Out-of-Pocket Maximum

2020 and 2021 Plan Year Information

Option AOption BOption C
Individual Out-of-Pocket Maximum

In-Network:
$2,000

Out-of-Network:
$4,000

In-Network:
$3,000

Out-of-Network:
$6,000

In-Network:
$5,500 (includes prescription drugs)

Out-of-Network:
$11,000 (includes prescription drugs)

Family Out-of-Pocket Maximum

In-Network:
$5,000

Out-of-Network:
$10,000

In-Network:
$7,500

Out-of-Network:
$15,000

In-Network:
$11,000 (includes prescription drugs)

Out-of-Network:
$20,000 (includes prescription drugs)

Out-of-Network Reimbursements

Out-of-network reimbursements are based on eligible expenses as determined by the Plan administrator. You are responsible for any payments required to the provider in excess of the reasonable and customary amount.

Amounts paid to out-of-network providers count toward the in-network and out-of-network annual deductible. The amount you pay toward your annual deductible is included in your out-of-pocket maximum.