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Your OUT OF POCKET EXPENSES

Please note that your deductible and out of pocket expenses were calculated based on recent claim activity, which may include cost sharing data from your medical and/or pharmacy carrier and are therefore subject to change. ValueOptions continually monitors the status of your out of pocket expenses to ensure that any timing related discrepancies are identified and corrected on your behalf. Please be aware that dollar amounts listed below may at times exceed your cost sharing under your behavioral health plan. Your other carriers, such as medical or pharmacy, may require a higher cost share amount.

Description
Individual  Amount Individual  Max
Family  Amount Family  Max
SHARED OUT OF POCKET MAXIMUM-
OUT OF NETWORK
$2530.00 $2530.00 $3000.00 $3000.00
SHARED OUT OF POCKET MAXIMUM-
IN NETWORK
$3500.00 $3500.00 $3930.00 $3930.00
 

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