MAXIMUM OUT-OF. POCKET EXPENSE means the total amount you pay each plan year for covered healthcare services. We will pay up to 100% of our allowance for the covered healthcare service for the rest of the plan year once you have met the maximum out-of-pocket expense. See the Summary of Medical Benefits for your maximum out-of-pocket expenses.
MAXIMUM OUT-OF. POCKET EXPENSE means the total amount you pay each plan year for covered healthcare services. We will pay up to 100% of our allowance for the covered healthcare service for the rest of the plan year once you have met the maximum out-of-pocket expense. See the Summary of Medical Benefits for your maximum out-of-pocket expenses. Copayments for benefits marked with a double asterisk (**) are not applied towards your maximum out-of-pocket expense. After meeting your maximum out-of-pocket expense you will continue to be responsible for these copayments. MEDICALLY NECESSARY (MEDICAL NECESSITY) means that the healthcare services provided to treat your illness or injury, upon review by BCBSRI are: • appropriate and effective for the diagnosis, treatment, or care of the condition, disease, ailment or injury for which it is prescribed or performed; • appropriate with regard to generally accepted standards of medical practice within the medical community or scientific evidence; • not primarily for the convenience of the member, the member’s family or provider of such member; and • the most appropriate in terms of type, amount, frequency, setting, duration, supplies or level of service, which can safely be provided to the member (i.e. no less expensive professionally acceptable alternative, is available). We will make a determination whether a healthcare service is medically necessary. You have the right to appeal our determination or to take legal action as described in Section
MAXIMUM OUT-OF. POCKET EXPENSE means the total amount of coinsurance that you must pay each plan year for certain covered dental care services provided by network dentists. We will pay up to 100% of our allowance for the rest of the plan year once you have met the maximum out-of-pocket expense. See the Summary of Benefits for your maximum out-of-pocket expenses.
