Coverage Basics
Understanding Deductibles, Copays & Out-of-Pocket Maximums
A plain-language walkthrough of the core cost terms on every plan, and how they work together when you actually use your coverage.
Deductible — what you pay first
The amount you pay out of pocket for covered services before your plan starts sharing costs. With a $1,500 deductible, for example, you cover the first $1,500 of eligible care yourself.
Copay — your flat fee per visit
A fixed dollar amount you pay for a specific service, such as $25 for a doctor visit or $10 for a prescription. Copays often apply even before you have met your deductible.
Out-of-pocket maximum — your yearly ceiling
The most you will pay in a plan year for covered care. Once your deductible, copays, and coinsurance add up to this limit, your plan pays 100% of covered services for the rest of the year.
How they work together
You pay copays and chip away at your deductible as you use care. After the deductible, you and the plan share costs through coinsurance—until you reach your out-of-pocket maximum, after which the plan covers the rest.