Plan is Secondary Sample Clauses

Plan is Secondary. If a Medical Group Member possesses health benefits coverage through another policy which is primary to PacifiCare under applicable coordination of benefits rules, including the Medicare secondary payor program, or if Medical Group Member is entitled to payment under a workers’ compensation policy or automobile insurance policy, Medical Group may pursue payment from the primary payor or workers’ compensation carrier consistent with applicable law and regulations and Medical Group’s contract, if any, with the primary payor. In such event, PacifiCare’s responsibility shall equal the amount of out-of-pocket expenses (i.e., Copayments, coinsurance, and deductibles) that Medical Group Member would incur in the absence of PacifiCare’s secondary coverage, minus the ISL Deductible and ISL Coinsurance.
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Plan is Secondary. If a Member possesses health benefits coverage through another policy which is primary to Health Plan under applicable coordination of benefits rules, including the Medicare secondary payor program, or if Member is entitled to payment under a workers' compensation policy or automobile insurance policy, Medical Group may pursue payment from the primary payor or workers' compensation carrier consistent with applicable law and regulations and Medical Group's contract, if any, with the primary payor. In such event, Health Plan's responsibility shall equal the amount of out-of-pocket expenses (i.e., Copayments and deductibles) that Member would incur in the absence of Health Plan's secondary coverage, minus the ISL Deductible and ISL Coinsurance.
Sample 1Sample 2
Plan is Secondary. If a Medical Group Member possesses health benefits coverage through another policy which is primary to PacifiCare under applicable coordination of benefits rules, including the Medicare secondary payor program, or if Medical Group Member is entitled to payment under a workers’ compensation policy or automobile insurance policy, Medical Group may pursue payment from the primary payor or workers’ compensation carrier consistent with applicable law and regulations and Medical Group’s contract, if any, with the primary payor. In such event, PacifiCare’s responsibility shall be limited to the amounts it would pay pursuant to the ISL Program described at Section 5.5 above, less all amounts collected from the primary insurer.
Sample 1

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