IQVIA Benefits Handbook
ANNUAL MEDICAL OUT-OF-POCKET MAXIMUM
Your annual medical out-of-pocket maximum is the most you must pay in a calendar year (including your annual deductible, office visit copays and coinsurance) toward covered eligible expenses.
Prescription copays under the $1,850 and $2,850 Deductible Plans with HSA also apply toward your medical deductible and out-of-pocket maximum. If you enroll in the $400 or $900 Deductible PPO Plan, prescription drug costs do not count toward the medical plan deductible; however, they do accumulate toward the out-of-pocket maximum.
In the Aetna plans, if you use an out-of-network provider, only Maximum Reimbursable Charges (MRC) for medically necessary services will count toward the annual out-of-pocket maximum. Amounts above MRC limits are not covered expenses and do not count toward your annual out-of-pocket maximum. The out-of-pocket maximum for each option is shown below:
Coverage Type
$400 Deductible
PPO Plan
$900 Deductible PPO Plan
$1,850 Deductible
Plan with HSA
$2,850 Deductible
Plan with HSA
 
In-Network
Out-of-Network
In-Network
Out-of-Network
In-Network
Out-of-Network
In-Network
Out-of-Network
  • Individual
  • $2,200
  • $4,400
  • $3,000
  • $6,000
  • $3,500
  • $7,000
  • $5,500
  • $11,000
  • Family
  • $4,400
  • $8,800
  • $6,000
  • $12,000
  • $6,500
  • $13,000
  • $11,000
  • $22,000
  • In the $1,850 Deductible Plan with HSA administered by Aetna, if you cover dependents, you and your covered family members must meet the family out-of-pocket maximum before the plan pays 100% of covered expenses for any family member. Medical and prescription drug expenses for one family member or for all family members can add up to the out-of-pocket maximum.
  • If you enroll in the $1,850 Deductible Plan with HSA administered by Kaiser or $2,850 Deductible Plan with HSA administered by Aetna or Kaiser, each individual needs to meet the out-of-pocket maximum before the plan pays 100% of covered expenses for that individual family member.
A Quick Note about Deductibles and Out-of-Pocket Maximums
Deductibles and out-of-pocket maximums for in-network and out-of-network services are combined, which means that covered expenses cross accumulate between in and out-of-network deductibles and maximums. All other plan maximums and service-specific maximums also cross accumulate between in- and out-of-network, unless otherwise noted.