Common use of Family Deductible Limit Clause in Contracts

Family Deductible Limit. This Contract has a family deductible limit of two Cash Deductibles for each Calendar Year. Once [Members] in a family meet the family Cash Deductible in a Calendar Year, We provide coverage for Covered Services and Supplies for all Members who are part of the covered family, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. What We pay is based on all the terms of this Contract.] [Please note: There are separate Cash Deductibles for [Tier 1] and [Tier 2] as shown on the Schedule of Insurance and Premium Rates.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 2] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 2] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider as well as for treatment, services or supplies given by a [Tier 1] Network that are applied to the [Tier 1] Deductible. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Each Calendar Year, the sum of the Covered Services and Supplies for each Member from a [Tier 2] Network Provider and those from a [Tier 1] Provider must exceed the [Tier 2] Cash Deductible before We pay benefits for [Tier 1] and [Tier 2] Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] or a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] (Use the above text if the Tier 1 deductible can be satisfied separately and allows a Member to be in benefit for further Tier 1 Covered Services and Supplies and is also applied toward the satisfaction of the Tier 2 deductible.)

Family Deductible Limit. For Other than Single Coverage The per Member Cash Deductible is not applicable. This Contract has a family deductible limit of two per Covered Family Cash Deductibles for each Calendar YearDeductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once [Members] any combination of Members in a family meet meets the family Per Covered Family Cash Deductible shown in a Calendar Yearthe Schedule, We provide coverage pay benefits for other Covered Services and Supplies for all Members who are part incurred by any member of the covered family, less any applicable Coinsurance or Copayments[copayment or] Coinsurance, for the rest of that Calendar [Calendar] [Plan] Year. What We The Per Member and Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. In the case of single coverage, for a Member, the Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a [Calendar] [Plan] Year. Once the Per Member Maximum Out of Pocket has been met during a [Calendar] [Plan] Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the [Calendar] [Plan] Year. In the case of coverage which is based on other than single coverage, for a Member, the per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a [Calendar] [Plan]Year. Once the terms Per Member Maximum Out of this ContractPocket has been met during a [Calendar][Plan]Year, no further Deductible or Coinsurance or Copayments will be required for such Covered Person for the rest of the [Calendar][Plan] Year. In the case of coverage which is other than single coverage, for a Covered Family, the Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a [Calendar] [Plan] Year. Once the Per Covered Family Maximum Out of Pocket has been met during a [Calendar] [Plan] Year, no further Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the [Calendar] [Plan] Year.] [Please note: There are separate Cash Deductibles for [Tier 1] and [Tier 2] as shown on the Schedule of Insurance and Premium Rates.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 2] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 2] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider [as well as for treatment, services or and supplies given by a [Tier 1] Network Provider that are applied to the [Tier 11 and Tier 2] DeductibleCash Deductibles]. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a For Single Coverage Only: [Tier 1] Network Provider Each [Calendar] [Plan] Year, a [Member] must have Covered Charges that exceed the [Tier 1] per [Member] Cash Deductible before We pay any benefits to the [Member] for those types of Covered Services and Supplies to that Membercharges. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a The [Tier 1] Network Provider, per [Member] Cash Deductible is shown in the Schedule. The Cash Deductible cannot be met with Non-Covered Charges. Only Covered Charges incurred by a [Member] while covered by this Contract, insured can be used to meet this the Cash Deductible. Once the [Tier 1] per [Member] Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies Charges above the Cash Deductible amount incurred by that the [Member], less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar [Calendar] [Plan] Year. Each Calendar Year, But all charges must be incurred while the sum [Member] is insured by this Contract. And what We pay is based on all the terms of the Covered Services this Contract including benefit limitations and Supplies for each Member from a exclusion provisions. For Single Coverage Only: [Tier 2] Network Provider and those from Each [Calendar] [Plan] Year, a [Tier 1Member] Provider must have Covered Charges that exceed the [Tier 2] per [Member] Cash Deductible before We pay any benefits to a [Member] for those charges. [Covered Charges applied to the [Tier 1] and per [Member] Cash Deductible also apply to this [Tier 2] Covered Services and Supplies to that per [Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] or a Cash Deductible.] The [Tier 2] Network Provider, per [Member] Cash Deductible is shown in the Schedule. The Cash Deductible cannot be met with Non-Covered Charges. Only Covered Charges incurred by a [Member] while covered by this Contract, insured can be used to meet this the Cash Deductible. Once the [Tier 2] per [Member] Cash Deductible is met, We pay benefits for other such Covered Services and Supplies Charges above the Cash Deductible amount incurred by that the [Member], less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar [Calendar] [Plan] Year. Neither But all charges must be incurred while the [Tier 1Member] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered is insured by this Contract can be used to meet either Cash DeductibleContract. What And what We pay is based on all the terms of the Contact including benefit limitations and exclusion provisions. For Other than Single Coverage: [Tier 1] The [Tier 1] per [Member] Cash Deductible is not applicable. This Contract has a [Tier 1] per Covered Family Cash Deductible which applies in all instances