Important:  This information is effective through Dec. 31, 2009. See the changes to coinsurance, medical deductible, and out-of-pocket limit for 2010.

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 out-of-pocket for medical services during a calendar year. The limit is $1,500 per person or $3,000 per family (all family members combined under one subscriber’s account). Once you have reached this limit, UMP pays 100% of the UMP allowed amount for covered medical services from network providers for the rest of the calendar year.

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

The following costs are not counted toward your annual medical out-of-pocket limit:

• Annual medical and prescription drug deductibles.

• Services that aren’t covered because you didn’t comply with medical review or preauthorization requirements.

• Charges beyond benefit maximums, limits, and the UMP allowed amount.

• Charges for expenses that aren’t covered.

• Copayments for emergency room care.

• Coinsurance, copayments, and ancillary charges for prescriptions filled at retail and mail-order pharmacies.

• Coinsurance or copayments for services for non-network providers, except when UMP pays at the out-of-area rate.

Note: Once you’ve met your annual medical out-of-pocket limit, you must still pay the costs listed above (except for the medical deductible). The medical out-of-pocket limit does not apply to services from non-network providers.

Exception: If you don’t have access to a network provider and the claim is paid at the out-of-area rate, UMP will pay 100% of the allowed amount after you have met your annual medical out-of-pocket limit. If the provider bills more than the UMP allowed amount, you will still be responsible for paying the difference, unless you were admitted to the hospital as a result of an emergency room visit.