Plan 3 - 6000

PHP Schedule of Benefits for Legacy 6000 HSA CUSTOM Sample Plan Benefit Overview Single Coverage In-Network Out-of-Network* Deductible** $6,000 per Member $12,000 per Member Coinsurance 20% up to $3,050 per Member 50% up to $6,100 per Member Total Out-of-Pocket Limit $8,050 per Member $16,100 per Member Family Coverage In-Network Out-of-Network* Deductible** $6,000 per Member or $12,000 per Family $12,000 per Member or $24,000 per Family Coinsurance 20% up to $3,050 per Member or $6,100 per Family 50% up to $6,100 per Member or $12,200 per Family Total Out-of-Pocket Limit $8,050 per Member or $16,100 per Family $16,100 per Member or $32,200 per Family Deductibles and Out-of-Pocket Limits are based on a Calendar Year benefit period, unless otherwise indicated herein. **Because the Plan is intended to be a qualified high deductible health plan, deductible may automatically adjust when the IRS implements cost of living changes each year. A new schedule may not be provided. In-Network: The In-Network Deductible and In-Network Total Out-of-Pocket Limit apply to all In-Network Covered Health Services unless otherwise stated. The In-Network Deductible and Coinsurance count toward the In-Network Total 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 In-Network Covered Health Services once the In-Network “per Member” Deductible is met by that Member. When the In-Network “per family” Deductible is met, PHP will pay for In-Network Covered Health Services for all Covered family Members. Coinsurance for a Member’s In-Network Covered Health Services is not required for the rest of the Calendar Year once the In-Network “per Member” Total Out-of-Pocket Limit is met by that Member. When the In-Network “per family” Total Out-of-Pocket Limit is met, Coinsurance for In-Network Covered Health Services is 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 Total 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 Total 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” PHP.POS.LG.NGF.SOBHDHP.01-PUBLISHED 2024 QP240068_L 7.24.2024