for exclusions Clause Samples

for exclusions. The amount you pay for covered healthcare services can differ based on the following: • the service was provided in an inpatient or outpatient setting, in a physician’s office, in your home, or from a pharmacy; • the healthcare provider is from a network provider or non-network provider; • a deductible, a copayment, or a benefit limit applies; • you reached your plan year maximum out-of-pocket expense; • there are exclusions from coverage that apply; or • our allowance for a covered healthcare service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider.

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for exclusions. The amount you pay for covered healthcare services can differ based on the following: • the service was provided in an inpatient or outpatient setting, in a physician’s office, in your home, or from a pharmacy; • the healthcare provider is from a network provider or non-network provider; • a deductible, a copayment, or a benefit limit applies; • the network provider has a Standard or Enhanced benefit designation; • you reached your plan year maximum out-of-pocket expense; • there are exclusions from coverage that apply; or • our allowance for a covered healthcare service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider.

for exclusions. The amount you pay for covered healthcare services can differ based on the following: • the service was provided in an inpatient or outpatient setting, in a physician’s office, in your home, or from a pharmacy; • the healthcare provider is from a network provider or non-network provider; • a deductible, a copayment, or a benefit limit applies; • you reached your plan year maximum out-of-pocket expense; • there are exclusions from coverage that apply; or • our allowance for a covered healthcare service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. The following network assignments shall apply to this plan: Network Assignments Important Information Network Provider Services Network providers are those healthcare providers that have entered into a contract to provide covered healthcare services for this plan. If you receive covered healthcare services from a network provider, the provider has agreed to accept our payment for covered healthcare services as payment in full, excluding your copayments, deductible (if any), and the difference between the benefit limit and our allowance. This plan uses the BlueCHiP provider network. Our service area for network providers includes Rhode Island and the counties of Connecticut and Massachusetts that border Rhode Island. Non-network Provider Services Non-network providers are those healthcare providers that have not entered into a contract to provide covered healthcare services for this plan. Services received from a non-network provider are not covered except in the following special circumstances: • emergency care (emergency room, urgent care and ground ambulance services); • air ambulance services; • we specifically approve the use of a non-network provider for covered healthcare services, see Network Authorization in Section 5 for details; Network Assignments Important Information • certain non-emergency covered healthcare services performed by a non-network provider at a network facility as described in Section 5; • otherwise, as required by law. In these special circumstances, the services rendered by a non- network provider will be covered at the network benefit level shown in the Summary of Medical Benefits. The deductible and maximum out-of-pocket expenses are calculated based on the lower of our allowance or the provider’s charge, unless special circumstances apply or otherwi...

for exclusions. The amount you pay for covered healthcare services can differ based on the following: • the service was provided in an inpatient or outpatient setting, in a physician’s office, in your home, or from a pharmacy; • the healthcare provider is from a Tier 1 or Tier 2 in-network provider, an out-of-network provider, or a non-participating provider; • the deductible (if any), copayment, or benefit limits applied; • you reached your plan year maximum out-of-pocket expense; • there are exclusions from coverage that apply; or • our allowance for a covered healthcare service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by an in-network provider. All of our payments at the benefit levels noted below are based upon a fee schedule called our

for exclusions. The amount you pay for covered healthcare services can differ based on the following: • the service was provided in an inpatient or outpatient setting, in a p h y s i cofificae, nin ’yosur home, or from a pharmacy; • the healthcare provider is from a network provider or non-network provider; • the deductible (if any), copayment, or benefit limits applied; • you reached your plan year maximum out-of-pocket expense; • there are exclusions from coverage that apply; or • our allowance for a covered healthcare service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. All of our payments at the benefit levels noted below are based upon a fee schedule called our