Common use of Annual Deductible Clause in Contracts

Annual Deductible. Certain services are subject to an Annual Deductible. This is the amount a Member must pay each Calendar Year for Covered Services before some Covered Services are paid under this Contract. It is also referred to as the Deductible. Please refer to Your Schedule of Benefits. Not all Covered Services are subject to the Deductible such as most Preventive Services. Your Plan’s Copayment amounts do not apply towards Your Deductible. Please refer to Your Schedule of Benefits for Your Plan’s Deductible amounts and for information about which services are not subject to the Deductible. Copayments and penalties are not considered when determining if You have satisfied Your Deductible. You have an individual Deductible. Once Your individual Deductible has been met, the Plan will pay benefits for Your Covered Services. Refer to Your Schedule of Benefits for Your Deductible amount. If You have enrolled in family coverage, or coverage for two (2) or more people; Your Plan has a Family Deductible. Some Covered Services will not be eligible for payment by the Plan until either the Per-Person Deductible or the Family Deductible has been met. Amounts paid by any Member in Your family toward their Per-Person Deductible will also apply to the Family Deductible. For example, if the individual Member’s Per-Person Deductible is $500, then up to $500 per Member can be applied to the Family Deductible. Once the Family Deductible has been met no Per-Person Deductible will apply and We will pay for Covered Services. Changes to the Deductible may only be made at renewal. Your Plan includes an Annual Out-of-Pocket Maximum to protect You and Your Dependents from the high cost of a catastrophic event. The Annual Out-of-Pocket Maximum is the most You will pay for Cost Sharing in a Calendar Year for certain Covered Benefits. Please refer to Your Schedule of Benefits for the Out-of-Pocket Maximum. Only Deductibles, Coinsurance, and Copay amounts paid out of Your pocket for Covered Benefits are applied to the Annual Out-of–Pocket Maximum. Once this amount is met then Covered Benefits are paid at 100% for the remainder of the Calendar Year. Deductibles and Copays amounts paid for vision services that are not Essential Health Benefits do not apply toward this Plan Out-of-Pocket Maximum as well. Once Your Deductible is satisfied, the Copay payments that You pay for Covered Services will apply to Your Out-of-Pocket Maximum. Amounts or services that do not apply to Your Out-of- Pocket Maximum are:  penalty amounts;  premium payments; and  amounts paid for non-Covered Benefits.

Annual Deductible. Certain services are subject to an Annual Deductible. This is the amount a Member must pay each Calendar Year for Covered Services before some Covered Services are paid under this Contract. It is also referred to as the Deductible. Please refer to Your Schedule of Benefits. Not all Covered Services are subject to the Deductible such as most Preventive Services. Your Plan’s Copayment amounts do not apply towards Your Deductible. Please refer to Your the Schedule of Benefits for Your Plan’s Deductible amounts and for information about which services are not subject to the Deductible. Copayments and penalties are not considered when determining if You have satisfied Your Deductible. You have an individual Deductible. Once Your individual Deductible has been met, the Plan will pay benefits for Your Covered Services. Refer to Your Schedule of Benefits for Your Deductible amount. If You have enrolled in family coverage, or coverage for two (2) or more people; Your Plan has a Family Deductible. Some Covered Services will not be eligible for payment by the Plan until either the Per-Person Deductible or the Family Deductible has been met. Amounts paid by any Member in Your family toward their Per-Person Deductible will also apply to the Family Deductible. For example, if the individual Member’s Per-Person Deductible is $500, then up to $500 per Member can be applied to the Family Deductible. Once the Family Deductible has been met met, no Per-Person Deductible will apply and We will pay for Covered Services. Changes to the Deductible may only be made at renewal. Your Plan includes an Annual Out-of-Pocket Maximum to protect You and Your Dependents from the high cost of a catastrophic event. The Annual Out-of-Pocket Maximum is the most You will pay for Cost Sharing in a Calendar Year for certain Covered Benefits. Please refer to Your Schedule of Benefits for the Out-of-Pocket Maximum. Only Deductibles, Coinsurance, and Copay amounts paid out of Your pocket for Covered Benefits are applied to the Annual Out-of–Pocket Maximum. Once this amount is met then Covered Benefits are paid at 100% for the remainder of the Calendar Year. Deductibles and Copays amounts paid for vision services that are not Essential Health Benefits do not apply toward this Plan Out-of-Pocket Maximum as well. Once Your Deductible is satisfied, the Copay payments that You pay for Covered Services will apply to Your Out-of-Pocket Maximum. Amounts or services that do not apply to Your Out-of- Pocket Maximum are:  penalty amounts;  premium payments; and  amounts paid for non-Covered Benefits.

