MMC Benefits Handbook
Out-of-Pocket Maximums
NOTE: Out-of-network services are not covered under the Anthem BCBS Narrow Network (National Blue High Performance Network (Blue HPN)) except for urgent and emergency care. There are some providers in New Jersey and Philadelphia that are listed as Tier 2 on Anthem BCBS's provider search (National Blue High Performance Network (Blue HPN)) that can be used and are covered at the out-of-network benefit level. Providers not labeled as Tier 2 cannot be used for out of network coverage.
The maximum amount you have to pay toward the cost of the medical care you receive in the course of one year (excluding your per paycheck contributions to participate in the Plan). The out-of-pocket maximums vary under each of the medical plan options as follows:
Plan feature
$400 Deductible Plan1
$900 Deductible Plan1
$1,500 Deductible Plan1
$2,850 Deductible Plan1
Out-of-pocket maximum
(including deductible)
In-network:
Employee: $2,200
Family2: $4,4003
Out-of-network:
Employee: $4,400
Family2: $8,8003
In-network:
Employee: $3,000
Family2: $6,0003
Out-of-network:
Employee: $6,000
Family2: $12,0003
In-network:
Employee: $3,000
Family2: $6,0004
Out-of-network:
Employee: $6,000
Family2: $12,0004
In-network:
Employee: $5,500
Family2: $11,0003
Out-of-network:
Employee: $11,000 Family2: $22,0003
1 These plans are named for the deductible applicable to the "individual" for in-network service providers. The deductibles applicable to any other coverage level (for example, "Family coverage") or for services provided by out-of-network service providers will be significantly higher than (in many instances, double) the amounts captured in the names of the plans.
2 "Family" applies to all coverage levels except Employee-Only.
3 Not "True" Family: For the $400, $900 and $2,850 Deductible Plans, if more than one person in a family is covered under this plan, there are two ways the plan will begin to pay benefits for a covered family member. When a family member meets his or her individual deductible, benefits begin for that family member only, but not for the other family members. When the family deductible is met, benefits begin for every covered family member whether or not they have met their own individual deductibles. The family deductible can only be met by a combination of family members, as amounts counted toward individual deductibles count toward the larger family deductible. The out-of-pocket maximum functions in the same way. When a family member meets his or her individual out-of-pocket maximum, the out-of-pocket maximum is satisfied for that family member only, but not for the other family members. When the family out-of-pocket maximum is met, the out-of-pocket maximum is satisfied for every covered family member whether or not they have met their own individual out-of-pocket maximums. The family out-of-pocket maximum can only be met by a combination of family members, as amounts counted toward individual out-of-pocket maximums count toward the larger family out-of-pocket maximum.
4 "True" Family: The $1,500 Deductible Plan does not require that you or a covered eligible family member meet the "individual" deductible in order to satisfy the family deductible. If more than one person in a family is covered under this plan, benefits begin for any one covered family member only after the family deductible is satisfied. The family deductible may be met by one family member or a combination of family members. The out-of-pocket maximum functions in the same way. If more than one person in a family is covered under this plan, the out-of-pocket maximum is satisfied for any one covered family member when the family out-of-pocket maximum is satisfied. The family out-of-pocket maximum may be met by one family member or a combination of family members.
Prescription drug expenses apply toward the out-of-pocket maximum, with the exception of specialty medications covered under the SaveOnSP Program described under "Are there mandatory discount or copay assistance programs applicable for specialty prescription drugs?."
The out-of-pocket maximum doesn't apply to:
  • Amounts exceeding Plan limits
  • Amounts in excess of a reasonable and customary charge
  • Preauthorization penalties
  • Services not covered by the Plan
  • Amounts exceeding the network negotiated price for prescription drugs.
Your deductible applies toward your out-of-pocket maximum.
Do in-network claims apply toward the out-of-network out-of-pocket maximum?
No. Only out-of-network claims apply toward the out-of-network out-of-pocket maximum.
NOTE: Out-of-network services are not covered under the Anthem BCBS Narrow Network (National Blue High Performance Network (Blue HPN)) except for urgent and emergency care. There are some providers in New Jersey and Philadelphia that are listed as Tier 2 on Anthem BCBS's provider search (National Blue High Performance Network (Blue HPN)) that can be used and are covered at the out-of-network benefit level. Providers not labeled as Tier 2 cannot be used for out of network coverage.
Do out-of-network claims apply toward the in-network out-of-pocket maximum?
Yes. Out-of-network claims apply toward the in-network out-of-pocket maximum. Also, in-network claims apply toward the in-network out-of-pocket maximum.
NOTE: Out-of-network services are not covered under the Anthem BCBS Narrow Network (National Blue High Performance Network (Blue HPN)) except for urgent and emergency care. There are some providers in New Jersey and Philadelphia that are listed as Tier 2 on Anthem BCBS's provider search (National Blue High Performance Network (Blue HPN)) that can be used and are covered at the out-of-network benefit level. Providers not labeled as Tier 2 cannot be used for out of network coverage.
How does the annual out-of-pocket maximum (limit) work for family members?
Under the $400 Deductible Plan
The Plan will begin reimbursing benefits for a covered family member at 100% once he or she has met the individual out-of-pocket maximum (even if the entire family out-of-pocket maximum has not been met).
Under the $900 Deductible Plan
The Plan will begin reimbursing benefits for a covered family member at 100% once he or she has met the individual out-of-pocket maximum (even if the entire family out-of-pocket maximum has not been met).
Under the $1,500 Deductible Plan
In meeting your family out-of-pocket maximum, each family member's (including a newborn's) covered expenses (medical and prescription drug expenses) count toward the family out-of-pocket maximum.
If you cover eligible family members, you must meet the family out-of-pocket maximum. Once this out-of-pocket maximum has been met, the Plan will pay benefits for all family members at 100% for in-network providers and 100% of reasonable and customary charges for out-of-network providers.
Under the $2,850 Deductible Plan
The Plan will begin reimbursing benefits for a covered family member at 100% once he or she has met the individual out-of-pocket maximum (even if the entire family out-of-pocket maximum has not been met).