Maximum Out of Pocket Information

Maximum-Out-of-Pocket Limit or Maximum-Out-of-Pocket Amount

Most Optima Health plans limit the dollar amount you will have to pay during your plan year. The maximum-out-of-pocket amount or limit is the total amount you and/or your dependents will pay out of pocket for Copayments, Coinsurance, and Deductibles during a plan year. Your specific maximum amount is determined by your plan benefits and can be found on your Optima Health FaceSheet or Schedule of Benefits in your Evidence of Coverage or Certificate of Insurance.

Depending on your health plan, Copayments, Coinsurance, and Deductibles you pay for certain services count toward this amount. Your specific plan may have separate maximum amounts for in-network services and out-of network services. Some out-of-pocket expenses do not apply to the maximum amount. A list of health services that do not count toward your maximum amount is listed on your FaceSheet or Schedule of Benefits. For those services, you will still have to pay your Copayments, Coinsurance, and Deductibles even after you have reached your maximum amount.

When you have reached your maximum amount, no further payments will be required for the plan year except for those services that do not apply toward this amount. Optima Health maintains a record of your payments and we will send you a letter within 30 days of reaching your out-of-pocket limit. Please present this letter to your physician when obtaining medical care to avoid further charges.

Should you have any questions or believe you are entitled to a refund for an overpayment against your maximum amount, please contact Member Services at the number on the back of your member ID card.