Annual Deductible. Certain services are subject to an Annual Deductible. This is the The amount a Member must you pay each Calendar Year for Covered Health Care Services per year before some Covered Services you are paid under this Contract. It is also referred eligible to as the Deductible. Please refer to Your Schedule of receive Benefits. Not all The Annual Deductible applies to Covered Health Care Services are subject to under the Deductible such Policy as most Preventive Services. Your Plan’s Copayment amounts do not apply towards Your Deductible. Please refer to Your indicated in this Schedule of Benefits including Covered Health Care Services provided under the Outpatient Prescription Drug Section. The Annual Deductible applies to Covered Health Care Services under the Policy as indicated in this Schedule of Benefits including Covered Health Care Services provided under the Pediatric Vision Care Services Section and the Pediatric Dental Care Services Section. $9,000 per Covered Person, not to exceed $18,000 for Your Plan’s Deductible amounts and all Covered Persons in a family. Benefits for information about which services outpatient prescription drugs on the PPACA Zero Cost Share Preventive Care Medications are not subject to payment of the Annual Deductible. Copayments and penalties are Coupons: We may not considered when determining if You have satisfied Your permit certain coupons or offers from pharmaceutical manufacturers or an affiliate to apply to your Annual Deductible. You have an individual Amounts paid toward the Annual Deductible for Covered Health Care Services that are subject to a visit or day limit will also be calculated against that maximum Benefit limit. As a result, the limited Benefit will be reduced by the number of days/visits used toward meeting the Annual Deductible. Once Your individual The amount that is applied to the Annual Deductible has been met, is calculated on the Plan will pay benefits for Your Covered Servicesbasis of the Allowed Amount or the Recognized Amount when applicable. Refer to Your The Annual Deductible does not include any amount that exceeds the Allowed Amount. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. The maximum you pay per year for Your Deductible amount. If You have enrolled in family coveragethe Annual Deductible, Co- payments or coverage for two (2) or more people; Your Plan has a Family Deductible. Some Covered Services will not be eligible for payment by the Plan until either the PerCo-Person Deductible or the Family Deductible has been met. Amounts paid by any Member in Your family toward their Per-Person Deductible will also apply to the Family Deductible. For example, if the individual Member’s Per-Person Deductible is $500, then up to $500 per Member can be applied to the Family Deductibleinsurance. Once the Family Deductible has been met no Per-Person Deductible will apply and We will pay for Covered Services. Changes to the Deductible may only be made at renewal. Your Plan includes an Annual Out-of-Pocket Maximum to protect You and Your Dependents from the high cost of a catastrophic event. The Annual Out-of-Pocket Maximum is the most You will pay for Cost Sharing in a Calendar Year for certain Covered Benefits. Please refer to Your Schedule of Benefits for you reach the Out-of-Pocket Maximum. Only DeductiblesLimit, Coinsurance, and Copay amounts paid out of Your pocket for Covered Benefits are applied to the Annual Out-of–Pocket Maximum. Once this amount is met then Covered Benefits are paid payable at 100% for of Allowed Amounts during the remainder rest of the Calendar Yearthat year. Deductibles and Copays amounts paid for vision services that are not Essential Health Benefits do not apply toward this Plan The Out-of-Pocket Maximum Limit applies to Covered Health Care Services under the Policy as wellindicated in this Schedule of Benefits including Covered Health Care Services provided under the Outpatient Prescription Drug Section. Once Your Deductible is satisfied, the Copay payments that You pay for Covered Services will apply to Your The Out-of-Pocket MaximumLimit applies to Covered Health Care Services under the Policy as indicated in this Schedule of Benefits including the Pediatric Dental Care Services Section and the Pediatric Vision Care Services Section. Details about the way in which Allowed Amounts or services that do not apply to Your are determined appear at the end of the Schedule of Benefits table. The Out-of- of-Pocket Maximum areLimit does not include any of the following and, once the Out-of-Pocket