14 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, Coinsurance, or Copayments 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. 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 we, on behalf of the Employer, have the right to collect such amou nts from you. The tables below outline the Plan’s Covered Services and the cost share(s) you must pay. In many spots you will see the statement, “Benefits are based on the setting in which Covered Services are received.” In these cases you should determine where you will receive the service (i.e., in a doctor’s office, at an outpatient hospital facility, etc.) and look up that location to find out which cos t share will apply. For example, you might get physical therapy in a doctor’s office, an outpatient hospital faci lity, or during an inpatient hospital stay. For services in the office, look up “Office Visits.” For services in the outpatient department of a hospital, look up “Outpatient Facility Services.” For services during an inpatient stay, look up “Inpatient Services.” Benefits Tier 1 In - Network Providers Tier 2 All Other In - Network Providers Tier 3 Out - of - Network Providers Allergy Services Benefits are based on the setting in which Covered Services are received. Benefits are based on the setting in which Covered Services are received. 50% Coinsurance after Deductible Ambulance Services (Ground, Air, and Water) Emergency Services 20% Coinsurance after Deductible For ground or water ambulance services, Out - of - Network Providers may also bill you for any charges that exceed the Plan’s Maximum Allowed Amount. This does not apply to air ambulance services. For air ambulance services, Out - of - Network Providers cannot bill you for more than your applicable In - Network Deductible, Coinsurance, and/or Copayment . Ambulance Services (Ground, Air, and Water) Non - Emergency Services 20% Coinsurance after Deductible For ground or water ambulance services, Out - of - Network Providers may also bill you for any charges that exceed the Plan’s Maximum Allowed Amount. This does not apply to air ambulance services. For air ambulance services, Out - of - Network Providers cannot bill you for more than your applicable In - Network Deductible, Coinsurance, and/or Copayment . Important Note: All scheduled ambulance services for non - Emergency transfers, except transfers from one acute Facility to another, must be approved through precertification. Please see “Getting Approval for Benefits” for details.