Common use of Higher Cost Share Hospitals Clause in Contracts

Higher Cost Share Hospitals. The Massachusetts hospitals listed below are the hospitals in which your cost share will be higher. Blue Cross Blue Shield will let you know if this list changes. • Baystate Medical Center • Boston Children’s Hospital • Xxxxxxx and Women’s Hospital • Cape Cod Hospital • Xxxx-Xxxxxx Cancer Institute • Fairview Hospital • Massachusetts General Hospital • North Shore Medical Center – Salem Campus • North Shore Medical Center – Union Campus • South Shore Hospital • Sturdy Memorial Hospital • UMass Memorial Medical Center – Memorial Campus • UMass Memorial Medical Center – University Campus There are several ways to find a preferred provider: • Look up a provider in the Provider Directory. If you need a copy of your directory, call Member Service at the number on your ID card. • Visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxx • Call our Physician Selection Service at 0-000-000-0000 If you have not satisfied your deductible, your provider may ask you to pay the actual charge for your care at the time of your visit. After the plan-year deductible has been met, you pay 20 percent coinsurance for most out- of-network covered services. Payments for out-of- network benefits are based on the Blue Cross Blue Shield of Massachusetts allowed charge as defined in your benefit description. You may be responsible for any difference between the allowed charge and the provider’s actual billed charge (this is in addition to your deductible and/or your coinsurance). Your out-of-pocket maximum is the most that you could pay during a plan year for deductible, copayments, and coinsurance for covered services. Your medical out-of-pocket maximumis $2,500 per member (or $5,000 per family) for in-network andout-of-network servicescombined. Yourprescriptiondrug out-of-pocket maximum is $1,000 per member (or $2,000 per family).

Higher Cost Share Hospitals. The Massachusetts hospitals listed below are the hospitals in which your cost share will be higher. Blue Cross Blue Shield will let you know if this list changes. • Baystate Medical Center • Boston Children’s Hospital • Xxxxxxx and Women’s Hospital • Cape Cod Hospital • Xxxx-Xxxxxx Cancer Institute • Fairview Hospital • Massachusetts General Hospital • North Shore Medical Center – Salem Campus • North Shore Medical Center – Union Campus • South Shore Hospital • Sturdy Memorial Hospital • UMass Memorial Medical Center – Memorial Campus • UMass Memorial Medical Center – University Campus There are several ways to find a preferred provider: • Look up a provider in the Provider Directory. If you need a copy of your directory, call Member Service at the number on your ID card. • Visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxx • Call our Physician Selection Service at 0-000-000-0000 If you have not satisfied your deductible, your provider may ask you to pay the actual charge for your care at the time of your visit. After the plan-year deductible has been met, you pay 20 percent coinsurance for most out- out-of-network covered services. Payments for out-of- of-network benefits are based on the Blue Cross Blue Shield of Massachusetts allowed charge as defined in your benefit description. You may be responsible for any difference between the allowed charge and the provider’s actual billed charge (this is in addition to your deductible and/or your coinsurance). Your out-of-pocket maximum is the most that you could pay during a plan year for deductible, copayments, and coinsurance for covered services. Your medical out-of-pocket maximumis maximum is $2,500 per member (or $5,000 per family) for in-network andoutand out-of-network servicescombinedservices combined. Yourprescriptiondrug Your prescription drug out-of-pocket maximum is $1,000 per member (or $2,000 per family).

Higher Cost Share Hospitals. The Massachusetts hospitals listed below are the hospitals in which your cost share will be higher. Blue Cross Blue Shield will let you know if this list changes. • Baystate Medical Center • Boston Children’s Hospital • Xxxxxxx and Women’s Hospital • Cape Cod Hospital • Xxxx-Xxxxxx Cancer Institute • Fairview Hospital • Massachusetts General Hospital • North Shore Medical Center – Salem Campus • North Shore Medical Center – Union Campus • South Shore Hospital • Sturdy Memorial Hospital • UMass Memorial Medical Center – Memorial Campus • UMass Memorial Medical Center – University Campus There are several ways to find a preferred provider: • Look up a provider in the Provider Directory. If you need a copy of your directory, call Member Service at the number on your ID card. • Visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxx • Call our Physician Selection Service at 0-000-000-0000 If you have not satisfied your deductible, your provider may ask you to pay topay the actual charge for actualchargefor your care at the time of your visit. After the planyourvisit.Aftertheplan-year deductible has been met, yeardeductiblehasbeenmet,you pay 20 percent coinsurance for most out- out-of-network covered services. Payments for out-of- of-network benefits are based on the Blue Cross Blue Shield of Massachusetts allowed charge as defined in your benefit description. You may be responsible for any difference between the allowed charge and the provider’s providerce actual billed charge (this is in addition to your deductible and/or your coinsurance). Your out-of-pocket maximum is the most that you could pay during a plan year for deductible, copayments, and coinsurance for covered services. Your medical out-of-pocket maximumis $2,500 per member (or $5,000 per family) for in-network andoutand out-of-network servicescombinedservices combined. Yourprescriptiondrug Yourprescription drug out-of-pocket maximum is $1,000 per member (or $2,000 per family).