Limit has been reached, you still will be required to pay the following:  penalty amounts;  premium payments; and  amounts paid • Any charges for non-Covered BenefitsHealth Care Services. • Charges that exceed Allowed Amounts, when applicable. Coupons: We may not permit certain coupons or offers from pharmaceutical manufacturers or an affiliate to apply to your Out-of-Pocket Limit. $9,100 per Covered Person, not to exceed $18,200 for all Covered Persons in a family. The Out-of-Pocket Limit includes the Annual Deductible. Co-payment is the amount you pay (calculated as a set dollar amount) each time you receive certain Covered Health Care Services. When Co-payments apply, the amount is listed on the following pages next to the description for each Covered Health Care Service. Please note that for Covered Health Care Services, you are responsible for paying the lesser of: • The applicable Co-payment. • The Allowed Amount or the Recognized Amount when applicable. SAMPLE Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. Co-insurance is the amount you pay (calculated as a percentage of the Allowed Amount or the Recognized Amount when applicable) each time you receive certain Covered Health Care Services. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in the Policy, Recognized Amounts. The Allowed Amounts provision near the end of this Schedule of Benefits will tell you when you are responsible for amounts that exceed the Allowed Amount.

Annual Deductible. Certain services are subject to an Annual Deductible. This is the The amount a Member must you pay each Calendar Year for Covered Health Care Services per year before some Covered Services you are paid under this Contract. It is also referred eligible to as the Deductible. Please refer to Your Schedule of receive Benefits. Not all The Annual Deductible applies to Covered Health Care Services are subject to under the Deductible such Policy as most Preventive Services. Your Plan’s Copayment amounts do not apply towards Your Deductible. Please refer to Your indicated in this Schedule of Benefits including Covered Health Care Services provided under the Outpatient Prescription Drugs section. The Annual Deductible applies to Covered Health Care Services under the Policy as indicated in this Schedule of Benefits including Covered Health Care Services provided under the Pediatric Vision Care Services section and the Pediatric Dental Care Services section. $6,700 per Covered Person, not to exceed $13,400 for Your Plan’s Deductible amounts and all Covered Persons in a family. Benefits for information about which services outpatient prescription drugs on the PPACA Zero Cost Share Preventive Care Medications are not subject to payment of the Annual Deductible. Copayments and penalties Amounts paid toward the Annual Deductible for Covered Health Care Services that are not considered when determining if You have satisfied Your subject to a visit or day limit will also be calculated against that maximum Benefit limit. As a result, the limited Benefit will be reduced by the number of days/visits used toward meeting the Annual Deductible. You have an individual DeductibleThe amount that is applied to the Annual Deductible is calculated on the basis of the Allowed Amount or the Recognized Amount when applicable. Once Your individual The Annual Deductible has been met, does not include any amount that exceeds the Plan will pay benefits for Your Covered ServicesAllowed Amount. Refer to Your Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. The maximum you pay per year for Your Deductible amount. If You have enrolled in family coveragethe Annual Deductible, Co-payments or coverage for two (2) or more people; Your Plan has a Family Deductible. Some Covered Services will not be eligible for payment by the Plan until either the PerCo-Person Deductible or the Family Deductible has been met. Amounts paid by any Member in Your family toward their Per-Person Deductible will also apply to the Family Deductible. For example, if the individual Member’s Per-Person Deductible is $500, then up to $500 per Member can be applied to the Family Deductibleinsurance. Once you reach the Family Deductible has been met no PerOut-Person Deductible will apply and We will pay for Covered Servicesof- Pocket Limit, Benefits are payable at 100% of Allowed Amounts during the rest of that year. Changes to the Deductible may only be made at renewal. Your Plan includes an Annual The Out-of-Pocket Maximum Limit applies to protect You and Your Dependents from Covered Health Care Services under the high cost Policy as indicated in this Schedule of a catastrophic eventBenefits including Covered Health Care Services provided under the Outpatient Prescription Drugs section. The Annual Out-of-Pocket Maximum is Limit applies to Covered Health Care Services under the most You will pay for Cost Sharing Policy as indicated in a Calendar Year for certain Covered Benefits. Please refer to Your this Schedule of Benefits for including the Pediatric Dental Care Services section and the Pediatric Vision Care Services section. