medical out-of-pocket limit. Even after you reach this limit, you will still pay 40% coinsurance, plus any difference between the plan’s allowed amount and the provider’s billed charge, for services by non-network providers. Exception: If claims are paid at the out-of-area rate, the plan will pay covered services at 100% of the allowed amount after you’ve met your medical out-of-pocket limit. However, you may still be billed for the difference between the provider’s charge and the allowed amount, unless you were admitted directly to the hospital from the emergency room.