where this ContractContract provides coverage that is not single only coverage. Once any combination of [Members] in a family meets the [Tier 1] per Covered Family Cash Deductible shown in the Schedule, We pay benefits for other Covered Charges incurred by any [Member] of the covered family, less any Coinsurance, for the rest of that [Calendar] [Plan] Year. For Other than Single Coverage: [Tier 2] The [Tier 2] per [Member] Cash Deductible is not applicable. This Contract has a [Tier 2] per Covered Family Cash Deductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once any combination of [Members] in a family meets the [Tier 2] per Covered Family Cash Deductible shown in the Schedule, We pay benefits for other Covered Charges incurred by any [Member] of the covered family, less any Coinsurance, for the rest of that [Calendar] [Plan] Year. [Note that Covered Charges applied to the [Tier 1] per Covered Family Cash Deductible also apply to this [Tier 2] per Covered Family Cash Deductible.] (Use the above text if the The [Tier 1 deductible can be satisfied separately and allows a Member to be in benefit for further Tier 2] Per [Member] and [Tier 1 and Tier 2] Per Covered Services Family Maximum Out of Pocket amounts are shown in the Schedule. For Single Coverage Only: [Tier 1] In the case of single coverage, for a [Member], the [Tier 1] Maximum Out of Pocket is the annual maximum dollar amount that a [Member] must pay as per [Member] Cash Deductible plus Coinsurance and Supplies Copayments for all covered services and is also applied toward supplies in a [Calendar] [Plan] Year. Once the satisfaction [Tier 1] per [Member] Maximum Out of Pocket has been met during a [Calendar] [Plan] Year, no further Deductible or Coinsurance or Copayments will be required for such [Member] for the rest of the Tier 2 deductible[Calendar] [Plan] Year.)

Family Deductible Limit. For Other than Single Coverage The per Member Cash Deductible is not applicable. This Contract has a family deductible limit of two per Covered Family Cash Deductibles for each Calendar YearDeductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once [Members] any combination of Members in a family meet meets the family Per Covered Family Cash Deductible shown in a Calendar Yearthe Schedule, We provide coverage pay benefits for other Covered Services and Supplies for all Members who are part incurred by any member of the covered family, less any applicable Coinsurance or Copayments[copayment or] Coinsurance, for the rest of that Calendar [Calendar] [Plan] Year. What We pay is based on all the terms The Per Member and Per Covered Family Maximum Out of this Contract.] [Please note: There Pocket amounts are separate Cash Deductibles for [Tier 1] and [Tier 2] as shown on the Schedule of Insurance and Premium Rates.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider. Each Cash Deductible is shown in the Schedule. Each In the case of single coverage, for a Member, the Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a [Calendar] [Plan] Year. Once the Per Member Maximum Out of Pocket has been met during a [Calendar] [Plan] Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the [Calendar] [Plan] Year. In the case of coverage which is other than single coverage, for a Member, the per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a [Calendar] [Plan]Year. Once the Per Member Maximum Out of Pocket has been met during a Calendar Year, each Member no further Deductible or Coinsurance or Copayments will be required for such Covered Person for the rest of the [Calendar][Plan] Year. In the case of coverage which is other than single coverage, for a Covered Family, the Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must have pay as per Covered Services Family Cash Deductible plus Coinsurance and Supplies from Copayments for all covered services and supplies in a [Tier 1Calendar] Network Provider that exceed [Plan] Year. Once the Cash Deductible before We pay benefits for those types Per Covered Family Maximum Out of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from Pocket has been met during a [Tier 1Calendar] Network Provider[Plan] Year, while no further Deductible or Coinsurance or Copayment will be required for members of the covered by family for the rest of the [Calendar] [Plan] Year.] The Contractholder who purchased this ContractContract may have purchased it to replace a plan the Contractholder had with some other carrier. The Member may have incurred charges for covered services and supplies under the Contractholder's old plan before it ended. If so, can these charges will be used to meet this Cash Deductible. Once the Contract’s Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 2] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 2] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider as well as for treatment, services or supplies given by a [Tier 1] Network that are applied to the [Tier 1] Deductible. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Each Calendar Year, the sum of the Covered Services and Supplies for each Member from a [Tier 2] Network Provider and those from a [Tier 1] Provider must exceed the [Tier 2] Cash Deductible before We pay benefits for [Tier 1] and [Tier 2] Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] or a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] (Use the above text if the Tier 1 deductible can be satisfied separately and allows a Member to be in benefit for further Tier 1 Covered Services and Supplies and is also applied toward the satisfaction of the Tier 2 deductible.)if:

