13 Schedule of Benefits In this section you will find an outline of the benefits included in your Plan and a summary of any Deductibles, Coinsurance, and Copayments that you must pay. Also listed are any Benefit Period Maximums or limits that apply. Please read the "What’s Covered" and Prescription Drugs section(s) for more details on the Plan’s Covered Services. Read the “What’s Not Covered” section for details on Excluded Services. All Covered Services are subject to the conditions, Exclusions, limitations, and terms of this Booklet including any endorsements, amendments, or riders. Benefits for Covered Services are based on the Maximum Allowed Amount, which is the most the Plan will allow for a Covered Service. Except for Surprise Billing Claims, if you use a Participating Provider, you will only have to pay applicable Deductibles, Coinsurance, and/or Copayments for Covered Services. However, if you use a Non-Participating Provider you may also have to pay the difference between the Non-Participating Provider’s billed charge and the Maximum Allowed Amount in addition to any Deductibles, Coinsurance, Copayments and non-covered charges. This amount can be substantial. Please read the “Claims Payment” section for more details. Deductibles, Coinsurance, and Benefit Period Maximums are calculated based upon the Maximum Allowed Amount, not the Provider’s billed charges. Essential Health Benefits provided within this Booklet are not subject to lifetime or annual dollar maximums. Certain non-essential health benefits, however, are subject to either a lifetime and/or dollar maximum. Essential Health Benefits are defined by federal law and refer to benefits in at least the following categories: • Ambulatory patient services, • Emergency services, • Hospitalization, • Maternity and newborn care, • Mental health and Substance Use Disorder Services, including behavioral health treatment, • Prescription drugs, • Rehabilitative and habilitative services and devices, • Laboratory services, • Preventive and wellness services, and • Chronic disease management and pediatric services, including oral and vision care. Such benefits shall be consistent with those set forth under the Patient Protection and Affordable Care Act of 2010 and any regulations issued pursuant thereto. Benefit Period Calendar Year Dependent Age Limit To the end of the month in which the child attains age 26. Deductible Participating Per Member $400