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 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. 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.