Do all expenses apply to a member’s medical maximum out of pocket?
No. Expenses applied toward the annual deductible do not apply toward the out-of-pocket maximum (except for Plan 9). Fixed dollar copayments and disallowed charges do not apply toward the annual deductible or out-of-pocket maximum. In addition (and to provide more clarification), a member is responsible for paying the following costs (they do not accrue toward the member’s out-of-pocket maximum and the member must pay for them even after their out-of-pocket maximum is met): • Fixed dollar copayments; • The out-of-pocket expenses for transplants performed at out of network transplant facilities; • The service authorization cost containment penalty; and • Disallowed charges.