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. The Out-of-Pocket Limit does not include any of the following and, once the Out-of-Pocket MaximumLimit has been reached, you still will be required to pay the following: • Any charges for non-Covered Health Care Services. Only Deductibles• Charges that exceed Allowed Amounts, Coinsurancewhen applicable. $9,200 per Covered Person, and Copay amounts paid out of Your pocket not to exceed $18,400 for all Covered Benefits are applied to the Annual Out-of–Pocket MaximumPersons in a family. Once this amount is met then Covered Benefits are paid at 100% for the remainder of the Calendar Year. Deductibles and Copays amounts paid for vision services that are not Essential Health Benefits do not apply toward this Plan The Out-of-Pocket Maximum Limit includes the Annual Deductible. Co-payment is the amount you pay (calculated as wella set dollar amount) each time you receive certain Covered Health Care Services. Once Your Deductible is satisfiedWhen Co-payments apply, the Copay payments amount is listed on the following pages next to the description for each Covered Health Care Service. Please note that You pay for Covered Health Care Services, you are responsible for paying the lesser of: • The applicable Co-payment. • The Allowed Amount or the Recognized Amount when applicable. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. Co-insurance is the amount you pay (calculated as a percentage of the Allowed Amount or the Recognized Amount when applicable) each time you receive certain Covered Health Care Services. SAMPLE Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in the Policy, Recognized Amounts. The Allowed Amounts provision near the end of this Schedule of Benefits will apply to Your Out-of-Pocket Maximum. Amounts or services tell you when you are responsible for amounts that do not apply to Your Out-of- Pocket Maximum are:  penalty amounts;  premium payments; and  amounts paid for non-Covered Benefitsexceed the Allowed Amount.

Annual Deductible. Certain services are subject to an Annual Deductible. This is the The amount a Member must you pay each Calendar Year for Covered Health Care Services per year before some Covered Services you are paid under this Contract. It is also referred eligible to as the Deductible. Please refer to Your Schedule of receive Benefits. Not all The Annual Deductible applies to Covered Health Care Services are subject to under the Deductible such Policy as most Preventive Services. Your Plan’s Copayment amounts do not apply towards Your Deductible. Please refer to Your indicated in this Schedule of Benefits including Covered Health Care Services provided under the Outpatient Prescription Drug Section. The Annual Deductible applies to Covered Health Care Services under the Policy as indicated in this Schedule of Benefits including Covered Health Care Services provided under the Pediatric Vision Care Services Section and the Pediatric Dental Care Services Section. $8,250 per Covered Person, not to exceed $16,500 for Your Plan’s Deductible amounts and all Covered Persons in a family. Benefits for information about which services outpatient prescription drugs on the PPACA Zero Cost Share Preventive Care Medications are not subject to payment of the Annual Deductible. Copayments and penalties Amounts paid toward the Annual Deductible for Covered Health Care Services that are not considered when determining if You have satisfied Your subject to a visit or day limit will also be calculated against that maximum Benefit limit. As a result, the limited Benefit will be reduced by the number of days/visits used toward meeting the Annual Deductible. You have an individual DeductibleThe amount that is applied to the Annual Deductible is calculated on the basis of the Allowed Amount or the Recognized Amount when applicable. Once Your individual The Annual Deductible has been met, does not include any amount that exceeds the Plan will pay benefits for Your Covered ServicesAllowed Amount. Refer to