Learn more about the out-of-pocket maximum and how to track it below. To find out how an out-of-pocket maximum works with other health care costs, see paying for health care.
How does the out-of-pocket maximum work?
The out-of-pocket maximum is the most you could pay for covered medical services and/or prescriptions each year. The out-of-pocket maximum does not include your monthly premiums. It typically includes your deductible, coinsurance and copays, but this can vary by plan.
Medical care for an ongoing health condition, an expensive medication or surgery could mean you meet your out-of-pocket maximum.
How do I track what I’ve paid?
Here’s an example of how out-of-pocket maximums work:
Jenny needs surgery and wants to make sure she receives the highest level of coverage. Before the surgery, she checks to make sure her doctor and hospital are in her plan network* and follows the required steps for prior authorizations.
- The total cost for Jenny’s surgery is $10,000 after the plan processes the claim.
- She has a $1,500 deductible with 20% coinsurance and an out-of-pocket maximum of $3,500.
Jenny pays her doctor and hospital $3,200 ($1,500 deductible plus $1,700 coinsurance). She has $300 more to pay before she reaches her out-of-pocket maximum.
If Jenny had gone out of her plan network for surgery, she would have a higher out-of-pocket maximum to reach. Her deductible might also be higher than for in-network care. This is why it’s so important to seek care in your plan network, because you’ll have lower out-of-pocket costs. Jenny would have to pay all costs that Blue Cross does not cover if she receives care out of her plan network. These costs will not count toward her in-network out-of-pocket maximum.
What happens when I reach my out-of-pocket maximum?
When you reach your in-network out-of-pocket maximum, your health plan pays for covered health care and prescriptions for the rest of the year. Your plan will pay these costs only if the services and prescriptions are medically necessary.