Summary Plan Description

Out-of-Pocket Maximums

The out-of-pocket maximums are the most a patient or family pays during the calendar year for certain covered medical expenses.

Medical

Each person covered under the plan has his or her own $4,000 out-of-pocket maximum. The following expenses accumulate towards the medical out-of-pocket maximum:

  • Network coinsurance – $2,300/person and $4,600/family.
  • Annual deductible – $200/person and $400/family.
  • Network office visit copayment – $10/office visit.
  • Emergency room copayment – $50/visit.

When you and your dependents have paid a combined out-of-pocket maximum of $8,000 in a calendar year for the out-of-pocket expenses listed above, no further out-of-pocket payment for these expenses is required for any family member during that calendar year. Out-of-pocket expenses incurred from non-network providers do not apply to these out-of-pocket maximums.

Prescription

Each person covered under the plan has his or her own $2,850 out-of-pocket maximum. The following expenses accumulate towards the prescription out-of-pocket maximum:

  • Retail pharmacy copayments.
  • Mail order copayments.
  • Retail Refill Allowance (RRA) coinsurance.

When you and your dependents have paid a combined out-of-pocket maximum of $5,700 in a calendar year for the out-of-pocket expenses listed above, no further out-of-pocket payment for these expenses is required for any family member during that calendar year.

Expenses Not Included In Out-of-Pocket Maximums

In addition to the annual deductible, coinsurance and copayment expenses described above, each person covered under the plan is responsible for the following out-of-pocket expenses which are not applied to the annual out-of-pocket maximums:

  • Expenses for services or supplies not covered under this plan.
  • Expenses for services or supplies not medically necessary.
  • Expenses which exceed medical benefit maximums.
  • Expenses which exceed the maximum allowable fee as determined by this plan for services provided by non-network providers.
  • Coinsurance expenses for chiropractic and TMJ/MPDS services and supplies.
  • Copayment and coinsurance expenses for covered services and supplies received from a non-network provider.
  • Expenses not covered as a result of a benefit reduction under the medical review programs.
  • All out-of-pocket expenses for dental and vision services and supplies, including expenses which exceed benefit maximums.