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The Out-of-Pocket Maximum

The Out-of-Pocket Maximum The out-of-pocket maximum is just what you’d expect from the name. It is the maximum of what you spend out-of-YOUR-pocket on the deductible, coinsurance and copayments (but not premiums or premium contributions). Once you reach the out-of-pocket maximum, the insurer pays 100% for in-network services for the rest of the year or benefit period. For non-Medicare plans, the out-of-pocket maximum is a combination of what you spend at the pharmacy and on medical services. For Medicare, medical and