Higher Cost Share Hospitals. The Massachusetts hospitals listed below are the hospitals in which your cost share will be higher. Blue Cross Blue Shield will let you know if this list changes. • Baystate Medical Center • Boston Children’s Hospital • Xxxxxxx and Women’s Hospital • Cape Cod Hospital • Xxxx-Xxxxxx Cancer Institute • Fairview Hospital • Massachusetts General Hospital • North Shore Medical Center – Salem Campus • North Shore Medical Center – Union Campus • South Shore Hospital • Sturdy Memorial Hospital • UMass Memorial Medical Center – Memorial Campus • UMass Memorial Medical Center – University Campus There are several ways to find a preferred provider: • Look up a provider in the Provider Directory. If you need a copy of your directory, call Member Service at the number on your ID card. • Visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxx • Call our Physician Selection Service at 0-000-000-0000 If you have not satisfied your deductible, your provider may ask you to pay the actual charge for your care topaythe actualchargefor yourcare at the time of your visit. After the planyourvisit.Aftertheplan-year deductible has been met, yeardeductiblehasbeenmet,you pay 20 percent coinsurance for most out- out-of-network covered services. Payments for out-of- of-network benefits are based on the Blue Cross Blue Shield of Massachusetts allowed charge as defined in your benefit description. You may be responsible for any difference between the allowed charge and the provider’s providerce actual billed charge (this is in addition to your deductible and/or your coinsurance). Your out-of-pocket maximum is the most that you could pay during a plan year for deductible, copayments, and coinsurance for covered services. Your medical out-of-pocket maximumis $2,500 per member (or $5,000 per family) for in-network andoutand out-of-network servicescombinedservices combined. Yourprescriptiondrug Yourprescription drug out-of-pocket maximum is $1,000 per member (or $2,000 per family).

Higher Cost Share Hospitals. The Massachusetts hospitals listed below are the hospitals in which your cost share will be higher. Blue Cross Blue Shield will let you know if this list changes. • Baystate Medical Center • Boston Children’s Hospital Childrenl Centerwil • Xxxxxxx Brigham and Women’s Hospital WomenCenterwill • Cape Cod Hospital • Xxxx-Xxxxxx Cancer Institute • Fairview Hospital • Massachusetts General Hospital • North Shore Medical Center – Salem Campus • North Shore Medical Center – Union Campus • South Shore Hospital • Sturdy Memorial Hospital • UMass Memorial Medical Center – Memorial Campus • UMass Memorial Medical Center – University Campus There are several ways to find a preferred provider: • Look up a provider in the Provider Directory. If you need a copy of your directory, call Member Service at the number on your ID card. • Visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxx • Call our Physician Selection Service at 0-000-000-0000 If you have not satisfied your deductible, your provider may ask you to pay topay the actual charge for actualchargefor your care at the time of your visit. After the planyourvisit.Aftertheplan-year deductible has been met, yeardeductiblehasbeenmet,you pay 20 percent coinsurance for most out- out-of-network covered services. Payments for out-of- of-network benefits are based on the Blue Cross Blue Shield of Massachusetts allowed charge as defined in your benefit description. You may be responsible for any difference between the allowed charge and the provider’s providerce actual billed charge (this is in addition to your deductible and/or your coinsurance). Your out-of-pocket maximum is the most that you could pay during a plan year for deductible, copayments, and coinsurance for covered services. Your medical out-of-pocket maximumis maximum is $2,500 per member (or $5,000 per family) for in-network andoutand out-of-network servicescombinedservices combined. Yourprescriptiondrug Your prescription drug out-of-pocket maximum is $1,000 per member (or $2,000 per family).

Higher Cost Share Hospitals. The Massachusetts hospitals listed below are the hospitals in which your cost share will be higher. Blue Cross Blue Shield will let you know if this list changes. • Baystate Medical Center • Boston Children’s Hospital Childrenl Centerwil • Xxxxxxx Brigham and Women’s Hospital WomenCenterwill • Cape Cod Hospital • Xxxx-Xxxxxx Cancer Institute • Fairview Hospital • Massachusetts General Hospital • North Shore Medical Center – Salem Campus • North Shore Medical Center – Union Campus • South Shore Hospital • Sturdy Memorial Hospital • UMass Memorial Medical Center – Memorial Campus • UMass Memorial Medical Center – University Campus There are several ways to find a preferred provider: • Look up a provider in the Provider Directory. If you need a copy of your directory, call Member Service at the number on your ID card. • Visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxx • Call our Physician Selection Service at 0-000-000-0000 If you have not satisfied your deductible, your provider may ask you to pay the actual charge for your care topaythe actualchargefor yourcare at the time of your visit. After the planyourvisit.Aftertheplan-year deductible has been met, yeardeductiblehasbeenmet,you pay 20 percent coinsurance for most out- out-of-network covered services. Payments for out-of- of-network benefits are based on the Blue Cross Blue Shield of Massachusetts allowed charge as defined in your benefit description. You may be responsible for any difference between the allowed charge and the provider’s providerce actual billed charge (this is in addition to your deductible and/or your coinsurance). Your out-of-pocket maximum is the most that you could pay during a plan year for deductible, copayments, and coinsurance for covered services. Your medical out-of-pocket maximumis maximum is $2,500 per member (or $5,000 per family) for in-network andoutand out-of-network servicescombinedservices combined. Yourprescriptiondrug Your prescription drug out-of-pocket maximum is $1,000 per member (or $2,000 per family).