Your Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. The maximum you pay per year for Your Deductible amount. If You have enrolled in family coveragethe Annual Deductible, Co-payments or coverage for two (2) or more people; Your Plan has a Family Deductible. Some Covered Services will not be eligible for payment by the Plan until either the PerCo-Person Deductible or the Family Deductible has been met. Amounts paid by any Member in Your family toward their Per-Person Deductible will also apply to the Family Deductible. For example, if the individual Member’s Per-Person Deductible is $500, then up to $500 per Member can be applied to the Family Deductibleinsurance. Once you reach the Family Deductible has been met no PerOut-Person Deductible will apply and We will pay for Covered Servicesof- Pocket Limit, Benefits are payable at 100% of Allowed Amounts during the rest of that year. Changes to the Deductible may only be made at renewal. Your Plan includes an Annual The Out-of-Pocket Maximum Limit applies to protect You and Your Dependents from Covered Health Care Services under the high cost Policy as indicated in this Schedule of a catastrophic eventBenefits including Covered Health Care Services provided under the Outpatient Prescription Drug Section. The Annual Out-of-Pocket Maximum is Limit applies to Covered Health Care Services under the most You will pay for Cost Sharing Policy as indicated in a Calendar Year for certain Covered Benefits. Please refer to Your this Schedule of Benefits for including the Pediatric Dental Care Services Section and the Pediatric Vision Care Services Section. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. The Out-of-Pocket Limit does not include any of the following and, once the Out-of-Pocket MaximumLimit has been reached, you still will be required to pay the following: • Any charges for non-Covered Health Care Services. Only Deductibles• Charges that exceed Allowed Amounts, Coinsurancewhen applicable. $9,450 per Covered Person, and Copay amounts paid out of Your pocket not to exceed $18,900 for all Covered Benefits are applied to the Annual Out-of–Pocket MaximumPersons in a family. Once this amount is met then Covered Benefits are paid at 100% for the remainder of the Calendar Year. Deductibles and Copays amounts paid for vision services that are not Essential Health Benefits do not apply toward this Plan The Out-of-Pocket Maximum Limit includes the Annual Deductible. Co-payment is the amount you pay (calculated as wella set dollar amount) each time you receive certain Covered Health Care Services. Once Your Deductible is satisfiedWhen Co-payments apply, the Copay payments amount is listed on the following pages next to the description for each Covered Health Care Service. Please note that You pay for Covered Health Care Services, you are responsible for paying the lesser of: • The applicable Co-payment. • The Allowed Amount or the Recognized Amount when applicable. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. Co-insurance is the amount you pay (calculated as a percentage of the Allowed Amount or the Recognized Amount when applicable) each time you receive certain Covered Health Care Services. SAMPLE Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in the Policy, Recognized Amounts. The Allowed Amounts provision near the end of this Schedule of Benefits will apply to Your Out-of-Pocket Maximum. Amounts or services tell you when you are responsible for amounts that do not apply to Your Out-of- Pocket Maximum are:  penalty amounts;  premium payments; and  amounts paid for non-Covered Benefitsexceed the Allowed Amount.

Annual Deductible. Certain services are subject to an Annual Deductible. This is the The amount a Member must you pay each Calendar Year for Covered Health Care Services per year before some Covered Services you are paid under this Contract. It is also referred eligible to as the Deductible. Please refer to Your Schedule of receive Benefits. Not all The Annual Deductible applies to Covered Health Care Services are subject to under the Deductible such Policy as most Preventive Services. Your Plan’s Copayment amounts do not apply towards Your Deductible. Please refer to Your indicated in this Schedule of Benefits including $7,250 per Covered Person, not to exceed $14,500 for Your Plan’s all Covered Persons in a family. Covered Health Care Services provided under the Outpatient Prescription Drug Section. The Annual Deductible amounts applies to Covered Health Care Services under the Policy as indicated in this Schedule of Benefits