Out-of-Pocket Maximum
An out-of-pocket maximum is the maximum amount you can be subject to pay for your pharmacy benefit plan in a plan year. Copayments paid towards your prescription medication contribute to your out-of-pocket maximum. After you reach the maximum defined by your pharmacy benefit plan, the plan will pay 100% for any covered service, and you will not have to pay any additional money out of pocket.
Example: If your out-of-pocket maximum is $3,000 on your pharmacy benefit plan, you can be subject to pay up to $3,000 for services and prescriptions through your copayment. Once you spend $3,000, the pharmacy benefit offered by your pharmacy benefit plan will cover any extra services, prescriptions, and costs for the rest of the year.
Deductible
A deductible is the amount you must pay out of pocket for services before the pharmacy benefit plan starts to pay.
Example: If your pharmacy benefit plan has a $1,500 deductible, you must pay the first $1,500 out of pocket before the pharmacy benefit plan starts covering any costs. Depending on the plan design, you may still have to pay copay amounts for additional services.