Benefit Maximums Clause Samples
Benefit Maximums. Some of the Authorized Benefits and Services described in this Certificate are covered for a limited number of days or visits per Contract Year. This is known as a benefit maximum. The Schedule of Out-of-Pocket Expense attached to this Certificate lists the maximums that apply to certain benefits. Once you have reached a maximum for a Covered Service, you will be responsible for the cost of additional services received during that Contract Year even when continued care is Medically/Clinically Necessary.
Benefit Maximums. Effective January 1, 2010 medically necessary inpatient alcohol and substance abuse treatment shall be unlimited.
Benefit Maximums. The Plan pays up to the annual benefit maximum amounts (listed on the Summary of Benefits insert for the Program under which you are covered) per person each year.
Benefit Maximums. Members must continue to pay any applicable copayments, Prescription Drug copayments and penalty amounts after meeting their Out-of- Pocket Maximum. Benefit Copayment Adult Physical Examination including Immunizations Visits are subject to the following visit maximum Adults 18-65 years old 1 visit per 12 month period Adults over 65 years old 1 visit per 12 month period Well Child Physical Examination including Immunizations Office Hours Visits After-Office Hours Visits E-visit by a Primary Care Physician Office Visits (Non-surgical E-visit by a Specialist 1 visit(s) per Calendar Year Benefit Copayment 30 combined Physical, Occupational and Speech Therapy visits per Calendar Year; Performed at a Hospital Outpatient Facility Complex Imaging Services, including, but not limited to: Magnetic Resonance Imaging (MRI); Computerized Axial Tomography (CAT); and Positron Emission Tomography (PET); and any other outpatient diagnostic imaging service costing over $500. Performed at a facility other than a Hospital Outpatient Facility Complex Imaging Services, including, but not limited to: Magnetic Resonance Imaging (MRI); Computerized Axial Tomography (CAT); and Positron Emission Tomography (PET); and any other outpatient diagnostic imaging service costing over $500. Performed at a Hospital Outpatient Facility Performed at a facility other than a Hospital Outpatient Facility Benefit Copayment Hospital Emergency Room or Outpatient Department Performed at a Hospital Outpatient Facility Performed at a facility other than a Hospital Outpatient Facility 60 visits per Calendar Year
Benefit Maximums. Benefits that are “Essential Health Benefits” as described by the Patient Protection and Affordable Care Act may not have annual or lifetime dollar limits. Any Benefit limitations are described in your Schedule of Benefits.
Benefit Maximums. Annual Deductible and Out‐of‐Pocket Maximums Deductible and Out‐of‐ Pocket Maximums In‐Network Out‐of‐Network Annual Deductible (per Calendar Year) Annual Out‐of‐Pocket Maximum (per Calendar Year) SCHEDULE OF MEDICAL BENEFITS Diabetic Education and Diabetic Nutrition Education Emergency Care Services Family Planning Hearing Lab and Radiology Services (non‐routine, facility and professional services) Pre‐authorization required for PET scans. Maternity and Newborn Care Nutritional and Dietary Formulas Retail Pharmacy – 30 day supply Specialty Pharmacy Professional/Physician Services (office visits) Rehabilitation Therapy Pediatric Vision ( under age 19) Administered by Vision Service Plan (VSP) Applies to Deductible In‐Network Providers (plan pays) Out of Network Providers (plan pays) MEDICAL BENEFITS DETAILS Acupuncture Services