including Covered Health Care Services provided under the Pediatric Vision Care Services Section and the Pediatric Dental Care Services Section. Benefits for information about which services outpatient prescription drugs on the PPACA Zero Cost Share Preventive Care Medications are not subject to payment of the Annual Deductible. Copayments and penalties Amounts paid toward the Annual Deductible for Covered Health Care Services that are not considered when determining if You have satisfied Your subject to a visit or day limit will also be calculated against that maximum Benefit limit. As a result, the limited Benefit will be reduced by the number of days/visits used toward meeting the Annual Deductible. You have an individual DeductibleThe amount that is applied to the Annual Deductible is calculated on the basis of the Allowed Amount or the Recognized Amount when applicable. Once Your individual The Annual Deductible has been met, does not include any amount that exceeds the Plan will pay benefits for Your Covered ServicesAllowed Amount. Refer to Your Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. The maximum you pay per year for Your Deductible amount. If You have enrolled in family coveragethe Annual Deductible, Co-payments or coverage for two (2) or more people; Your Plan has a Family Deductible. Some Covered Services will not be eligible for payment by the Plan until either the PerCo-Person Deductible or the Family Deductible has been met. Amounts paid by any Member in Your family toward their Per-Person Deductible will also apply to the Family Deductible. For example, if the individual Member’s Per-Person Deductible is $500, then up to $500 per Member can be applied to the Family Deductibleinsurance. Once you reach the Family Deductible has been met no PerOut-Person Deductible will apply and We will pay for Covered Servicesof- Pocket Limit, Benefits are payable at 100% of Allowed Amounts during the rest of that year. Changes to the Deductible may only be made at renewal. Your Plan includes an Annual The Out-of-Pocket Maximum Limit applies to protect You and Your Dependents from Covered Health Care Services under the high cost Policy as indicated in this Schedule of a catastrophic eventBenefits including Covered Health Care Services provided under the Outpatient Prescription Drug Section. The Annual Out-of-Pocket Maximum is Limit applies to Covered Health Care Services under the most You will pay for Cost Sharing Policy as indicated in a Calendar Year for certain Covered Benefits. Please refer to Your this Schedule of Benefits for including the Pediatric Dental Care Services Section and the Pediatric Vision Care Services Section. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. The Out-of-Pocket Limit does not include any of the following and, once the Out-of-Pocket MaximumLimit has been reached, you still will be required to pay the following: • Any charges for non-Covered Health Care Services. Only Deductibles• Charges that exceed Allowed Amounts, Coinsurancewhen applicable. $9,450 per Covered Person, and Copay amounts paid out of Your pocket not to exceed $18,900 for all Covered Benefits are applied to the Annual Out-of–Pocket MaximumPersons in a family. Once this amount is met then Covered Benefits are paid at 100% for the remainder of the Calendar Year. Deductibles and Copays amounts paid for vision services that are not Essential Health Benefits do not apply toward this Plan The Out-of-Pocket Maximum Limit includes the Annual Deductible. Co-payment is the amount you pay (calculated as wella set dollar amount) each time you receive certain Covered Health Care Services. Once Your Deductible is satisfiedWhen Co-payments apply, the Copay payments amount is listed on the following pages next to the description for each Covered Health Care Service. Please note that You pay for Covered Services will apply to Your OutHealth Care Services, you are responsible for paying the lesser of: • The applicable Co-ofpayment. • The Allowed Amount or the Recognized Amount when applicable. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. Co-Pocket Maximuminsurance is the amount you pay (calculated as a percentage of the Allowed Amount or the Recognized Amount when applicable) each time you receive certain Covered Health Care Services. Details about the way in which Allowed Amounts or services that do not apply to Your Out-of- Pocket Maximum are:  penalty amounts;  premium payments; and  amounts paid for non-Covered Benefitsare determined appear at the end of the Schedule of Benefits table.

