14 Per Family –All other Members combined $1,200 When the Deductible applies, you must pay it before benefits begin. See the sections below to find out when the Deductible applies. Copayments and Coinsurance are separate from and do not apply to the Deductible. Any amounts applied to the Deductible for costs you pay during the last three months of the Benefit Period will also apply to the next Benefit Period’s Deductible. Coinsurance Participating Plan Pays 80% Member Pays 20% Reminder: Except for Surprise Billing Claims, your Coinsurance will be based on the Maximum Allowed Amount. If you use an approved Non-Participating Provider, you may have to pay Coinsurance plus the difference between the Non-Participating Provider’s billed charge and the Maximum Allowed Amount. Note: The Coinsurance listed above may not apply to all benefits, and some benefits may have a different Coinsurance. Please see the rest of this Schedule for details. Out-of-Pocket Limit Participating Per Member $1,500 Per Family - All other Members combined $5,600 The Out-of-Pocket Limit includes all Deductibles, Coinsurance, and Copayments you pay during a Benefit Period unless otherwise indicated below. It does not include charges over the Maximum Allowed Amount or amounts you pay for non-Covered Services. The Out-of-Pocket Limit does not include amounts you pay for following benefits: • Human Organ and Tissue Transplant (Bone Marrow / Stem Cell), Cellular and Gene Therapy Services from a Non-Participating Provider. No one person covered under a family plan will pay more than their individual Out-of-Pocket Limit. Once the Out-of- Pocket Limit is satisfied, you will not have to pay any additional Deductibles, Coinsurance, or Copayments for the rest of the Benefit Perio, except for the services listed above. Important Notice about Your Cost Shares In certain cases, if a Provider is paid amounts that are your responsibility, such as Deductibles, Copayments or Coinsurance, such amounts may be collected directly from you. You agree that the Claims Administrator, on behalf of the Employer, has the right to collect such amounts from you.