Family Deductible Limit. For Other than Single Coverage The per Member Cash Deductible is not applicable. This Contract has a family deductible limit of two per Covered Family Cash Deductibles for each Calendar YearDeductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once [Members] any combination of Members in a family meet meets the family Per Covered Family Cash Deductible shown in a Calendar Yearthe Schedule, We provide coverage pay benefits for other Covered Services and Supplies for all Members who are part Charges incurred by any member of the covered family, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. What We pay is based on all the terms The Per Member and Per Covered Family Maximum Out of this Contract.] [Please note: There Pocket amounts are separate Cash Deductibles for [Tier 1] and [Tier 2] as shown on the Schedule of Insurance and Premium Rates.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider. Each Cash Deductible is shown in the Schedule. Each In the case of single coverage, for a Member, the Maximum Out of Pocket is the annual maximum dollar amount that a member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per member Maximum Out of Pocket has been met during a Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash no further Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, Copayments will be required for such Member for the rest of that the Calendar Year. Each In the case of coverage which is other than single coverage, for a member, the per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per Member Maximum Out of Pocket has been met during a Calendar Year, each Member must have Covered Services and Supplies from a [Tier 2] Network Provider that exceed the Cash no further Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 2] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, Copayments will be required for such Member for the rest of that the Calendar Year. Neither In the [Tier 1] nor case of coverage which is other than single coverage, for a Covered Family, the [Tier 2] Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as per Covered Family Cash Deductible can be plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per Covered Family Maximum Out of Pocket has been met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] [The [Tier 1] Deductible is for treatment, services or supplies given by during a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider as well as for treatment, services or supplies given by a [Tier 1] Network that are applied to the [Tier 1] Deductible. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash no further Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, Copayment will be required for members of the covered family for the rest of that the Calendar Year. Each Calendar Year, the sum of the Covered Services and Supplies for each Member from a [Tier 2] Network Provider and those from a [Tier 1] Provider must exceed the [Tier 2] Cash Deductible before We pay benefits for [Tier 1] and [Tier 2] Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] or a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] (Use [Members] are entitled to receive the above text if benefits in the Tier 1 deductible can be satisfied separately following sections when Medically Necessary and allows a Member Appropriate, subject to be the payment by [Members] of applicable copayments [Cash Deductible,][or Coinsurance] as stated in benefit for further Tier 1 Covered the applicable Schedule of Services and Supplies and is also applied toward subject to the satisfaction terms, conditions and limitations of this Contract. Read the Tier 2 deductibleentire Contract to determine what treatment, services and supplies are limited or excluded.)

Family Deductible Limit. For Other than Single Coverage The per Member Cash Deductible is not applicable. This Contract has a family deductible limit of two per Covered Family Cash Deductibles for each Calendar YearDeductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once [Members] any combination of Members in a family meet meets the family Per Covered Family Cash Deductible shown in a Calendar Yearthe Schedule, We provide coverage pay benefits for other Covered Services and Supplies for all Members who are part incurred by any member of the covered family, less any applicable Coinsurance or Copayments[copayment or] Coinsurance, for the rest of that Calendar [Calendar] [Plan] Year. What We Maximum Out of Pocket: The Per Member and Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. In the case of single coverage, for a Member, the Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a [Calendar] [Plan] Year. Once the Per Member Maximum Out of Pocket has been met during a [Calendar] [Plan] Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the [Calendar] [Plan] Year. In the case of coverage which is based on other than single coverage, for a Member, the per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a [Calendar] [Plan]Year. Once the terms Per Member Maximum Out of this ContractPocket has been met during a [Calendar][Plan]Year, no further Deductible or Coinsurance or Copayments will be required for such Covered Person for the rest of the [Calendar][Plan] Year. In the case of coverage which is other than single coverage, for a Covered Family, the Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a [Calendar] [Plan] Year. Once the Per Covered Family Maximum Out of Pocket has been met during a [Calendar] [Plan] Year, no further Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the [Calendar] [Plan] Year.] [Please note: There are separate Cash Deductibles for [Tier 1] and [Tier 2] as shown on the Schedule of Insurance and Premium Rates.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 2] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 2] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider [as well as for treatment, services or and supplies given by a [Tier 1] Network Provider that are applied to the [Tier 11 and Tier 2] DeductibleCash Deductibles]. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a The Cash Deductible: For Single Coverage Only: [Tier 1] Network Provider Each [Calendar] [Plan] Year, a [Member] must have Covered Charges that exceed the [Tier 1] per [Member] Cash Deductible before We pay any benefits to the [Member] for those types of Covered Services and Supplies to that Membercharges. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a The [Tier 1] Network Provider, per [Member] Cash Deductible is shown in the Schedule. The Cash Deductible cannot be met with Non-Covered Charges. Only Covered Charges incurred by a [Member] while covered by this Contract, insured can be used to meet this the Cash Deductible. Once the [Tier 1] per [Member] Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies Charges above the Cash Deductible amount incurred by that the [Member], less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar [Calendar] [Plan] Year. Each Calendar Year, But all charges must be incurred while the sum [Member] is insured by this Contract. And what We pay is based on all the terms of the Covered Services this Contract including benefit limitations and Supplies for each Member from a exclusion provisions. For Single Coverage Only: [Tier 2] Network Provider and those from Each [Calendar] [Plan] Year, a [Tier 1Member] Provider must have Covered Charges that exceed the [Tier 2] per [Member] Cash Deductible