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Out-of-pocket maximum

The most you'll have to pay for covered services in a plan year before insurance covers 100% of costs.

Updated Sep 26, 2026

The out-of-pocket maximum is a cap on what you'll pay for covered care in a plan year — including deductibles, copays, and coinsurance. Once you hit this limit, your insurance covers 100% of additional covered costs, including ongoing GLP-1 prescriptions, for the rest of the plan year.

HealthCare.gov's definition adds that the 100% applies to covered in-network care (HealthCare.gov (external link)).

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    Related terms

    • Semaglutide salt forms — Versions of semaglutide such as semaglutide sodium and semaglutide acetate, which the FDA says are different active ingredients from the semaglutide base used in approved drugs, with no known lawful basis for compounding.
    • Open enrollment — The annual window when you can enroll in or change your health plan, and the time to compare GLP-1 coverage across the plans available to you.
    • P&T committee (Pharmacy and Therapeutics committee) — The panel of physicians, pharmacists, and other clinicians that reviews the clinical evidence behind a plan's formulary: which drugs are acceptable, which are interchangeable, and what restrictions apply.
    • API (active pharmaceutical ingredient) — The raw drug substance in a medication that produces its effect — for example, semaglutide itself, before it is formulated into a pen or vial.
    • Certificate of analysis (CoA) — A document reporting the lab test results for a specific batch of a drug ingredient or product, such as identity, purity, and contaminants.

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