MMC Benefits Handbook
Out-of-Pocket Maximums
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).
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Plan feature
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Surest Copay Plan
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Out-of-pocket maximum
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In-network:
Employee: $2,200
Family1: $4,4002
Out-of-network:
Employee: $4,400
Family1: $8,8002
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1 "Family" applies to all coverage levels except Employee-Only.
2 Not "True" Family: Individual and family deductibles do not apply to this plan. When a covered family member meets his or her individual out-of-pocket maximum, the out-of-pocket maximum is met for that covered family member only, but not for the other covered family members. When the family out-of-pocket maximum is met, the out-of-pocket maximum is met for all covered family members, whether or not each has met the individual out-of-pocket maximum. The family out-of-pocket maximum can only be met by a combination of covered family members, as amounts counted toward individual out-of-pocket maximums count toward the larger family out-of-pocket maximum.
Prescription drug expenses apply toward the out-of-pocket maximum, with the exception of specialty medications covered under the PrudentRx Program, as 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
- Prior authorization penalties
- Services not covered by the Plan
- Amounts exceeding the network negotiated price for prescription drugs.
Your copays apply towards your out-of-pocket maximum.
Do in-network claims apply toward the in-network out-of-pocket maximum?
Yes. In-network claims apply toward the in-network out-of-pocket maximum.
Do in-network claims apply toward the out-of-network out-of-pocket maximum?
No. In-network claims do not apply toward the out-of-network out-of-pocket maximum.
Do out-of-network claims apply toward the out-of-network out-of-pocket maximum?
Yes. Out-of-network claims apply toward the out-of-network out-of-pocket maximum.
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.
How does the annual out-of-pocket maximum (limit) work for family members?
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).
How does the annual out-of-pocket maximum (limit) work for family members?
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).