before We pay any benefits to a [Member] for those charges. [Covered Charges applied to the [Tier 1] and per [Member] Cash Deductible also apply to this [Tier 2] Covered Services and Supplies to that per [Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] or a Cash Deductible.] The [Tier 2] Network Provider, per [Member] Cash Deductible is shown in the Schedule. The Cash Deductible cannot be met with Non-Covered Charges. Only Covered Charges incurred by a [Member] while covered by this Contract, insured can be used to meet this the Cash Deductible. Once the [Tier 2] per [Member] Cash Deductible is met, We pay benefits for other such Covered Services and Supplies Charges above the Cash Deductible amount incurred by that the [Member], less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar [Calendar] [Plan] Year. Neither But all charges must be incurred while the [Tier 1Member] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered is insured by this Contract can be used to meet either Cash DeductibleContract. What And what We pay is based on all the terms of the Contact including benefit limitations and exclusion provisions. For Other than Single Coverage: [Tier 1] The [Tier 1] per [Member] Cash Deductible is not applicable. This Contract has a [Tier 1] per Covered Family Cash Deductible which applies in all instances where this ContractContract provides coverage that is not single only coverage. Once any combination of [Members] in a family meets the [Tier 1] per Covered Family Cash Deductible shown in the Schedule, We pay benefits for other Covered Charges incurred by any [Member] of the covered family, less any Coinsurance, for the rest of that [Calendar] [Plan] Year. For Other than Single Coverage: [Tier 2] The [Tier 2] per [Member] Cash Deductible is not applicable. This Contract has a [Tier 2] per Covered Family Cash Deductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once any combination of [Members] in a family meets the [Tier 2] per Covered Family Cash Deductible shown in the Schedule, We pay benefits for other Covered Charges incurred by any [Member] of the covered family, less any Coinsurance, for the rest of that [Calendar] [Plan] Year. [Note that Covered Charges applied to the [Tier 1] per Covered Family Cash Deductible also apply to this [Tier 2] per Covered Family Cash Deductible.] (Use the above text if the Maximum Out of Pocket: The [Tier 1 deductible can be satisfied separately and allows a Member to be in benefit for further Tier 2] Per [Member] and [Tier 1 and Tier 2] Per Covered Services Family Maximum Out of Pocket amounts are shown in the Schedule. For Single Coverage Only: [Tier 1] In the case of single coverage, for a [Member], the [Tier 1] Maximum Out of Pocket is the annual maximum dollar amount that a [Member] must pay as per [Member] Cash Deductible plus Coinsurance and Supplies Copayments for all covered services and is also applied toward supplies in a [Calendar] [Plan] Year. Once the satisfaction [Tier 1] per [Member] Maximum Out of Pocket has been met during a [Calendar] [Plan] Year, no further Deductible or Coinsurance or Copayments will be required for such [Member] for the rest of the Tier 2 deductible[Calendar] [Plan] Year.)

Family Deductible Limit. This Contract has a family deductible limit of two Cash Deductibles for each Calendar Year. Once [Members] in a family meet the family Cash Deductible in a Calendar Year, We provide coverage for Covered Services and Supplies for all Members who are part of the covered family, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. What We pay is based on all the terms of this Contract.] [Please note: There are separate Cash Deductibles for [Tier 1] and [Tier 2] as shown on This credit will be applied whether Your previous coverage was under a plan with Us or with another carrier. You will be required to provide Us with adequate documentation of the Schedule amounts satisfied. Maximum out of Insurance and Premium Rates.] [The [Tier 1] Deductible is for treatment, services or supplies given by pocket means the annual maximum dollar amount that a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have pay as Copayment, Deductible and Coinsurance for all Covered Services and or Supplies from in a [Tier 1] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Each Except as stated below, all amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Except as stated below, once the Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Covered Services or Supplies for the remainder of the Calendar Year.] Once Members in a family meet the family Maximum Out of Pocket, each no other Member must have Covered Services and Supplies from a [Tier 2] Network Provider in that exceed the Cash Deductible before We family will be required to pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 2] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or amounts as Copayments, Deductible or Coinsurance for covered services and supplies for the rest remainder of that the Calendar Year. Neither [Members] are entitled to receive the [Tier 1] nor benefits in the [Tier 2] Cash Deductible can be met with Non-Covered Services following sections when Medically Necessary and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] [The [Tier 1] Deductible is for treatmentAppropriate, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider as well as for treatment, services or supplies given by a [Tier 1] Network that are applied subject to the payment by [Tier 1Members] Deductible. Each of applicable copayments [Cash Deductible is shown Deductible,][or Coinsurance] as stated in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash Deductible before We pay benefits for those types applicable Schedule of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Each Calendar Year, the sum of the Covered Services and Supplies for each Member from a [Tier 2] Network Provider and those from a [Tier 1] Provider must exceed the [Tier 2] Cash Deductible before We pay benefits for [Tier 1] and [Tier 2] Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] or a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] (Use the above text if the Tier 1 deductible can be satisfied separately and allows a Member to be in benefit for further Tier 1 Covered Services and Supplies and is also applied toward subject to the satisfaction terms, conditions and limitations of this Contract. Read the Tier 2 deductibleentire Contract to determine what treatment, services and supplies are limited or excluded.)

