Your Costs for Care
What Is the Out-of-Pocket Limit?
The out-of-pocket limit is the maximum total amount you pay to your network providers for covered services and prescription drugs during a calendar year (see below for expenses not included). The limit is $4,200 for one person on an account, or $8,400 when more than one person is covered on an account. Once you have reached this limit, the plan pays 100% of the allowed amount for covered services from network providers for the rest of the calendar year.
Your deductible does count toward your out-of-pocket limit. The following costs do not count toward your out-of-pocket limit, and must be paid even after the limit has been met:
- Services and expenses that aren't covered.
- Ancillary charges for prescription drugs.
- Charges for services exceeding benefit maximums. For example, the maximum for vision hardware is $150 every two calendar years; charges over $150 do not apply to this limit.
- Charges for services beyond benefit limits. For example, the benefit limit for chiropractic care is 10 visits. Costs for visits you receive over 10 do not count toward the out-of-pocket limit.
- Your member coinsurance (40%) paid to non-network providers after your deductible is met.*
- Charges that exceed the allowed amount. When a non-network provider's billed charge exceeds the plan's allowed amount, the difference between the allowed amount and the provider's billed charge does not apply to the out-of-pocket limit, except for dialysis and ambulance services.
- Prescription drug costs that exceed the allowed amount: If you get covered drugs from a non-network pharmacy and the pharmacy charges you more than the plan's allowed amount, the plan covers only up to the allowed amount.
* This is a change from the UMP CDHP 2012 Certificate of Coverage: your member coinsurance paid to non-network providers does apply to your out-of-pocket limit.
