Annual Out-of-Pocket Limits

Out-of-pocket limits provide financial protection for you, by limiting certain cost-sharing amounts you must pay for Allowable Charges in a calendar year. The Plan applies two types of out-of-pocket limits, which have different amounts and take into account different expenses. These two limits are described below.

INP

PPO

OON 

Medical Out-of-Pocket Limit
(calendar year)
$2,000 per person
$4,000 per family
(applies for ER)
$4,000 per person
$8,000 per family
$12,000 of AC per person
$24,000 of AC per family
Combined Medical/Prescription Out-of-Pocket Limit
(calendar year)
$6,850 per person
$13,700 per family
None

The following information summarizes how the out-of-pocket limits work:

  • For the “per person” limits, the amounts you pay during the year that are subject to an out-of-pocket limit are added up throughout the year. For the “per family” limits, the amounts you pay for each person in the family are added together throughout the year. When you reach an applicable out-of-pocket limit, you are not required to pay additional amounts subject to the applicable limit for the remainder of the year.
  • The medical out-of-pocket limit does not include copays or prescription drugs.
  • Neither the medical out-of-pocket limit nor the combined medical/prescription out-of-pocket limit include:

    • The 25% benefit penalty (100% benefit penalty for transplants) for preauthorization non-compliance (if required for a specific service)
    • The 40% penalty for Care Coordination non-compliance (if required)
    • The 40% penalty for using a provider that is not a Plan-approved Center of Expertise (if required)
    • Premiums
    • Amounts paid above Allowable Charges
    • Covered services not considered essential health benefits by federal law (such as chiropractic and acupuncture)
    • Any reduction in the amounts you are required to pay by a provider or manufacturer, such as through a coupon, rebate, credit, discount, or similar arrangement
    • Expenses that exceed benefit limits set by the Medical Plan or Prescription Drug Plan or that are not otherwise eligible for coverage

  • The out-of-pocket limits are combined for INP and PPO, but not for OON; in other words, your INP expenses apply to the PPO limits, and vice versa.

Example of how the medical limit works: Carl, his wife Helen, and his daughter Julia have all been incurring PPO medical expenses throughout the year. When they add up the Allowable Charges they have paid toward deductible and coinsurance, they see their progress toward their out-of-pocket limit:

  • Carl: $300 (deductible) + $1,000 (coinsurance) = $1,300
  • Helen: $300 (deductible) + $3,000 (coinsurance) = $3,300
  • Julia: $200 (deductible) + $3,200 (coinsurance) = $3,400

While no one in Carl’s family has reached their $4,000 PPO individual medical out-of-pocket limit, collectively Carl’s family has paid $8,000 in deductible plus coinsurance, thus reaching the family medical out-of-pocket limit. For the rest of the calendar year, there will be no cost to Carl for PPO and INP Allowable Charges subject to the medical limit incurred by his family.


Example of how the combined medical/prescription limit works: So far during the year, Jan has paid Allowable Charges of only $3,000 in deductible and coinsurance for PPO medical expenses, so she has not yet met the $4,000 medical limit. However, she has also been using several very expensive prescription drugs; her in-network prescription drug coinsurance payments so far during the year add up to $3,850. Therefore, she has reached the $6,850 combined medical/prescription limit. For the rest of the calendar year, there will be no cost to Jan for PPO and INP Allowable Charges subject to the combined limit, as well as in-network prescription drug expenses.

In addition, Jan has twin sons who both have required several very expensive prescription drugs. Their in-network prescription coinsurance payments so far during the year add up to $3,850 for Tony and to $3,000 for Tom. While neither Tony nor Tom have reached their $6,850 individual combined limit, collectively their out-of-pocket expenses plus Jan’s $6,850 adds up to $13,700. Thus, the family has reached the combined medical/prescription limit. For the rest of the calendar year, there will be no cost to Jan for PPO and INP Allowable Charges subject to the combined limit, as well as in-network prescription drug expenses, incurred by her family.


Covered services not considered essential health benefits by federal law are not included in the medical out-of-pocket limit, nor are they included in the combined medical/prescription limit. For more information about essential health benefits, see https://www.cms.gov/cciio/resources/data-resources/ehb.html. Following are examples of services that are covered by the Plan (subject to certain limits) but that are not essential health benefits:

  • Chiropractic care
  • Acupuncture
  • Private-duty nursing

Non-essential health benefits example: Mike takes several very expensive prescription drugs and also gets regular chiropractic treatments from a PPO provider. After 10 months, he has paid $6,000 of Allowable Charges in prescription drug coinsurance, and he has paid $1,000 of Allowable Charges in deductible and coinsurance for chiropractic treatments. The $6,000 for prescription drugs does not apply toward the medical out-of-pocket limit, but it does apply toward the combined medical/prescription out-of-pocket limit. The $1,000 for chiropractic does not apply to either limit. Therefore, Mike has met neither the $4,000 medical limit nor the $6,850 combined limit.