Common use of Out-of-Network Benefits Clause in Contracts

Out-of-Network Benefits. The out-of-network benefits portion of this Contract provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. READ THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueCross BlueShield of Western New York 000 Xxxx Xxxxxxx Xx. Buffalo, New York 14202 President & CEO This is Your individual Contract for preferred provider organization coverage issued by BlueCross BlueShield of Western New York. This Contract, together with the attached Schedule of Benefits, applications, and any amendment or rider amending the terms of this Contract, constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract. We will refund any Premium paid including any Contract fees or other charges.

Out-of-Network Benefits. The out-of-network benefits portion of this Contract provides coverage when You receive Covered Services from Non-Participating Providers. Your out-of-pocket expenses will be higher when You receive out-of-network benefits. In addition to Cost-Sharing, You will also be responsible for paying any difference between the Allowed Amount and the Non-Participating Provider’s charge. READ THIS ENTIRE CONTRACT CAREFULLY. IT IS YOUR RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS CONTRACT. This Contract is governed by the laws of New York State. The insurance evidenced by this Contract provides DENTAL insurance ONLY. This Contract is a New York State of Health, The Official Health Plan Marketplace, certified stand-alone dental plan offered outside the New York State of Health. If You need foreign language assistance to understand this Contract, You may call Us at 0-000-000-0000 This is Your PREFERRED PROVIDER ORGANIZATION INSURANCE CONTRACT Issued by BlueCross BlueShield of Western Northeastern New York 000 00 Xxxxxxx Xxxx Xxxxxxx Xx. BuffaloXxxxx Latham, New York 14202 12110 President & CEO This is Your individual Contract for preferred provider organization coverage issued by BlueCross BlueShield of Western Northeastern New York. This Contract, together with the attached Schedule of Benefits, applications, and any amendment or rider amending the terms of this Contract, constitute the entire agreement between You and Us. You have the right to return this Contract. Examine it carefully. If You are not satisfied, You may return this Contract to Us and ask Us to cancel it. Your request must be made in writing within ten (10) days from the date You receive this Contract. We will refund any Premium paid including any Contract fees or other charges.