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. 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. 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 Consistent with the amount explained above in this definition. Generally providers who are not part requirements of the LifeWise Connect Affordable Care Act the allowed amount will be the greater of the following:  The median amount in-network are not covered on your plan. However, if a covered service is not available from LifeWise Connect provider, you can receive benefits providers have agreed to accept for the same services provided  The amount Medicare would allow for the same services  The amount calculated by an the same method the plan uses to determine payment to out-of-network provider providers In addition to your deductible, copayments and coinsurance, you will be responsible for charges received from out-of-network providers above the allowed amount. If you have questions about this information, please call us 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 detailsnumber listed on your LifeWise ID card.

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.