What is an out-of-pocket (OOP) maximum?

An out-of-pocket (OOP) maximum is the most money you can pay during your plan year. Once the money you spend on covered healthcare costs meets this maximum, your plan usually covers 100% of future costs for the rest of the plan year.

Note: Not all plans cover 100% of costs once you meet the maximum. View your Full Coverage Booklet to learn more about your specific plan.

Eligible expenses

Only certain expenses count towards your maximum. These expenses are:

• Copays

• Deductible

• Coinsurance

Expenses that don’t count towards your maximum are:

• Premiums

• Balance-billing charges (any remaining balance for a service that your insurance plan won’t cover)

• Services that aren’t covered by your plan

Example: Your plan year begins January 1st. Your insurance plan has a $5000 out-of-pocket maximum. By September, you’ve spent $5000 on copays, coinsurance, and your deductible. Your plan will now cover 100% of eligible expenses until the plan year ends on December 31st.