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Term Details - Out-of-Pocket Limit

Maximum amount that a member or family must pay toward their medical care in a given year in deductibles, coinsurance and co-payments. Once this limit is met, the plan will cover the costs of covered health services until the new policy year begins. However, a health plan may specifically exclude certain costs from the out-of-pocket maximum. For example, an individual member may not be able to count the costs of non-covered services that he or she incurs, or any costs incurred by failing to follow the health planís prior approval process.

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