Part 2 – Explanation of Terms (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 11 United States). For these covered services, the full amount of the health care provider’s actual charge is used to calculate your claim payment. Exception: For health care providers who do not have a payment agreement with Blue Cross Blue Shield HMO Blue or, for health care providers outside of Massachusetts, with the local Blue Cross and/or Blue Shield Plan, there may be times when Blue Cross Blue Shield HMO Blue is able to negotiate a fee with the provider that is less than the allowed charge that would have been used to calculate your claim payment (as described in the above paragraph). When this happens, the “negotiated fee” will be used as the allowed charge to calculate your claim payment and you will not have to pay the amount of the provider’s charge that is in excess of the negotiated fee. You will only have to pay your deductible and/or your copayment and/or your coinsurance, whichever applies. Blue Cross Blue Shield HMO Blue will send you a written notice about your claim that will tell you how your claim was calculated, including the allowed charge, the amount paid to the provider, and the amount you must pay to the provider. Pharmacy Providers Blue Cross Blue Shield HMO Blue may have payment arrangements with pharmacy providers that may result in rebates on covered drugs and supplies. The cost that you pay for a covered drug or supply is determined at the time you buy the drug or supply. The cost that you pay will not be adjusted for any later rebates, settlements, or other monies paid to Blue Cross Blue Shield HMO Blue from pharmacy providers or vendors. Appeal An appeal is something you do if you disagree with a Blue Cross Blue Shield HMO Blue decision to deny a request for coverage of health care services or drugs, or payment, in part or in full, for services or drugs you already received. You may also make an appeal if you disagree with a Blue Cross Blue Shield HMO Blue decision to stop coverage for services that you are receiving. For example, you may ask for an appeal if Blue Cross Blue Shield HMO Blue doesn’t pay for a service, item, or drug that you think you should be able to receive. Part 10 explains what you have to do to make an appeal. It also explains the review process. Balance Billing There may be certain times when a health care provider will bill you for the difference between the provider’s charge and the allowed charge. This is called balance billing. A preferred provider cannot balance bill you for covered services. See “allowed charge” above for information about the allowed charge and the times when a health care provider may balance bill you. Benefit Limit For certain health care services or supplies, there may be day, visit, or dollar benefit maximums that apply to your coverage in this health plan. The Schedule of Benefits for your plan option and Part 5 of this Subscriber Certificate describe the benefit limits that apply to your coverage. (Also refer to riders—if there are any—that apply to your coverage in this health plan.) Once the amount of the benefits that you have received reaches the benefit limit for a specific covered service, no more benefits will be provided by this health plan for those health care services or supplies. When this happens, you must pay the full amount of the provider’s charges that you incur for those health care services or supplies that are more than the benefit limit. An overall lifetime benefit limit will not apply for coverage in this health plan.