Out-of-pocket limit

The out-of-pocket limit is the most a member will pay for the combined total of all copays, coinsurance and deductibles for covered services in a benefit period (usually a calendar year). Once the out-of-pocket limit is met, HAP pays the entire allowed amount for covered services.*

As of January 1, 2016, non-grandfathered health plans must cap in-network out-of-pocket expenses to:

  • $6,850 individual
  • $13,700 family

  • For Qualified High Deductible Health Plans, the out-of-pocket limit is:
  • $6,550 individual
  • $13,100 family

  • While most health insurance carriers are only offering single-source policies (one source to administer both medical and pharmacy benefits), only HAP gives you the flexibility to make your own pharmacy benefit choices.

    For large groups with existing HAP health plans, we will work with you and your consultants to help identify combined medical and pharmacy out-of-pocket limits. This will also help you comply with the 2015 combined limits under the ACA. This does not apply to Qualified Health Plans.

    Please be advised that HAP does not have access to the records of pharmacy benefit providers. We are only able to monitor out-of-pocket limits for medical services associated with your HAP health plan.

    *The out-of-pocket limit never includes your monthly premium, non-covered prescriptions, or non-covered medical services and devices.
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