Out-of-pocket

What is out-of-pocket?

Out-of-pocket or OOP is the amount of the health plan member pays for covered services. An out-of-pocket expense is an expense to the health plan member.

Out-of-pocket expenses usually include deductibles, co-insurance, co-payments, pharmacy costs, and any additional costs due to lab visits.

Healthplans will usually define the out-of-pocket maximum or out-of-pocket limit which is the most a health plan member will have to pay for covered services in a plan year. After spending this amount on deductibles, copayments, and coinsurance, the health plan pays 100% of the costs of covered benefits.