What is an Out-of-Pocket Maximum?
A set dollar amount deemed as the most that you’ll have to pay out-of-pocket during a plan year. It serves as a reassurance that regardless of the out-of-pocket expenses for you in one Plan year, you will never owe more than the set out-of-pocket maximum. Knowing this can help you in budgeting for your healthcare needs.
How is it calculated?
Each time the Plan deems a covered expense your responsibility to pay, these expenses are being applied toward the Out-of-Pocket Max accumulator. Once you accumulate your designated out-of-pocket maximum amount, the Plan will begin to cover benefits without any additional member out-of-pocket costs.
What does this mean?
After the out-of-pocket is met, you will not be responsible for any copays or coinsurances for the remainder of the plan year (January 1 - December).
Each benefit has a set out-of-pocket max for covered services under that particular benefits.
Annual Out-of-Pocket Max per Plan Benefit:
Member copays for drugs covered under the Pharmacy Benefit will be applied to the Pharmacy Out-of-Pocket Max.
Member copays for services and supplies covered under the EPO Benefit will be applied to the EPO Out-of-Pocket Max.
Expenses paid toward the Plus Deductible, health plan premiums, and non-covered services will not be applied toward an out-of-pocket max.
Member’s 20% cost-sharing (coinsurance) for services and supplies covered under the Plus Benefit will be applied to the Plus Out-of-Pocket Max.