|
Allowed amount is the most the plan pays for a specific covered service or supply. See the table below for how the plan determines the allowed amount for specific services and provider types.
| Type of Provider/Service |
Provider Network Status |
Location of Provider |
Allowed Amount |
| Professional services, durable medical equipment, supplies, and prostheses |
Network |
Throughout the U.S., including Washington State |
Lesser of contracted fee schedule amount or billed charge |
| Non-network |
Throughout the U.S., including Washington State |
Lesser of the fee schedule amount or billed charge |
| Hospitals and other facilities |
Network |
Throughout the U.S., including Washington State |
As contracted |
| Non-network |
Inside Washington State |
Based on allowed amounts for network facilities |
| Non-network |
Outside Washington State |
Eligible billed charges, or rates negotiated with the facility |
| Prescription drugs* |
All prescription drug providers (network and non-network) |
Everywhere, including outside the U.S. |
Washington State Rx Services' standard reimbursement, unless other contractual arrangements or terms apply |
* When medications not normally self-administered are received in a provider's office, the allowed amount is based on a percentage of the Average Wholesale Price (AWP) or a percentage of the Average Sales Price (ASP). The ASP is determined by the Centers for Medicare & Medicaid Services.
|
