OUT-OF-POCKET EXPENSES AND MAXIMUMS Benefit Plan(s) 001, 002, 003, 004, 005 DEDUCTIBLES A Deductible is an amount of money paid once per Plan Year by the Covered Person before any Covered Expenses are paid by this Plan. A Deductible applies to each Covered Person up to a family Deductible limit. When a new Plan Year begins, a new Deductible must be satisfied. Deductible amounts are shown on the Schedule of Benefits. Generally, the applicable Deductible must be met before any benefits will be paid under this Plan. However, certain covered benefits may be considered Preventive / Routine Care and paid first dollar. The Deductible amounts that the Covered Person Incurs for Covered Expenses, including covered Pharmacy expenses, will be used to satisfy the Deductible(s) shown on the Schedule of Benefits. The Deductible amounts that the Covered Person Incurs at an in-network provider will apply to the in- network total individual and family Deductible. The Deductible amounts that the Covered Person Incurs at an out-of-network provider will apply to the out-of-network total individual and family Deductible. PLAN PARTICIPATION Plan Participation is the percentage of Covered Expenses that the Covered Person is responsible for paying after the Deductible is met. The Covered Person pays this percentage until the Covered Person’s (or family’s, if applicable) annual out-of-pocket maximum is reached. The Plan Participation rate is shown on the Schedule of Benefits. Any payment for an expense that is not covered under this Plan will be the Covered Person’s responsibility. ANNUAL OUT-OF-POCKET MAXIMUMS The annual out-of-pocket maximum is the most the Covered Person pays each year for Covered Expenses. There are separate in-network and out-of-network out-of-pocket maximums for this Plan. Annual out-of-pocket maximums are shown on the Schedule of Benefits. Amounts the Covered Person Incurs for Covered Expenses will be used to satisfy the Covered Person’s (or family’s, if applicable) annual out-of-pocket maximum(s). If the Covered Person’s out-of-pocket expenses in a Plan Year exceed the annual out-of-pocket maximum, the Plan pays 100% of the Covered Expenses through the end of the Plan Year. The following will not be used to meet the out-of-pocket maximums: • Penalties, legal fees and interest charged by a provider. • Expenses for excluded services. • Any charges above the limits specified elsewhere in this document. • Pharmacy out-of-network Co-pays and out-of-network Plan Participation amounts for Prescription benefits. • Any amounts over the Recognized Amount, Usual and Customary amount, Negotiated Rate, or established fee schedule that this Plan pays. The eligible out-of-pocket expenses that the Covered Person Incurs at an in-network provider will apply to the in-network total out-of-pocket maximum. The eligible out-of-pocket expenses that the Covered Person Incurs at an out-of-network provider will apply to the out-of-network total out-of-pocket maximum. -31- 7670-00-413597