Common use of OUT-OF-POCKET MAXIMUM Clause in Contracts

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. 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. 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 Generally providers who are not part of the LifeWise Connect network are not covered on your plan. However, if a covered service is not available from LifeWise Connect provider, you can receive benefits for services provided by an out-of-network provider at the in-network benefit level. See Prior Authorization for details. 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 Dialysis Due To End Stage Renal Disease In-Network Providers The allowable charge is the amount explained above in this definition. Out-of-Network Providers Generally providers who are not part of the LifeWise Connect network are not covered on your plan. However, if a covered service is not available from LifeWise Connect provider, you can receive benefits for services provided by an out-of-network provider at the in-network benefit level. See BlueCard® Program Prior Authorization for details. The amount we pay for dialysis will be no less than a comparable provider that has a contracting agreement with us and Other Inter-Plan Arrangements no more than 90% of billed charges. See Chemotherapy, Radiation Therapy and Kidney Dialysis for more detail about providers outside Washington and Alaska who have agreements with other Blue Cross Blue Shield Licenseesdetails.

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-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 or other Blue Cross Blue Shield Licensees have negotiated with providers who have signed contracts with us and in Washington are in your provider network. See the Summary of Your Costs for the name of your provider Heritage Signature network. Out-of-Network Generally providers who are not part of the Heritage Signature network are not covered on your plan. However, if a covered service is not available from Heritage Signature provider, you can receive benefits for services provided by an out-of-network provider at the in-network benefit level. See Prior Authorization for details. 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. The out-of-pocket maximum is a limit on how much you pay each calendar year. After you meet the out-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 or other Blue Cross Blue Shield Licensees have negotiated with providers who have signed contracts with us and in Washington are in your provider network. See the Summary of Your Costs for the name of your provider Heritage Signature network. Out-of-Network Generally providers who are not part of the Heritage Signature network are not covered on your plan. However, if a covered service is not available from Heritage Signature provider, you can receive benefits for services provided by an out-of-network provider at the in-network benefit level. See Prior Authorization for details. 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. 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 Generally providers who are not part of the LifeWise Connect network are not covered on your plan. However, if a covered service is not available from LifeWise Connect provider, you can receive benefits for services provided by an out-of-network provider at the in-network benefit level. See Prior Authorization for details. 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 Dialysis Due To End Stage Renal Disease In-Network Providers The allowable charge is the amount explained above in this definition. Out-of-Network Providers Generally providers who are not part of the LifeWise Connect network are not covered on your plan. However, if a covered service is not available from LifeWise Connect provider, you can receive benefits for services provided by an out-of-network provider at the in-network benefit level. See BlueCard® Program Prior Authorization for details. The amount we pay for dialysis will be no less than a comparable provider that has a contracting agreement with us and Other Inter-Plan Arrangements no more than 90% of billed charges. See Chemotherapy, Radiation Therapy and Kidney Dialysis for more detail about providers outside Washington and Alaska who have agreements with other Blue Cross Blue Shield Licenseesdetails.

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 Emergency Services Consistent with the requirements of the Affordable Care Act the allowed amount will be the greater of the following:  The median amount in-network providers have agreed to accept for the same services  The amount Medicare would allow for the same services  The amount calculated by the same method the plan uses to determine payment to out-of-network providers In addition to your deductible, copayments and Other Intercoinsurance, you will be responsible for charges received from out-Plan Arrangements for more detail of-network providers above the allowed amount. If you have questions about providers outside Washington and Alaska who have agreements with other Blue Cross Blue Shield Licenseesthis information, please call us at the number listed on your LifeWise ID card.