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 • 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 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.