Out-of-Pocket-Maximum Explained [Sharp Healthcare Plan Benefits] 



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 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.   



For more on your Sharp Healthcare Plan, click here! 

Didn’t answer your question? Click here to head to our main support page. There you can search for more answer or pose a question to our staff. 

You can also email us at support@sdpeba.org or call us at 888-315-8027! 

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