Annual Deductible. Certain services are subject to an Annual Deductible. This is the The amount a Member must you pay each Calendar Year for Covered Health Care Services per year before some Covered Services you are paid under this Contract. It is also referred eligible to as the Deductible. Please refer to Your Schedule of receive Benefits. Not all The Annual Deductible applies to Covered Health Care Services are subject to under the Deductible such Policy as most Preventive Services. Your Plan’s Copayment amounts do not apply towards Your Deductible. Please refer to Your indicated in this Schedule of Benefits including Covered Health Care Services provided under the Outpatient Prescription Drugs section. The Annual Deductible applies to Covered Health Care Services under the Policy as indicated in this Schedule of Benefits including Covered Health Care Services provided under the Pediatric Vision Care Services section and the Pediatric Dental Care Services section. Benefits for Your Plan’s Deductible amounts and for information about which services outpatient prescription drugs on the PPACA Zero Cost Share Preventive Care Medications are not subject to payment of the Annual Deductible. Copayments and penalties are $3,400 per Covered Person, not considered when determining if You have satisfied Your to exceed $6,800 for all Covered Persons in a family. Coupons: We may not permit certain coupons or offers from pharmaceutical manufacturers or an affiliate to apply to your Annual Deductible. You have an individual Amounts paid toward the Annual Deductible for Covered Health Care Services that are subject to a visit or day limit will also be calculated against that maximum Benefit limit. As a result, the limited Benefit will be reduced by the number of days/visits used toward meeting the Annual Deductible. Once Your individual The amount that is applied to the Annual Deductible has been met, is calculated on the Plan will pay benefits for Your Covered Servicesbasis of the Allowed Amount or the Recognized Amount when applicable. Refer to Your The Annual Deductible does not include any amount that exceeds the Allowed Amount. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. The maximum you pay per year for Your Deductible amount. If You have enrolled in family coveragethe Annual Deductible, Co- payments or coverage for two (2) or more people; Your Plan has a Family Deductible. Some Covered Services will not be eligible for payment by the Plan until either the PerCo-Person Deductible or the Family Deductible has been met. Amounts paid by any Member in Your family toward their Per-Person Deductible will also apply to the Family Deductible. For example, if the individual Member’s Per-Person Deductible is $500, then up to $500 per Member can be applied to the Family Deductibleinsurance. Once the Family Deductible has been met no Per-Person Deductible will apply and We will pay for Covered Services. Changes to the Deductible may only be made at renewal. Your Plan includes an Annual Out-of-Pocket Maximum to protect You and Your Dependents from the high cost of a catastrophic event. The Annual Out-of-Pocket Maximum is the most You will pay for Cost Sharing in a Calendar Year for certain Covered Benefits. Please refer to Your Schedule of Benefits for you reach the Out-of-Pocket Maximum. Only DeductiblesLimit, Coinsurance, and Copay amounts paid out of Your pocket for Covered Benefits are applied to the Annual Out-of–Pocket Maximum. Once this amount is met then Covered Benefits are paid payable at 100% for of Allowed Amounts during the remainder rest of the Calendar Yearthat year. Deductibles and Copays amounts paid for vision services that are not Essential Health Benefits do not apply toward this Plan The Out-of-Pocket Maximum Limit applies to Covered Health Care Services under the Policy as wellindicated in this Schedule of Benefits including Covered Health Care Services provided under the Outpatient Prescription Drug Section. Once Your Deductible is satisfied, the Copay payments that You pay for Covered Services will apply to Your The Out-of-Pocket MaximumLimit applies to Covered Health Care Services under the Policy as indicated in this Schedule of Benefits including the Pediatric Dental Care Services Section and the Pediatric Vision Care Services Section. Details about the way in which Allowed Amounts or services that do not apply to Your are determined appear at the end of the Schedule of Benefits table. The Out-of- of-Pocket Maximum areLimit does not include any of the following and, once the Out-of-Pocket Limit has been reached, you still will be required to pay the following:  penalty amounts;  premium payments; and  amounts paid • Any charges for non-Covered BenefitsHealth Care Services. • Charges that exceed Allowed Amounts, when applicable. Coupons: We may not permit certain coupons or offers from pharmaceutical manufacturers or an affiliate to apply to your Out-of-Pocket Limit. $9,200 per Covered Person, not to exceed $18,400 for all Covered Persons in a family. The Out-of-Pocket Limit includes the Annual Deductible. Co-payment is the amount you pay (calculated as a set dollar amount) each time you receive certain Covered Health Care Services. When Co-payments apply, the amount is listed on the following pages next to the description for each Covered Health Care Service. Please note that for Covered Health Care Services, you are responsible for paying the lesser of: • The applicable Co-payment. • The Allowed Amount or the Recognized Amount when applicable. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. SAMPLE Co-insurance is the amount you pay (calculated as a percentage of the Allowed Amount or the Recognized Amount when applicable) each time you receive certain Covered Health Care Services. Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of Benefits table. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in the Policy, Recognized Amounts. The Allowed Amounts provision near the end of this Schedule of Benefits will tell you when you are responsible for amounts that exceed the Allowed Amount.