Family Deductible Limit. For Other than Single Coverage The per Member Cash Deductible is not applicable. This Contract has a family deductible limit of two per Covered Family Cash Deductibles for each Calendar YearDeductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once [Members] any combination of Members in a family meet meets the family Per Covered Family Cash Deductible shown in a Calendar Yearthe Schedule, We provide coverage pay benefits for other Covered Services and Supplies for all Members who are part incurred by any member of the covered family, less any applicable Coinsurance or Copayments[copayment or] Coinsurance, for the rest of that Calendar [Calendar] [Plan] Year. What We pay is based on all the terms Maximum Out of this Contract.] [Please notePocket: There The Per Member and Per Covered Family Maximum Out of Pocket amounts are separate Cash Deductibles for [Tier 1] and [Tier 2] as shown on the Schedule of Insurance and Premium Rates.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider. Each Cash Deductible is shown in the Schedule. Each In the case of single coverage, for a Member, the Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a [Calendar] [Plan] Year. Once the Per Member Maximum Out of Pocket has been met during a [Calendar] [Plan] Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the [Calendar] [Plan] Year. In the case of coverage which is other than single coverage, for a Member, the per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a [Calendar] [Plan]Year. Once the Per Member Maximum Out of Pocket has been met during a Calendar Year, each Member no further Deductible or Coinsurance or Copayments will be required for such Covered Person for the rest of the [Calendar][Plan] Year. In the case of coverage which is other than single coverage, for a Covered Family, the Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must have pay as per Covered Services Family Cash Deductible plus Coinsurance and Supplies from Copayments for all covered services and supplies in a [Tier 1Calendar] Network Provider that exceed [Plan] Year. Once the Cash Deductible before We pay benefits for those types Per Covered Family Maximum Out of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from Pocket has been met during a [Tier 1Calendar] Network Provider[Plan] Year, while no further Deductible or Coinsurance or Copayment will be required for members of the covered by family for the rest of the [Calendar] [Plan] Year.] The Contractholder who purchased this ContractContract may have purchased it to replace a plan the Contractholder had with some other carrier. The Member may have incurred charges for covered services and supplies under the Contractholder's old plan before it ended. If so, can these charges will be used to meet this Cash Deductible. Once the Contract’s Cash Deductible if: the charges were incurred during the [Calendar] [Plan] Year in which this Contract starts or during the 90 days preceding the effective date, whichever is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, greater period; this Contract would have provided coverage for the rest of that Calendar Year. Each Calendar Year, each charges if this Contract had been in effect: the Member must have Covered Services and Supplies from a [Tier 2] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred was covered by the Member for treatment, services or supplies from a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 2] Covered Services old plan when it ended and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by enrolled in this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of its Effective Date; and this Contract.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider as well as for treatment, services or supplies given by a [Tier 1] Network that are applied to the [Tier 1] Deductible. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Each Calendar Year, the sum Contract takes effect immediately upon termination of the Covered Services and Supplies for each Member from a [Tier 2] Network Provider and those from a [Tier 1] Provider must exceed the [Tier 2] Cash Deductible before We pay benefits for [Tier 1] and [Tier 2] Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] or a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contractprior plan.] (Use the above text if the Tier 1 deductible can be satisfied separately and allows a Member to be in benefit for further Tier 1 Covered Services and Supplies and is also applied toward the satisfaction of the Tier 2 deductible.)

