All of Sharp’s healthcare plans offer an “out-of-pocket maximum.” This dollar value is the upper limit on what you will pay for covered medical expenses in a given benefit year.
This number, which is sometimes called an “out-of-pocket limit,” varies from plan to plan, but in essence is there to protect you in case you need a lot of medical attention in a given year.
Copays and Coinsurance are Covered
Basically, any time you use your copay or coinsurance, you’re putting money toward your out-of-pocket maximum. Unfortunately, that means that money put towards a deductible (like the one in the Health Saver plan) does not go toward your out-of-pocket maximum.
Once you hit your out-of-pocket-maximum, your copay and coinsurance will go down to 0 for the rest of that benefit year. Meaning, if you normally pay $20 for X-Rays, once you hit your limit, you’ll pay $0.
There are restrictions to what exactly goes towards your limit. Anything listed as a “supplemental benefit,” on your EOB (explanation of benefits) such as reproductive services, acupuncture, and others that are covered by the Sharp Classic plan do not contribute to your out-of-pocket maximum.
Lifetime maximums have been banned in the United States, but the phrase still appears on many EOB forms. A lifetime maximum was an old model of insurance that limited the amount of money your insurance would cover.
No Sharp insurance plans have a lifetime maximum. Even though the name is similar, it is quite different from the out-of-pocket maximum.
Payment toward pills and medication do not contribute to your out-of-pocket maximum. There is a 30-day maximum for specifically oral cancer treatment medication, but other than that prescription medication is only affected by your copay or coinsurance as reflected on your explanation of benefits.
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