The out-of-pocket limit is the maximum amount that a family has to pay for network deductible, coinsurance and copayments for covered medical expenses in a calendar year before benefits will be paid at 100 percent. The network out-of-pocket maximum protects a family from having to pay catastrophic medical bills in a given year. There is no family out-pocket-limit for out-of-network services.
Do these expenses count toward Out-of-Pocket Limit?
Included in Out-of-Pocket Limit | Not Included in Out-of-Pocket Limit |
|---|---|
✔ Network calendar year deductibles | ❌ Expenses in excess of the allowable charge |
✔ Office visit copayments | ❌ Expenses in excess of Plan maximum limits |
✔ Telehealth provider visit copayments | ❌ Utilization review penalties |
✔ Prescription drug deductible | ❌ Services not covered by the Plan including those found in the Limitations and Exclusions section |
✔ Prescription drug copayments | ❌ Generic drug differential amounts |
✔ Emergency room copayments | ❌ Services not considered medically necessary |
✔ Network coinsurance paid for hospital inpatient services | |
✔ Network coinsurance paid for other covered medical expenses |