Your Out-of-Pocket Maximum
The out-of-pocket maximum limits the amount you pay towards the cost of covered medical expenses (including your medical and prescription drug copays, coinsurance and payments toward satisfying the annual deductible) in a calendar year.
Under the PPO plans, your prescription drug copays will only count toward your in-network out-of-pocket maximum. With the HSA plans, prescription costs count toward meeting your medical plan deductible and out-of-pocket maximum.
Your out-of-pocket maximum is based on the Plan you are enrolled in and the number of people you cover. If you are enrolled in one of the PPO or HSA plans, the out-of-pocket maximum is also determined by whether you use in-network or out-of-network providers. See the chart in "Your Medical Benefits" for specific out-of-pocket maximums.
The individual out-of-pocket maximum is the most that will apply to any one family member, regardless of which UnitedHealthcare plan you choose. Once you or a covered dependent reaches the individual out-of-pocket maximum, the Plan pays 100% of that person's eligible expenses for the rest of the calendar year. Once your family out-of-pocket maximum is reached, the Plan pays 100% of eligible expenses for the rest of the calendar year for you and all your covered dependents.
The family out-of-pocket limit may be satisfied by any combination of covered expenses incurred by any covered family member. However, no one family member may contribute more than the individual out-of-pocket maximum.
Family Out-of-Pocket Maximum Example
Assume that you enroll in the Choice PPO plan and have a family of four. When you use in-network doctors and facilities, the annual family out-of-pocket maximum is $6,250 under the Choice PPO plan. Here is an example of how the in-network family out-of-pocket maximum might be satisfied:
Participant
Covered Expenses
Employee:
$2,950
Spouse:
$2,000
Child #1:
$1,000
Child #2:
$300
Total:
$6,250
The out-of-pocket maximum includes your medical copays (including those for covered health services available in Your Prescription Drug Benefits), your share of the coinsurance and payments toward satisfying the annual deductible. It does not include:
  • Your contributions toward the cost of medical coverage (your premium)
  • Any amounts over reasonable and customary fee limits or the allowance based on the Minimum Necessary Reimbursement Program (MNRP), as defined in "Medical Plan Definitions."
  • The amounts of any penalty you incur by not obtaining prior authorization as required
  • Any amounts over plan limits for organ transplants
Out-of-pocket expenses incurred for in-network services apply toward the in-network out-of-pocket maximum only. Only out-of-pocket expenses incurred for out-of-network services apply toward the out-of-network out-of-pocket maximum.