Family Deductible Limit. For Other than Single Coverage The per Member Cash Deductible is not applicable. This Contract has a family deductible limit of two per Covered Family Cash Deductibles for each Calendar YearDeductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once [Members] any combination of Members in a family meet meets the family Per Covered Family Cash Deductible shown in a Calendar Yearthe Schedule, We provide coverage pay benefits for other Covered Services and Supplies for all Members who are part Charges incurred by any member of the covered family, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. What We pay is based on all the terms Maximum Out of this Contract.] [Please notePocket: There The Per Member and Per Covered Family Maximum Out of Pocket amounts are separate Cash Deductibles for [Tier 1] and [Tier 2] as shown on the Schedule of Insurance and Premium Rates.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider. Each Cash Deductible is shown in the Schedule. Each In the case of single coverage, for a Member, the Maximum Out of Pocket is the annual maximum dollar amount that a member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per member Maximum Out of Pocket has been met during a Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash no further Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, Copayments will be required for such Member for the rest of that the Calendar Year. Each In the case of coverage which is other than single coverage, for a member, the per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per Member Maximum Out of Pocket has been met during a Calendar Year, each Member must have Covered Services and Supplies from a [Tier 2] Network Provider that exceed the Cash no further Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 2] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, Copayments will be required for such Member for the rest of that the Calendar Year. Neither In the [Tier 1] nor case of coverage which is other than single coverage, for a Covered Family, the [Tier 2] Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as per Covered Family Cash Deductible can be plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per Covered Family Maximum Out of Pocket has been met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] [The [Tier 1] Deductible is for treatment, services or supplies given by during a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider as well as for treatment, services or supplies given by a [Tier 1] Network that are applied to the [Tier 1] Deductible. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash no further Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, Copayment will be required for members of the covered family for the rest of that the Calendar Year. Each Calendar Year, the sum of the Covered Services and Supplies for each Member from a [Tier 2] Network Provider and those from a [Tier 1] Provider must exceed the [Tier 2] Cash Deductible before We pay benefits for [Tier 1] and [Tier 2] Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] or a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] (Use [Members] are entitled to receive the above text if benefits in the Tier 1 deductible can be satisfied separately following sections when Medically Necessary and allows a Member Appropriate, subject to be the payment by [Members] of applicable copayments [Cash Deductible,][or Coinsurance] as stated in benefit for further Tier 1 Covered the applicable Schedule of Services and Supplies and is also applied toward subject to the satisfaction terms, conditions and limitations of this Contract. Read the Tier 2 deductibleentire Contract to determine what treatment, services and supplies are limited or excluded.)

Family Deductible Limit. For Other than Single Coverage The per Member Cash Deductible is not applicable. This Contract has a family deductible limit of two per Covered Family Cash Deductibles for each Calendar YearDeductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once [Members] any combination of Members in a family meet meets the family Per Covered Family Cash Deductible shown in a Calendar Yearthe Schedule, We provide coverage pay benefits for other Covered Services and Supplies for all Members who are part Charges incurred by any member of the covered family, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. What We Maximum Out of Pocket: The Per Member and Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. In the case of single coverage, for a Member, the Maximum Out of Pocket is the annual maximum dollar amount that a member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per member Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. In the case of coverage which is based on other than single coverage, for a member, the per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the terms Per Member Maximum Out of this ContractPocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. In the case of coverage which is other than single coverage, for a Covered Family, the Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the Calendar Year.] [Please note: There are separate Cash Deductibles for [Tier 1] and [Tier 2] as shown on the Schedule of Insurance and Premium Rates.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network ProviderInsurance. The other is for treatment, services or supplies given by a [Tier 2] Network Provider. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 2] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 2] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider [as well as for treatment, services or and supplies given by a [Tier 1] Network Provider that are applied to the [Tier 11 and Tier 2] DeductibleCash Deductibles]. Each Cash Deductible is shown in the ScheduleSchedule of Services and Supplies. The Cash Deductible: For Single Coverage Only: [Tier 1] Each Calendar Year, each Member You must have Covered Services and Supplies from a Charges that exceed the [Tier 1] Network Provider that exceed the per Member Cash Deductible before We pay any benefits to You for those types of Covered Services and Supplies to that Membercharges. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a The [Tier 1] Network Provider, per Member Cash Deductible is shown in the Schedule. The Cash Deductible cannot be met with Non-Covered Charges. Only Covered Charges incurred by You while covered by this Contract, insured can be used to meet this the Cash Deductible. Once the [Tier 1] per Member Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies Charges above the Cash Deductible amount incurred by that MemberYou, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. But all charges must be incurred while You are insured by this Policy. And what We pay is based on all the terms of this Policy including benefit limitations and exclusion provisions. For Single Coverage Only: [Tier 2] Each Calendar Year, the sum of the You must have Covered Services and Supplies for each Member from a [Tier 2] Network Provider and those from a [Tier 1] Provider must Charges that exceed the [Tier 2] per Member Cash Deductible before We pay any benefits to You for those charges. [Covered Charges applied to the [Tier 11 ] and per Member Cash Deductible also apply to this [Tier 2] Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the per Member for treatment, services or supplies from a [Tier 1Cash Deductible.] or a The [Tier 2] Network Provider, per Member Cash Deductible is shown in the Schedule. The Cash Deductible cannot be met with Non-Covered Charges. Only Covered Charges incurred by You while covered by this Contract, insured can be used to meet this the Cash Deductible. Once the [Tier 2] per Member Cash Deductible is met, We pay benefits for other such Covered Services and Supplies Charges above the Cash Deductible amount incurred by that MemberYou, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can But all charges must be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered You are insured by this Contract can be used to meet either Cash DeductiblePolicy. What And what We pay is based on all the terms of this Contract.Policy including benefit limitations and exclusion provisions. For Other than Single Coverage: [Tier 1] (Use The [Tier 1] per Member Cash Deductible is not applicable. This Policy has a [Tier 1] per Covered Family Cash Deductible which applies in all instances where this Policy provides coverage that is not single only coverage. Once any combination of Members in a family meets the above text if [Tier 1] per Covered Family Cash Deductible shown in the Tier 1 deductible can be satisfied separately and allows a Member to be in benefit Schedule, We pay benefits for further Tier 1 other Covered Services and Supplies and is also applied toward the satisfaction Charges incurred by any member of the covered family, less any Coinsurance, for the rest of that Calendar Year. For Other than Single Coverage: [Tier 2 deductible2] The [Tier 2] per Member Cash Deductible is not applicable. This Policy has a [Tier 2] per Covered Family Cash Deductible which applies in all instances where this Policy provides coverage that is not single only coverage. Once any combination of Members in a family meets the [Tier 2] per Covered Family Cash Deductible shown in the Schedule, We pay benefits for other Covered Charges incurred by any member of the covered family, less any Coinsurance, for the rest of that Calendar Year. [Note that Covered Charges applied to the [Tier 1] per Covered Family Cash Deductible also apply to this [Tier 2] per Covered Family Cash Deductible.)]

