OUT-OF-POCKET MAXIMUM. The out-of-pocket maximum is a limit on how much you pay each calendar year. After you meet the out-of-pocket maximum this plan pays 100% of the allowed amount for the rest of the calendar year. See the Summary of Your Costs for further detail. Expenses that do not apply to the out-of-pocket maximum include: • Charges above the allowed amount • Services above any benefit maximum limit or durational limit • Services not covered by this plan • Services from out-of-network providers • Covered services that say they do not apply to the out-of-pocket maximum on the Summary of Your Costs ALLOWED AMOUNT This plan provides benefits based on the allowed amount for covered services. We reserve the right to determine the amount allowed for any given service or supply. The allowed amount is described below. In-Network The allowed amount is the fee that we have negotiated with providers who have signed contracts with us and are in your provider network. See the Summary of Your Costs for the name of your provider network. Out-of-Network For contracted providers the allowed amount is the fee that we have negotiated with providers who have signed contracts with us. For non-contracted providers the allowed amount is the least of the following (unless a different amount is required under applicable law or agreement): • An amount that is no less than the lowest amount we pay for the same or similar service from a comparable provider that has a contracting agreement with us • 125% of the fee schedule determined by the Centers for Medicare and Medicaid Services (Medicare), if available • The provider’s billed charges See BlueCard® Program and Other Inter-Plan Arrangements for more detail about providers outside Washington and Alaska who have agreements with other Blue Cross Blue Shield Licensees.
OUT-OF-POCKET MAXIMUM. Shall be defined as the total maximum of any Eligible Charges paid, or payable as defined by a payment schedule or arrangement by a Covered Person to a Participating Provider to satisfy any applicable Deductible, Co-Payment, and/or Co-Insurance specified in this Agreement before the Plan will begin to pay Covered Services at one hundred percent (100%) for the remainder of the Plan Year, subject to the maximum amounts provided in the Plan as indicated in Exhibit .
OUT-OF-POCKET MAXIMUM a specified dollar amount of Deductible, Coinsurance and Copayment expenses, if any, Incurred by a Member for Covered Services in a Benefit Period, after which the level of benefits payable by the Plan is increased to one hundred percent (100%) of the Plan Allowance such that the Member will not be liable for any additional Deductible, Coinsurance or Copayment expenses in that Benefit Period.
OUT-OF-POCKET MAXIMUM. Your out-of-pocket maximum is not the same as your deductible. Generally, it is the total out-of-pocket limit INCLUDING deductible, co-pays, and co-insurances before the insurance will pay 100% of all covered services. Once again, this varies between insurance policies. If you have any questions, please call your health plan to have further clarification. We are out-of-network for all other plans not listed. You can still be seen, but you will have to pay for all the charges incurred at the time of service with us determined by our fee schedule, NOT at contracted insurances rates which tends to be lower than cash market rates. We will be happy to provide you with an itemized list of coded diagnosis and charges which you can submit to your insurance to receive reimbursement for out-of-network services you have received. Please note that we do not guarantee that you will be reimbursed for the full amount of charges incurred. In fact, it varies depending on limitations and restrictions of your plan. We understand that health insurance coverage is difficult and outright confusing to understand at times. We encourage you to ask questions. If we can be of any assistance, please ask. Once again, this is a very broad explanation of an insurance policy. However, for more specific answers to any of your questions, please call your insurance. By signing this form, you have read and understand our policy. Patient’s Name: Date:
OUT-OF-POCKET MAXIMUM. The out-of-pocket expense maximum applicable to covered services or supplies obtained on an in-network basis under the Health Care PPO Option during any calendar year will be $1,400 for 2016, $1,550 for 2017, $1,700 for 2018 and $1,815 for 2019 per individual and $3,500 for 2016, $3,875 for 2017, $4,250 for 2018 and $4,537.50 for 2019 per family. The out-of- pocket expense maximum applicable to covered services or supplies obtained on an out-of-network basis under the Health Care PPO Option during any calendar year will be $2,300 for 2016, $2,600 for 2017, $2,800 for 2018 and $2,990 for 2019 per individual and $5,750 for 2016, $6,500 for 2017, $7,000 for 2018 and $7,475 for 2019 per family. Expenses that apply towards the out-of-pocket maximum are aggregated between in-network and out-of-network expenses to reach the applicable out-of-pocket maximum. The family annual out-of-pocket maximums can be satisfied by any combination of family members within a calendar year; however, an enrolled associate or eligible dependent will never satisfy more than his or her own individual amounts. Amounts paid towards the deductible will apply towards the annual out-of-pocket maximum. (Amend the following section of the VMEP: Section 6.2.3.)
OUT-OF-POCKET MAXIMUM. An annual out-of-pocket expense maximum under the Health Care PPO Option will apply to prescription drugs purchased at mail order pharmacies of $786.52 for 2016 and 2017, and for each calendar year thereafter, the annual out-of-pocket expense maximum will increase by 6% when compared to the annual out-of-pocket expense maximum for the prior year. Any expenses incurred as a result of the provisions of Section VIII.2.B.5)(b) of this 2016 MOU regarding a member paying the difference between the cost of a brand name and a generic drug when a generic equivalent is available will not count toward the out-of-pocket maximum.
OUT-OF-POCKET MAXIMUM. An annual out-of-pocket expense maximum under the Health Care PPO Option will apply to prescription drugs purchased at mail order pharmacies of $786.52.
OUT-OF-POCKET MAXIMUM. The limit on the total amount of Coinsurance, Copayments and Deductibles You must pay out of Your pocket annually for In-Network Covered Services.
OUT-OF-POCKET MAXIMUM. Maintain medical and carved out pharmacy Claims for integrated Medical/Rx out of pocket maximum accumulation to ensure compliance with the PPACA. • Forms. Furnish necessary forms to OGB for its Plan Participants’ eligibility and Claims activities. • Claim, Administrative Appeals and Clinical External Reviews. Provide assistance to OGB in complying with grievance and appeal procedures adopted by OGB and as outlined in the Benefit Plan or Summary Plan Document.
OUT-OF-POCKET MAXIMUM. (1) The Out of Pocket Maximum is the maximum amount you will pay for Covered Services in a Plan Year. The Out of Pocket Maximum is listed on the Schedule of Benefits.
