The coinsurance maximum is the maximum amount that a family has to pay in coinsurance for covered medical expenses in a calendar year before benefits will be paid at 100 percent of the allowable charge. If an enrollee has family coverage, there is no separate coinsurance maximum for each individual. The family coinsurance maximum also applies when both husband and wife are covered separately as enrollees, one of the enrollees has family coverage, and both are enrolled in Base Coverage. The amount paid toward meeting the calendar year medical deductible, preventive medications deductible, telehealth provider visit copayments, emergency room copayments, and prescription drug copayments do not count toward satisfying the coinsurance maximum.
The initial $5,500 of coinsurance is applied to both the network and out-of-network coinsurance maximum. After the initial $5,500 has been applied, only the coinsurance amount for services rendered by out-of-network providers will be applied to the additional $2,000 out-of-network coinsurance maximum.