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Out-of-Pocket Maximums
An out-of-pocket (OOP) maximum is a maximum amount you will pay for the
services covered by your plan or policy during a plan year.
- Usually not counted toward your OOP: Chiropractic, mental health, and substance abuse care costs; deductibles; copays for medical services (such as doctor visits); and prescription costs. (Exception: If you have a Health Savings Account, all covered services count toward your OOP.)
- Preferred vs. alternate: Some plans may have different OOP maximums for costs you pay for preferred vs. alternate level services.
- Individual: Each subscriber and each dependent on a plan have their own identical individual OOP maximum. Only costs paid for one individual apply toward his or her individual OOP maximum.
- Family: Once the total costs you pay reach the family OOP maximum, you don't need to reach each individual's OOP maximum as well.
