14 Deductible In - Network Out - of - Network If you, the Subscriber, are the only person covered by this Plan, only the “per Member” amounts apply to you. If you, the Subscriber, also cover Dependents (other family members) under this Plan, only the “per Family” amounts apply. The In - Network and Out - of - Network Deductibles are separate and cannot be combined. 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. Coinsurance In - Network Out - of - Network Plan Pays 80% 60% Member Pays 20% 40% Reminder: Except for Surprise Billing Claims, your Coinsurance will be based on the Maximum Allowed Amount. If you use an Out - of - Network Provider, you may have to pay Coinsurance plus the difference between the Out - of - Network 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 In - Network Out - of - Network Subscriber $4,000 $8,000 Subscriber Plus One $ 7,5 00 $ 16,000 Subscriber Plus Two or More Family Members - All other Members combined $8,000 $16,000 The Out - of - Pocket Limit includes all Deductibles and Coinsurance 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: • Out - of - Network Human Organ and Tissue Transplant (Bone Marrow / Stem Cell), Cellular and Gene Therapy Services . No one person covered under a family plan will pay more than their individual Out - of - Pocket Limit. Once th e Out - of - Pocket Limit is satisfied, you will not have to pay any additional Deductibles or Coinsurance for the rest of the Benefit Period , except for the services listed above . The In - Network and Out - of - Network Out - of - Pocket Limits are separate and do not apply toward each other.