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The out-of-pocket limit is the most you pay during a calendar year for covered services from preferred and participating providers. Once you meet this limit for the year, the plan pays for covered services by preferred and participating providers at 100 percent of the allowed amount.
Expenses are counted from January 1, 2018, or your first day of enrollment (whichever is later); through December 31, 2018, or your last day of enrollment (whichever is first).
Your out-of-pocket limit depends on the number of persons covered on the account.
- One person covered: $4,200.
- Two or more persons covered: $8,400. Once an individual meets $6,850 in covered out-of-pocket expenses annually, the plan will pay for covered services at 100 percent for that individual.
- Your coinsurance paid to preferred and participating providers.
- Your out-of-pocket costs for covered prescription drugs and products.
- Your deductible.
For exceptions, see “Exceptions: Out-of-network provider services that count” below.
- Amounts paid by the plan, including services covered in full.
- Your monthly premium.
- Non-network pharmacy charges that exceed the allowed amount.
- Balance billed amounts.
- Your coinsurance paid to out-of-network providers (note that out-of-network coinsurance does count toward your deductible).
- Services not covered by the plan.
- Amounts that are more than a maximum dollar amount paid by the plan. For example, the plan pays a maximum of $150 for adult vision hardware once every two calendar years. Any amount you pay over $150 does not count toward the out-of-pocket limit.
- Amounts paid for services exceeding a benefit limit. For example, the benefit limit for acupuncture is 16 visits. If you have more than 16 acupuncture visits in one year, you will pay in full for those visits and what you pay will not count toward this limit.
Note: You will still be responsible for paying numbers 2–8 above after you meet your out-of-pocket limit.
Services by out-of-network providers are paid by the plan at 60 percent of the allowed amount (see below for exceptions). Even after you meet your out-of-pocket limit, you will pay 40 percent coinsurance for out-of-network provider services and the provider may still balance bill you.
Exceptions: out-of-network provider services that count
For dialysis, the plan will pay 100 percent of the network rate after you meet your medical out-of-pocket limit.
For the services listed below only, your coinsurance and balance billed amounts for out-of-network provider services will count toward your out-of-pocket limit. In addition, the plan will pay 100 percent of billed charges for these services after you meet your out-of-pocket limit.
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