Summary Plan Description
The out-of-pocket maximums are the most a patient or family pays during the calendar year for certain covered medical expenses.
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.
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.
Related Health & Security Content
- 2017 Summary of Material Modifications (1/31/2017)
- 2017 Summary of Material Modifications (1/1/2017)
- 2016 Summary of Material Modifications
- 2014 Summary of Material Modifications
2017 Summary of Benefits and Coverage
Delta Dental of Washington
VSP Vision Care
Quit For Life
See All the Plan Rules and Forms Related to Events in Your Life