What is included in my out-of-pocket maximum?

The total amount of your deductible plus coinsurance and copayment amounts is how you accumulate to reach your maximum out-of-pocket. However, there are differences in this based on the current status of your plan:

  • If your plan is grandfathered or non-grandfathered transitional, then the office visit, emergency room, and pharmacy copays do NOT apply towards your out-of-pocket maximum
  • If your plan is an ACA-compliant plan, in-network office visit, emergency room and pharmacy copays DO apply towards your out-of-pocket maximum.