Out-of-Pocket Maximum

Provider Type

  • Physicians
  • Hospitals 
  • Ancillary

When the member's total copayments, coinsurance and applicable deductible payments during any calendar or plan year, equal the out-of-pocket maximum (OOPM) listed in the Schedule of Benefits , no further deductibles (if applicable), copayments or coinsurance are required from the member for the remainder of that calendar or plan year.

Eligible copayments or coinsurance amounts paid by the member for services provided through the PPO plan apply towards the OOPM for out-of-network providers. In addition, the coinsurance paid for services provided through out-of-network providers applies towards the OOPM for PPO. Refer to the Schedule of Benefits for plan exceptions.