WHAT IS OUT OF POCKET MAXIMUM

Out-of-Pocket Maximum

The Out-of-Pocket Maximum (OOPM) amounts below are the maximum amounts you must pay for
covered services during a particular Calendar Year.

Once the total amount of all Copayments you pay for covered services under this Evidence of Coverage in any one Calendar Year equals "Out-of-Pocket Maximum" amount, no payment for covered services and benefits may be imposed on any Member

The OOPM amounts for this Plan (Excludes Prescription Drugs) are:
One Member ...................................Three (3) inpatient copayments per person per calendar
year.

Family (three or more Members) ...Not Applicable


How the OOPM Works

Keep a record of your payment for covered medical services and supplies. When the total in a Calendar Year reaches the OOPM amount shown above, contact the Member Services Department at the telephone number shown on your Health Net ID Card for instructions.

• If an individual Member pays amounts for covered services in a Calendar Year that equal the OOPM amount shown above for an individual Member, no further payment is required for that Member for the remainder of the Calendar Year.

You must notify Health Net when the OOPM amount has been reached. Please keep a copy of all
receipts and canceled checks for payments for Covered Services as proof of Copayments made.