Plan 1 - 2000

PHP Schedule of Benefits for CUSTOM 2000 Sample Plan Benefit Overview In-Network Out-of-Network* Per Member Deductible $2,000 $4,000 Per Family Deductible $4,000 $8,000 Per Member Out-of-Pocket Limit $5,000 $10,000 Per Family Out-of-Pocket Limit $8,000 $16,000 There may be more than one Deductible and Out-of-Pocket Limit set forth in the Contract. Deductibles and Out-of-Pocket Limits are based on a Calendar Year benefit period, unless otherwise indicated herein. In-Network: The In-Network Deductible and In-Network Out-of-Pocket Limit apply to all In-Network Covered Health Services unless otherwise stated. In-Network Copays do not count toward the In-Network Deductible. The In-Network Deductible, Copays and Coinsurance count toward the In-Network Out-of- Pocket Limit. If a Provider, a facility, or anyone else reduces or waives the required cost sharing (Deductible, Copays, Coinsurance) for a particular claim, we reserve the right to adjust the amount charged, the amount eligible under the terms of the policy, your Deductible and/or Out-of-Pocket Limit, to accurately reflect the amount actually charged for that claim. This Plan is embedded: PHP will pay for a Member’s Covered Health Services once the “per Member” Deductible is met by that Member. When the “per family” Deductible is met, PHP will pay for Covered Health Services for all Covered family Members. Copays and Coinsurance for a Member’s Covered Health Services are not required for the rest of the Calendar Year once the “per Member” Out-of-Pocket Limit is met by that Member. When the “per family” Out-of-Pocket Limit is met, Copays and Coinsurance for Covered Health Services are not required for the rest of the Calendar Year for all Covered family Members. Out-of-Network: The Out-of-Network Deductible and Out-of-Network Out-of-Pocket Limit apply to all Out-of- Network Covered Health Services unless otherwise stated. The Out-of-Network Deductible and Coinsurance count toward the Out-of-Network Out-of-Pocket Limit. If a Provider, a facility, or anyone else reduces or waives the required cost sharing (Deductible, Copays, Coinsurance) for a particular claim, we reserve the right to adjust the amount charged, the amount eligible under the terms of the policy, your Deductible and/or Out-of-Pocket Limit, to accurately reflect the amount actually charged for that claim. This Plan is embedded: PHP will pay for a Member’s Out-of-Network Covered Health Services once the Out-of- Network “per Member” Deductible is met by that Member. When the Out-of-Network “per family” Deductible is met, PHP will pay for Out-of-Network Covered Health Services for all Covered family Members. Coinsurance for a Member’s Out-of-Network Covered Health Services is not required for the rest of the Calendar Year once the Out-of-Network “per Member” Total Out-of-Pocket Limit is met by that Member. When the Out-of-Network “per family” Total Out-of-Pocket Limit is met, Coinsurance for Out-of-Network Covered Health Services is not required for the rest of the Calendar Year for all Covered family Members. Expenses you incur on non-Covered Services do not count toward the applicable In-Network or Out-of- Network Deductible or toward the applicable In-Network or Out-of-Network Out-of-Pocket Limit. This schedule is a summary of the benefits available to you. It also may help you understand how much you may have to pay for a particular service. Before getting any Health Services, you should review your Certificate of Coverage and contact us to check your Coverage. PHP.POS.LG.NGF.SOBTRAD.JSC.01-PUBLISHED 2024 P_240082_L 09.09.2024