Maximum Out of Pocket Sample Clauses

Maximum Out of Pocket. The [Tier 1 and Tier 2] Per Member and [Tier 1 and Tier 2] Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. For Single Coverage Only: [Tier 1] In the case of single coverage, for a Member, the [Tier 1] Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 1] per Member Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. For Single Coverage Only: [Tier 2] In the case of single coverage, for a Member, the [Tier 2] Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. [All per Member Cash Deductible plus Coinsurance and Copayments applied to the [Tier 1] per Member Maximum Out of Pocket also apply to this [Tier 2] per Member Maximum Out of Pocket.] Once the [Tier 2] per Member Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. For Other than Single Coverage: [Tier 1] In the case of coverage which is other than single coverage, for a Member, the [Tier 1] per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as [Tier 1] per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 1] per Member Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 1] Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. In the case of coverage which is other than single coverage, for a Covered Family, the [Tier 1] Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as [Tier 1] per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 1] per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 1] Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the Calendar Year. For Other than Single Coverag...
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Maximum Out of Pocket. Expense The maximum out-of-pocket expense accumulates separately for network and non-network services. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out-of- pocket expense. Individual Plan Per contract year $6,350 $9,600 Family Plan Per contract year $12,700 The contract year family maximum out-of- pocket expense is met by adding the amount of covered health care expenses applied to the maximum out-of-pocket expense for all family members; however no one family member can contribute more than $6,350 the individual maximum out-of-pocket expense amount towards the contract year family maximum out-of- pocket expense. $19,200 The contract year family maximum out-of- pocket expense is met by adding the amount of covered health care expenses applied to the maximum out-of-pocket expense for all family members; however no one family member can contribute more than $9,600 the individual maximum out-of-pocket expense amount towards the contract year family maximum out-of- pocket expense. Medical Benefits Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Ambulance Ground $50 NO The level of coverage is the same as Tier 1 network provider The level of coverage is the same as Tier 1 network provider Air/Water Up to the maximum benefit of $3,000 per occurrence $50 NO The level of coverage is the same as Tier 1 network provider The level of coverage is the same as Tier 1 network provider Behavioral Health - Mental Health Inpatient * Unlimited days at a general hospital or a specialty hospital. 20% YES 20% YES 60% YES Outpatient, Inter- mediate Care Services* See Section 3.3 for details. 0% NO 0% NO 60% YES In the office/in your home rendered by PCP ^ Includes individual and group sessions. $10 NO $10 for a member up to nineteen (19) years old NO 60% YES $30 for a member nineteen (19) and older In the office/in your home rendered by Specialist Includes individual and group sessions. $30 NO $30 NO 60% YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network...
Sample 1

