Out-of-pocket maximums

You pay a certain amount of covered expenses each plan year before the PPO Options begin paying 100% of contracted or recognized charges for most covered services. This is your medical coverage plan year out-of-pocket maximum.

Each BP PPO Option has separate network and out-of-network medical coverage plan year out-of-pocket maximums. These maximums are exclusive of each other. This means that covered network expenses — including the network deductible — count only toward meeting the network medical out-of-pocket maximum. Network expenses do not count toward meeting the out-of-network medical coverage out-of-pocket maximum. Similarly, covered out-of-network expenses — including the out-of-network deductible — count toward meeting the out-of-network medical out-of-pocket maximum, but do not count toward meeting the network medical out-of-pocket maximum.

In addition, each Health+Savings PPO Option has two separate out-of-pocket maximum amounts for network expenses, and two more for out-of-network expenses. Under the Health+Savings option, the lower out-of-pocket maximum amounts apply only if you have You Only coverage. The higher out-of-pocket maximum amounts apply if you have You + Spouse, You + Child(ren) or You + Family coverage, even if only one family member incurs medical expenses during the year. Under the Health+Savings options, the lower You Only out-of-pocket maximum amounts would not apply to any covered individual in your family if you have You + Spouse, You + Child(ren) or You + Family coverage.

Under the HealthPlus and Standard PPO options, any medical expense that counts toward an individual's out-of-pocket maximum automatically counts toward the family out-of-pocket maximum. For example, once you meet the family plan year network out-of-pocket maximum, no other covered family member is required to meet his/her individual network out-of-pocket maximum for that plan year before plan benefits are paid at 100%.

The expenses that apply to the out-of-pocket maximum vary depending on the option in which you are enrolled.

If you are enrolled in this option…
The following expenses apply to the option’s medical out-of-pocket maximum…
The following expenses do not apply to the option’s medical out-of-pocket maximum and are payable by you even after the out-of-pocket maximum has been met…
HealthPlus PPO or Standard PPO Option
  • Deductibles.
  • Coinsurance.
  • Office visit copays.
  • Emergency room/urgent care facility copays.
  • Expenses under the Prescription Drug Program.
  • Charges above the recognized charge limits.
  • Penalties for noncompliance with precertification provisions.
  • Expenses not covered by the PPO Option.
Health+Savings PPO Option
  • Deductibles.
  • Coinsurance.
  • Office visit copays.
  • Emergency room/urgent care facility copays.
  • Expenses under the Prescription Drug Program.
  • Charges above the recognized charge limits.
  • Penalties for noncompliance with precertification provisions.
  • Expenses not covered by the PPO Option.

 

Publication date: April 2019

 

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