Medical out-of-pocket limit

Prescription drugs do not count toward your medical out-of-pocket limit.

About drug out-of-pocket limit

How your medical out-of-pocket limit works

The medical out-of-pocket limit is the most you pay in a calendar year for covered services from preferred providers. Once you meet this limit for the year, the plan pays 100 percent of the allowed amount for covered services from preferred providers.

Enrollee type Amount
Employees and retirees not enrolled in Medicare, including dependents $2,000 per person
$4,000 per family* (2 or more enrolled)
Retirees enrolled in Medicare Part A and Part B, including dependents $2,500 per person
$5,000 per family* (2 or more enrolled)

*Family means all members combined under one subscriber's account.

What counts toward this limit?

What doesn't count toward this limit?

  1. Amounts paid by the plan, including services covered in full (preventive).
  2. Prescription drug costs, including the prescription drug deductible. (Learn about your prescription drug out-of-pocket limit, which is counted separately.)
  3. Your coinsurance paid to out-of-network providers (out-of-network coinsurance does count toward your medical deductible).
  4. Balance billed amounts. See "Exceptions: Out-of-network provider services that count" below.
  5. Services not covered by the plan.
  6. Amounts 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 medical out-of-pocket limit.
  7. 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. See limited benefit for more benefits with this type of limit.

What you pay after reaching your medical out-of-pocket limit

You will still be responsible for paying numbers 2–7 above after you meet your medical out-of-pocket limit.

You still pay for out-of-network provider services

Services by out-of-network providers are paid by the plan at 60 percent of the allowed amount (unless noted below for exceptions). Even after you meet your medical out-of-pocket limit, you will pay 40 percent coinsurance for out-of-network provider services and the provider may balance bill you.

Note that the 40 percent you pay and balance billed amounts paid to out-of-network providers do not count toward your medical out-of-pocket limit. However, amounts paid to out-of-network providers up to the plan's allowed amount do count toward your medical deductible. Balance billed amounts never apply toward your medical deductible.

Exceptions: Out-of-network provider services that count

In certain cases, your coinsurance and balance billed amounts for out-of-network provider services will count toward your medical out-of-pocket limit. In addition, the plan will pay 100 percent of billed charges for these services after you meet your medical out-of-pocket limit.

  • Ambulance
  • Dialysis
  • Services for which you have an approved network waiver.
  • Cochlear Implant Processor Supplier.
  • Ocularists (creation and fitting of prosthetic eyes)