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. 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 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. 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. 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 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. 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 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. 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. 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. 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 The allowable charge is the amount explained above in this definition. 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. The amount we pay for dialysis will be no less than a comparable provider that has a contracting agreement with us and no more than 90% of billed charges. See Chemotherapy, Radiation Therapy and Kidney Dialysis for more details.
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.
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 • Covered services that say they do not apply to the out-of-pocket maximum on the Summary of Your Costs 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. The allowed amount is the fee that we or other Blue Cross Blue Shield Licensees have negotiated with providers who have signed contracts and in Washington are in the Heritage Signature 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. have signed contracts with us. • 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 expense maximum applicable to covered services or supplies obtained on an in-network basis under the HCN 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 HCN 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 6.1.4.)
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.
(2) Once the Out of Pocket Maximum is reached, we will pay 100% of the Benefits for Covered Services.
(3) Copayments, Coinsurance and the Deductible apply towards 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 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.