Related to Maximum Out of Pocket

  • Out-of-Pocket Expenses In addition to Beneficial Owner Servicing Fees and Networked Account Servicing Fees paid in accordance with Section 3 of this Agreement, the Investment Company shall reimburse FTIS monthly (i) for all classes of shares, other than any Class R6 shares, for the following out-of-pocket expenses paid to third parties in connection with the servicing of Accounts as required under the terms of this Agreement and (ii) for any Class R6 shares, for the following out-of-pocket expenses paid to third parties in connection with the servicing of shareholder accounts as required under the terms of this Agreement:  Expenses in connection with the preparation and physical or electronic delivery of shareholder communications required under the terms of this Agreement, such as prospectuses, shareholder reports, tax information, proxy statements, and shareholder statements. Such amounts paid to third parties include, but are not limited to, costs of printing, mailing, stationary, forms, postage, and electronic delivery. In the case of out-of-pocket expenses incurred by FTIS or an affiliate associated with the printing of new account confirming prospectuses (which prospectuses the Investment Company is obligated to deliver under its Underwriting Agreement and that FTIS agrees to deliver, on behalf of the Fund, in connection with the confirmation process), FTIS and the Investment Company each will pay one-half (50%) of the costs of printing the new account confirming prospectus (including, but not limited to, print on demand prospectuses used for that purpose);  Telephone costs associated with servicing shareholders in accordance with this agreement;  ACH, Federal Reserve and bank charges for check clearance, electronic funds transfers, wire transfers, and other banking charges associated with account and cash reconciliation for shareholder activity;  Data Storage: Retention of electronic and paper account records; and other costs associated with data storage of account records and transactions records (e.g., magnetic tape, microfilm and microfiche, and digital images);  Insurance against loss of Share certificates when in transit;  Terminals, transmitting lines and any expenses incurred in connection with such terminals and lines established and/or maintained by FTIS to perform its obligations under this agreement;  Amounts paid to independent accounting firms to perform independent audits of FTIS and the issuance of reports such as a SOC-1;  Amounts paid in connection with use of national data bases to comply with requirements for locating lost shareholders;  Proxy solicitation and tabulation expenses;  NSCC expenses. Costs associated with NSCC system use, including networking services, hardware and circuits to send customer cost basis information, commission and 12b-1 fees to brokerage firms  All other miscellaneous expenses reasonably incurred by FTIS in the performance of its obligations under the Agreement, excluding the costs relating to the compensation of Agents as contemplated under Section 14 of the Agreement. This Schedule B may be amended by FTIS upon not less than 30 days' written notice to the Investment Company, subject to approval by the Board. SCHEDULE C Beneficial Owner Servicing Fees and Networked Account Servicing Fees for each fiscal year of the Fund may not exceed (i), for each contract with an institution based on Fund assets, 15 basis points (0.15%) of such Fund's net assets attributable to the appropriate class of shares for which such institution provides services as contemplated by Section 3(b)(ii) and (iii) of this Agreement (“Services”) or (ii) for each contract with an institution based upon a flat per account fee, $16 per account for accounts that are not subject to a contingent deferred sales charge for which the institution provides Services and $19 per account for accounts that are subject to a contingent deferred sales charge for which the institution provides Services. This Schedule C may be amended only upon agreement in advance of FTIS, the Investment Company and its Board of Trustees/Directors. SCHEDULE D As the registered transfer agent and shareholder servicing agent for the Funds, FTIS is responsible for providing overall support for the customers of each Fund, including shareholders, financial advisors, distribution intermediaries, and other authorized representatives. FTIS controls the flow of the customer interactions, processes transactions, and handles inquiries while ensuring mitigation of operational, financial, regulatory, and reputational risk. FTIS is responsible for affecting activity in accordance with fund policies, (e.g. Rule 12b-1 payments, fund openings, reorganizations, closings), as well as required trade confirmations, statements, and tax reporting. FTIS maintains relationships with the back offices of intermediaries and ensures appropriate payments to intermediaries and other service vendors in accordance with this Agreement. Specific functions FTIS performs in accordance with securities laws, IRS laws or other regulations include: AS TRANSFER AGENT FOR THE INVESTMENT COMPANY, FTIS WILL:  Upon receipt of proper authorization, record the transfer of Fund shares ("Shares") in its transfer records in the name(s) of the appropriate legal shareholder(s) of record; and  Upon receipt of proper authorization, redeem Shares, debit shareholder accounts and provide for payment to shareholders. AS SHAREHOLDER SERVICE AGENT FOR THE INVESTMENT COMPANY, FTIS WILL:  Receive from the Investment Company, from the Investment Company's Principal Underwriter or from a Fund shareholder, in a manner acceptable to FTIS, information necessary to record Share sales and redemptions and to generate sale and/or redemption confirmations; o Mail, or electronically transmit, sale and/or redemption confirmations;  Coordinate the delivery of an account opening prospectus with delivery of initial purchase confirmations;  Accept and process payments from investors and their broker-dealers or other agents, for the purchase of Shares;  Support the use of automated systems for payment and other share transactions, such as NSCC Fund/Serv and Networking and other systems which may be reasonably requested by FTIS customers;  Keep records as necessary to implement any deferred sales charges, exchange restrictions or other policies of the Investment Company affecting Share transactions, including without limitation any restrictions or policies applicable to certain classes of shares, as stated in the applicable prospectus; o Requisition Shares in accordance with instructions of the Principal Underwriter, if applicable; o Open, maintain and close shareholder accounts;  Establish registration of ownership of Shares in accordance with generally accepted form;  Maintain records of (i) issued Shares and (ii) number of shareholders and their aggregate shareholdings classified according to their residence in each State of the United States or foreign country;  Accept and process telephone exchanges and redemptions for Shares in accordance with a Fund's Telephone Exchange and Redemption Privileges as described in the Fund's current prospectus.  Maintain and safeguard records for each shareholder showing name(s), address, number of any certificates issued, and number of Shares registered in such name(s), together with continuous proof of the outstanding Shares, and dealer identification, and reflecting all current changes. On request, provide information as to an investor's qualification for Cumulative Quantity Discount. Provide all accounts with, at minimum, quarterly and year-end historical statements;  Provide on request a duplicate set of records for file maintenance in the Investment Company's office;  Provide for the proper allocation of proceeds of share sales to the Investment Company and to the Principal Underwriter, in accordance with the applicable prospectus;  Redeem Shares and provide for the preparation and delivery of liquidation proceeds, including the processing of redemption checks and maintain checking account records;  Exercise reasonable and good-faith business judgment in the registration of Share transfers, pledges and releases from pledges in accordance with the California Uniform Commercial Code - - Investment Securities;  Upon receipt of proper documentation, place stop transfers, obtain necessary insurance forms, and cancel lost, stolen or destroyed Share certificates, and record ownership of Shares formerly represented by such certificates in its transfer records in the name(s) of the appropriate legal shareholder(s) of record, so long as applicable;  Check surrendered certificates for stop transfer restrictions, so long as applicable. Although FTIS cannot ensure the genuineness of certificates surrendered for cancellation, it will employ all due reasonable care in deciding the genuineness of such certificates and the guarantor of the signature(s) thereon; o Cancel surrendered certificates and record ownership of Shares formerly represented by such certificates in its transfer records in the name(s) of the appropriate legal shareholder(s) of record, so long as applicable;

