Keep medical limits separate from prescription drug costs

Reviewed by Joseph Lipari on 2026-10-24.

Sort the numbers into medical, drug and premium categories

A Medicare Advantage medical maximum out-of-pocket limit concerns qualifying covered Part A/Part B medical services under the plan’s rules. It is not a household spending ceiling: premiums and Part D drug spending are separate.

In-network and combined network limits also have different meanings. Read which expenses count and how they accumulate in the matching Evidence of Coverage before calculating what remains to be paid.

Map one record to the right category

The retained 2027 record for H5216-435-002 separates these fields:

Reported amount	What to verify
$7,850 in-network medical limit	Which covered in-network medical costs count under the plan’s rules.
$13,900 combined medical limit	How qualifying in- and out-of-network medical spending counts toward the combined limit.
$450 drug deductible, with Tier 1 and Tier 2 excluded	The deductible does not apply to those two reported tiers; verify the drug’s actual tier, coverage and cost sharing.

Do not add the two medical limits into a $21,750 allowance. They describe overlapping network categories, not separate sums to spend. The drug deductible is another category; it is not part of either medical limit.

The extract identifies Tier 1 and Tier 2 as excluded from this drug deductible. Excluded from a deductible does not mean every drug on those tiers is free or covered. Pharmacy, supply length, formulary and other plan rules still matter.

Check the example’s source: 2027 H5216-435-002

Humana Essentials Plus Giveback (PPO). These are frozen public-data excerpts prepared 2026-10-24. CMS archive hashes and selected raw rows matched the retained extract. This check does not establish a member’s coverage or a new insurer-document review.

Field	Retained value
In-network medical limit	$7,850.00
Combined medical limit	$13,900.00
Separate out-of-network cap field	No separate cap reported for this field
Drug deductible	$450.00
Tiers excluded from this deductible	Tier 1, Tier 2

Download the frozen example evidence (JSON) · Open the annual data file

CMS files, field names and row locations

The annual data file may contain multiple plans. Find H5216-435-002 and contractYear: 2027. The frozen evidence file keeps this example separate from later data revisions.

In-network medical limit: benefits.moop.inNetwork
pbp_Section_D.txt: pbp_d_out_pocket_amt
Combined medical limit: benefits.moop.combined
pbp_Section_D.txt: pbp_d_comb_max_enr_amt
Separate out-of-network cap field: benefits.moop.caps.outOfNetwork / benefits.moop.outOfNetwork
pbp_Section_D.txt: pbp_d_oon_max_enr_oopc_yn, pbp_d_oon_max_enr_oopc_amt
Drug deductible: benefits.rx.deductible.amount
pbp_mrx.txt: mrx_alt_ded_amount / deductible mode; Landscape: Annual Part D Deductible Amount
Tiers excluded from this deductible: benefits.rx.deductible.excludedTiers
pbp_mrx.txt: mrx_alt_no_ded_tier, decoded with the pinned CMS dictionary

pbp_Section_A.txt: data-record position 4397 (header excluded); row SHA-256 c3234d5781530f0ce9e6bb98ffb487fa0e58c00a5845565a07f6a8c5cb98a63a.
pbp_Section_D.txt: data-record position 4395 (header excluded); row SHA-256 b50e20df3623b1232e059b051654af2871521cf624a76c3d2ddeca8f47b5cd6a.
pbp_b1a_inpat_hosp.txt: data-record position 4395 (header excluded); row SHA-256 c90ec561ebeb0eb68a6cebd1741221088443cdd8c116980cb8534fba6e228ac4.
pbp_mrx.txt: data-record position 4395 (header excluded); row SHA-256 d51e97f337d18a700aa845c17644724384baf33eba7b3d031ef5dc37dfc1c754.

Landscape amount fields agree across 47 matched geographic rows. Their data-record positions are included in the frozen evidence.

