What Is the Medical Out-of-Pocket Limit?

The medical out-of-pocket limit is the maximum total amount you pay to your network providers for covered medical services during a calendar year; this limit does not include your premium or other expenses listed below. Once you have reached this limit, the plan pays 100% of the allowed amount for covered medical services from preferred providers for the rest of the calendar year.

For employees and retirees not enrolled in Medicare and their dependents, this limit is $2,000 per person or $4,000 per family. For retirees enrolled in Medicare, the limit is $2,500 per person or $5,000 per family. "Family" means all members combined under one subscriber's account.

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 pharmacies. There is no limit to your annual out-of-pocket cost for prescription drugs.

Your medical deductible does count toward your medical out-of-pocket limit. The following costs do not count toward your medical out-of-pocket limit. In addition, you must pay these costs after the limit has been met (except for the prescription drug deductible):

  • Prescription drug deductible.
  • Services and expenses that aren’t covered.
  • Charges for services exceeding benefit maximums. For example, the maximum for adult vision hardware is $150 every two calendar years; charges over $150 do not apply to this limit.
  • Charges for services beyond benefit limits. For example, the benefit limit for spinal and extremity manipulations is 10 visits. Costs for more than 10 visits do not count toward the out-of-pocket limit.
  • Your member coinsurance (40%) paid to out-of-network providers, after your medical deductible is met.
  • Charges that exceed the allowed amount. When an out-of-network provider's billed charge exceeds the allowed amount, the difference between the allowed amount and the provider's billed charge (balance billing) does not apply to the medical out-of-pocket limit, except for dialysis and ambulance services.
  • Prescription drug costs: coinsurance paid for prescription drugs. In the case of non-network pharmacies, any difference between the allowed amount and the pharmacy's billed charges does not apply to this limit.

ALERT! Services by out-of-network providers are never paid at 100%. Even after you reach your medical out-of-pocket limit, you will still pay 40% coinsurance and the provider may balance bill you.

NOTE: For how this worked in 2013, see your plan's 2013 Certificate of Coverage.