Family Deductible Limit. For Other than Single Coverage The per Member Cash Deductible is not applicable. This Contract has a family deductible limit of two per Covered Family Cash Deductibles for each Calendar YearDeductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once [Members] any combination of Members in a family meet meets the family Per Covered Family Cash Deductible shown in a Calendar Yearthe Schedule, We provide coverage pay benefits for other Covered Services and Supplies for all Members who are part Charges incurred by any member of the covered family, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. What We Maximum Out of Pocket: The Per Member and Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. In the case of single coverage, for a Member, the Maximum Out of Pocket is the annual maximum dollar amount that a member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per member Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. In the case of coverage which is based on other than single coverage, for a member, the per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the terms Per Member Maximum Out of this ContractPocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. In the case of coverage which is other than single coverage, for a Covered Family, the Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the Calendar Year.] [Please note: There are separate Cash Deductibles for [Tier 1] and [Tier 2] as shown on the Schedule of Insurance and Premium Rates.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network ProviderInsurance. The other is for treatment, services or supplies given by a [Tier 2] Network Provider. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 2] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 2] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider [as well as for treatment, services or and supplies given by a [Tier 1] Network Provider that are applied to the [Tier 11 and Tier 2] DeductibleCash Deductibles]. Each Cash Deductible is shown in the ScheduleSchedule of Services and Supplies. The Cash Deductible: For Single Coverage Only: [Tier 1] Each Calendar Year, each Member You must have Covered Services and Supplies from a Charges that exceed the [Tier 1] Network Provider that exceed the per Member Cash Deductible before We pay any benefits to You for those types of Covered Services and Supplies to that Membercharges. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a The [Tier 1] Network Provider, per Member Cash Deductible is shown in the Schedule. The Cash Deductible cannot be met with Non-Covered Charges. Only Covered Charges incurred by You while covered by this Contract, insured can be used to meet this the Cash Deductible. Once the [Tier 1] per Member Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies Charges above the Cash Deductible amount incurred by that MemberYou, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. But all charges must be incurred while You are insured by this Contract. And what We pay is based on all the terms of this Contract including benefit limitations and exclusion provisions. For Single Coverage Only: [Tier 2] Each Calendar Year, the sum of the You must have Covered Services and Supplies for each Member from a [Tier 2] Network Provider and those from a [Tier 1] Provider must Charges that exceed the [Tier 2] per Member Cash Deductible before We pay any benefits to You for those charges. [Covered Charges applied to the [Tier 11 ] and per Member Cash Deductible also apply to this [Tier 2] Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the per Member for treatment, services or supplies from a [Tier 1Cash Deductible.] or a The [Tier 2] Network Provider, per Member Cash Deductible is shown in the Schedule. The Cash Deductible cannot be met with Non-Covered Charges. Only Covered Charges incurred by You while covered by this Contract, insured can be used to meet this the Cash Deductible. Once the [Tier 2] per Member Cash Deductible is met, We pay benefits for other such Covered Services and Supplies Charges above the Cash Deductible amount incurred by that MemberYou, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can But all charges must be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered You are insured by this Contract can be used to meet either Cash DeductibleContract. What And what We pay is based on all the terms of this Contract.Contract including benefit limitations and exclusion provisions. For Other than Single Coverage: [Tier 1] (Use The [Tier 1] per Member Cash Deductible is not applicable. This Contract has a [Tier 1] per Covered Family Cash Deductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once any combination of Members in a family meets the above text if [Tier 1] per Covered Family Cash Deductible shown in the Tier 1 deductible can be satisfied separately and allows a Member to be in benefit Schedule, We pay benefits for further Tier 1 other Covered Services and Supplies and is also applied toward the satisfaction Charges incurred by any member of the covered family, less any Coinsurance, for the rest of that Calendar Year. For Other than Single Coverage: [Tier 2 deductible2] The [Tier 2] per Member Cash Deductible is not applicable. This Contract has a [Tier 2] per Covered Family Cash Deductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once any combination of Members in a family meets the [Tier 2] per Covered Family Cash Deductible shown in the Schedule, We pay benefits for other Covered Charges incurred by any member of the covered family, less any Coinsurance, for the rest of that Calendar Year. [Note that Covered Charges applied to the [Tier 1] per Covered Family Cash Deductible also apply to this [Tier 2] per Covered Family Cash Deductible.)]

