Topic Area:  

  • Understanding Your Costs

Does cost sharing for prescription and dental count towards my out-of-pocket maximum?

Prescription drugs

The amounts you pay for prescription drugs covered by your plan would count towards your out-of-pocket maximum. If you purchase a prescription that is not covered by your plan for whatever reason (it's not on the plan's formulary, it's considered experimental, etc.), it would not count.

Not all health plans include prescription coverage, so you may be interested in a stand-alone prescription plan which is available for individual purchase. These plans have a separate deductible, so your payments for prescriptions under an individual plan will not count toward your health insurance plan out-of-pocket maximum.

Dental care

Many health insurance plans now include pediatric dental coverage. If your child received pediatric dental services and your medical health plan included that benefit, the cost sharing would count towards your out-of-pocket maximum.

Adult dental care and pediatric dental care not included in your medical health plan are likely covered by a separate dental insurance plan, if you have coverage. Any cost sharing associated with this kind of care under a dental plan would not count towards your out-of-pocket maximum for your medical plan.

Helpful Tips

  • Know if your prescription and dental coverage are part of your health plan or separate.

Know your deductible amounts by plan. If you have questions, contact your plan.

4/19/2018