Medical out-of-pocket limit

What is the medical out-of-pocket limit?

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

Your medical out-of-pocket limit depends on your enrollee type:

  • Employees and retirees not enrolled in Medicare, including dependents: $2,000 per person and $4,000 per family*
  • Retirees enrolled in Medicare Part A and Part B, including dependents: $2,500 per person and $5,000 per family*

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

Note: Prescription drug costs do not count toward your medical out-of-pocket limit. Learn about your prescription drug out-of-pocket limit.

What counts toward this limit?

What doesn't count toward this limit?

  1. Amounts paid by the plan, including services covered in full.
  2. Your monthly premiums.
  3. Prescription drug costs, including the prescription drug deductible. (Learn about your prescription drug out-of-pocket limit, which is counted separately by Washington State Rx Services.)
  4. Your coinsurance paid to out-of-network providers (note that out-of-network coinsurance does count toward your medical deductible).
  5. Balance billed amounts. 
  6. Services not covered by the plan.
  7. 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 medical out-of-pocket limit.
  8. 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 examples of more benefits with this type of limit.

What will I pay after reaching this limit?

You will still be responsible for paying numbers 2–8 above after you meet your medical out-of-pocket limit. Learn about your prescription drug 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. 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: The 40 percent coinsurance you pay and any balance billed amounts do not count toward your medical out-of-pocket limit. However, the 40 percent coinsurance paid to out-of-network providers does count toward your medical deductible. Balance billed amounts never apply toward your medical deductible.