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What’s an Annual Copayment Maximum?

The annual copayment maximum is a fixed limit or cap to your total out-of-pocket expense for most covered services in a calendar year or plan year. Most HMSA plans have a specific annual copayment maximum to limit your payments for medical care in a given year.

When the total of the copayment and deductible amounts you pay throughout the year reaches your plan’s annual copayment maximum, you’re no longer responsible to pay for copayments or deductibles unless specified by your plan. Please check your Guide to Benefits for the annual copayment maximum amount specific to your plan and to learn whether your plan’s annual copayment maximum applies to the calendar or plan year.

To view your plan’s annual copayment maximum and how much you have accumulated towards your copayment maximum, log in to My Account on hmsa.com and click the View Benefits link on the right of the home page or call HMSA Customer Relations.

Amounts that don’t apply

Listed below are some payments that don’t go toward meeting your copayment maximum. See your Guide to Benefits for other instances where payments don’t count toward the copayment maximum. You’re responsible for these amounts even after you meet the copayment maximum.

  • Copayments for medical foods, prescription drugs and supplies, contraceptives, and HMSA’s Online Care. Depending on your plan, there may be other items or services that don’t apply to the annual copayment maximum. Please review your Guide to Benefits.
  • Payments for services after a benefit maximum has been reached. Please see benefit maximum.
  • The difference between the actual charge and the eligible charge for services you receive from a nonparticipating provider.
  • Payments for noncovered services.
  • Any amounts you owe in addition to your copayment for covered services.

For example:

This plan has a calendar year individual copayment maximum of $2,500 and a family copayment maximum of $7,500.

MemberIndividual copayments paidAs ofFamily Amount Total
John$2,0006/15/12$2,000
Mary$2,5007/15/12$4,500
Sue$1,50010/1/12$6,000
Tim$1,50011/18/12$7,500

On July 15, 2012, Mary has met her individual copayment maximum and she will not have to make any copayments after that date until the end of the year. The family met their copayment maximum on November 18, 2012. For the rest of the year, no member of the family will be required to make a copayment for services.

For additional important information, we encourage you to read: