Out-of-pocket limit

The maximum amount members pay for covered health expenses

The Affordable Care Act’s 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, we pay the entire allowed amount for covered services for the rest of the benefit period.

Costs due to monthly premiums, non-covered prescriptions and non-covered medical services do not count toward the out-of-pocket limit.

2027 out-of-pocket limits

As of January 1, 2027, non-qualified high deductible health (non-HSA) plans must cap in-network out-of-pocket expenses at:

• $12,000 individual
• $24,000 family

For qualified high deductible health plans, which can be paired with a health savings account, the out-of-pocket limit is:

• $8,700 individual
• $17,400 family

The minimum deductible is:

• $1,750 individual
• $3,500 family

The maximum contribution is:

• $4,500 individual
• $9,000 family

Pharmacy benefits

Most health insurance companies offer single-source policies that administer medical and pharmacy benefits. We give you the flexibility to make your own pharmacy benefit choices.

If you’re a large group with an existing health plan, we’ll help you identify combined medical and pharmacy out-of-pocket limits. This will help your business comply with the combined limits under the ACA. Combined benefits don't apply to qualified health plans.

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