  • Copayments and annual out-of-pocket maximums For the first and second year of the contract: Tier 1 copayment: Fourteen dollar ($14) copayment per prescription or refill for a Tier 1 drug dispensed in a thirty (30) day supply. Tier 2 copayment: Twenty-five dollar ($25) copayment per prescription or refill for a Tier 2 drug dispensed in a thirty (30) day supply. Tier 3 copayment: Fifty dollar ($50) copayment per prescription or refill for a Tier 3 drug dispensed in a thirty (30) day supply. Out of pocket maximum: There is an annual maximum eligible out-of-pocket expense limit for prescription drugs of eight hundred dollars ($800) per person or one thousand six hundred dollars ($1,600) per family.

  • Lifetime maximums and non-prescription out-of-pocket maximums Coverage under Advantage is not subject to a per person lifetime maximum. In the first and second years of the contract, coverage under Advantage is subject to a plan year, non-prescription drug, out-of-pocket maximum of one thousand seven hundred dollars ($1,700) per person or three thousand four hundred dollars ($3,400) per family for members whose primary care clinic is in Cost Level 1 or Cost Level 2; two thousand four hundred dollars ($2,400) per person or four thousand eight hundred dollars ($4,800) per family for members whose primary care clinic is in Cost Level 3; and three thousand six hundred dollars ($3,600) per person or seven thousand two hundred dollars ($7,200) per family for members whose primary care clinic is in Cost Level 4.

  • Reimbursable Expenses; Maximum Total Payment; Invoicing District will make no payment until this Contract is fully executed by the authorized representatives of both parties.

  • Maximum order The Contractor is not obligated to honor—

  • Treatment of Unallowable Costs Previously Submitted for Payment Defendants further agree that within 90 days of the Effective Date of this Agreement they shall identify to applicable Medicare and TRICARE fiscal intermediaries, carriers, and/or contractors, and Medicaid and FEHBP fiscal agents, any Unallowable Costs (as defined in this Paragraph) included in payments previously sought from the United States, or any State Medicaid program, including, but not limited to, payments sought in any cost reports, cost statements, information reports, or payment requests already submitted by Defendants or any of their subsidiaries or affiliates, and shall request, and agree, that such cost reports, cost statements, information reports, or payment requests, even if already settled, be adjusted to account for the effect of the inclusion of the Unallowable Costs. Defendants agree that the United States, at a minimum, shall be entitled to recoup from Defendants any overpayment plus applicable interest and penalties as a result of the inclusion of such Unallowable Costs on previously-submitted cost reports, information reports, cost statements, or requests for payment. Any payments due after the adjustments have been made shall be paid to the United States pursuant to the direction of the Department of Justice and/or the affected agencies. The United States reserves its rights to disagree with any calculations submitted by Defendants or any of their subsidiaries or affiliates on the effect of inclusion of Unallowable Costs (as defined in this Paragraph) on Defendants or any of their subsidiaries or affiliates’ cost reports, cost statements, or information reports.

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