CMS approved 2027 PBP ZIP · CMS CY2027 Landscape 202609.1 ZIP

PBP dictionary: PBP_Benefits_2027_dictionary.xlsx. PBP ZIP SHA-256: 6d8430e2ecb51acf3cc8547f12dd73506aa73f0dccf034cc3c3393868576ff47. Retained normalized snapshot SHA-256: f4813cbbe4f3c5b5a865934ce9a62b89ad44f3def88e487716fcd02abea5bee3.

Keep the annual Part D rule separate from a plan field

Medicare’s drug-cost guidance, checked October 24, 2026, states that the out-of-pocket threshold for covered Part D drugs is $2,400 for 2027 ($2,100 for 2026). After qualifying spending reaches the applicable threshold, covered Part D drugs enter catastrophic coverage with no out-of-pocket charge for the rest of that calendar year.

Only spending and payments that qualify under Part D count; Medicare notes that certain payments made on a person’s behalf can count. The threshold is not a monthly premium, a drug deductible, a medical limit, or a limit on every drug-related expense. A blank threshold field in a plan extract is not permission to assume that the annual rule is absent. Read Medicare’s year-specific drug-cost guidance and the applicable plan documents.

A standalone drug record does not describe medical coverage

2027 S5884-101-000 is a standalone Part D record. Medical inpatient benefits and medical limits are not applicable to that record. This says nothing about the person’s separate medical coverage.

Its retained record reports a $700 drug deductible with no tier exclusions reported. Use the drug-specific fields and documents; do not interpret its absent medical amounts as $0 medical costs.

Check the example’s source: 2027 S5884-101-000

Humana Basic Rx Plan (PDP). These are frozen public-data excerpts prepared 2026-10-24. CMS archive hashes and selected raw rows matched the retained extract. This check does not establish a member’s coverage or a new insurer-document review.

Field	Retained value
Drug deductible	$700.00
Tiers excluded from this deductible	No tier exclusions reported

Download the frozen example evidence (JSON) · Open the annual data file

CMS files, field names and row locations

The annual data file may contain multiple plans. Find S5884-101-000 and contractYear: 2027. The frozen evidence file keeps this example separate from later data revisions.

Drug deductible: benefits.rx.deductible.amount
pbp_mrx.txt: mrx_alt_ded_amount / deductible mode; Landscape: Annual Part D Deductible Amount
Tiers excluded from this deductible: benefits.rx.deductible.excludedTiers
pbp_mrx.txt: mrx_alt_no_ded_tier, decoded with the pinned CMS dictionary

pbp_Section_A.txt: data-record position 7742 (header excluded); row SHA-256 cbc0a91e25b6dfdb63ef89d19c76d29f078b794de58128743aaadaaf44cdb01e.
pbp_mrx.txt: data-record position 7740 (header excluded); row SHA-256 b8bbfb5ce26ca1cd6251fddcd27da6cae63721b6e884a9ae265fbe81014abe16.

Landscape amount fields agree across 2 matched geographic rows. Their data-record positions are included in the frozen evidence.

CMS approved 2027 PBP ZIP · CMS CY2027 Landscape 202609.1 ZIP

Use this limit-reading checklist

Write down the coverage year and whether the amount is medical, drug or premium-related.
For medical limits, identify the network category and ask what spending counts toward each applicable limit.
For a drug deductible, check excluded tiers, then verify the actual drug, pharmacy and supply length.
If MPL says “No separate cap” for a network field, check the in-network and combined limits. The label does not mean unlimited coverage.
Keep zero, not reported and not applicable distinct.

Select the same coverage year for both records in comparison. A public record cannot establish eligibility or predict a member’s total annual spending.

Primary sources

Reference sources consulted for guide preparation on 2026-10-24. Retained insurer-document checks have their own stated dates and scope; those checks were not repeated during guide preparation. Public datasets and documents can be revised. An annual record is not a personalized eligibility determination.

Examples use the retained 2027 normalized snapshot. SHA-256: f4813cbbe4f3c5b5a865934ce9a62b89ad44f3def88e487716fcd02abea5bee3.

All guides · Review policy · Report a correction