Northwest Carpenters Health and Security Plan

Medical and Prescription Drug 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:

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:

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.

Medical Expenses Not Included in Out-of-pocket Maximum

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, acupuncture, massage therapy, and TMJ/MPDS services and supplies.
  • Copayment and coinsurance expenses for covered services and supplies received from a non-network provider, except as otherwise provided in this plan.
  • Expenses not covered as a result of a benefit reduction under the medical review programs.

Last Updated: 04/25/2023