Family Deductible Limit. For Other than Single Coverage The per Member Cash Deductible is not applicable. This Contract has a family deductible limit of two per Covered Family Cash Deductibles for each Calendar YearDeductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once [Members] any combination of Members in a family meet meets the family Per Covered Family Cash Deductible shown in a Calendar Yearthe Schedule, We provide coverage pay benefits for other Covered Services and Supplies for all Members who are part Charges incurred by any member of the covered family, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. What We The Per Member and Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. In the case of single coverage, for a Member, the Maximum Out of Pocket is the annual maximum dollar amount that a member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per member Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. In the case of coverage which is based on other than single coverage, for a member, the per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the terms Per Member Maximum Out of this ContractPocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. In the case of coverage which is other than single coverage, for a Covered Family, the Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the Calendar Year.] [Please note: There are separate Cash Deductibles for [Tier 1] and [Tier 2] as shown on the Schedule of Insurance and Premium Rates.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network ProviderInsurance. The other is for treatment, services or supplies given by a [Tier 2] Network Provider. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 2] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 2] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider [as well as for treatment, services or and supplies given by a [Tier 1] Network Provider that are applied to the [Tier 11 and Tier 2] DeductibleCash Deductibles]. Each Cash Deductible is shown in the ScheduleSchedule of Services and Supplies. For Single Coverage Only: [Tier 1] Each Calendar Year, each Member You must have Covered Services and Supplies from a Charges that exceed the [Tier 1] Network Provider that exceed the per Member Cash Deductible before We pay any benefits to You for those types of Covered Services and Supplies to that Membercharges. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a The [Tier 1] Network Provider, per Member Cash Deductible is shown in the Schedule. The Cash Deductible cannot be met with Non-Covered Charges. Only Covered Charges incurred by You while covered by this Contract, insured can be used to meet this the Cash Deductible. Once the [Tier 1] per Member Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies Charges above the Cash Deductible amount incurred by that MemberYou, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. But all charges must be incurred while You are insured by this Contract. And what We pay is based on all the terms of this Contract including benefit limitations and exclusion provisions. For Single Coverage Only: [Tier 2] Each Calendar Year, the sum of the You must have Covered Services and Supplies for each Member from a [Tier 2] Network Provider and those from a [Tier 1] Provider must Charges that exceed the [Tier 2] per Member Cash Deductible before We pay any benefits to You for those charges. [Covered Charges applied to the [Tier 11 ] and per Member Cash Deductible also apply to this [Tier 2] Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the per Member for treatment, services or supplies from a [Tier 1Cash Deductible.] or a The [Tier 2] Network Provider, per Member Cash Deductible is shown in the Schedule. The Cash Deductible cannot be met with Non-Covered Charges. Only Covered Charges incurred by You while covered by this Contract, insured can be used to meet this the Cash Deductible. Once the [Tier 2] per Member Cash Deductible is met, We pay benefits for other such Covered Services and Supplies Charges above the Cash Deductible amount incurred by that MemberYou, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can But all charges must be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered You are insured by this Contract can be used to meet either Cash DeductibleContract. What And what We pay is based on all the terms of this Contract.Contract including benefit limitations and exclusion provisions. For Other than Single Coverage: [Tier 1] (Use The [Tier 1] per Member Cash Deductible is not applicable. This Contract has a [Tier 1] per Covered Family Cash Deductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once any combination of Members in a family meets the above text if [Tier 1] per Covered Family Cash Deductible shown in the Tier 1 deductible can be satisfied separately and allows a Member to be in benefit Schedule, We pay benefits for further Tier 1 other Covered Services and Supplies and is also applied toward the satisfaction Charges incurred by any member of the covered family, less any Coinsurance, for the rest of that Calendar Year. For Other than Single Coverage: [Tier 2 deductible2] The [Tier 2] per Member Cash Deductible is not applicable. This Contract has a [Tier 2] per Covered Family Cash Deductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once any combination of Members in a family meets the [Tier 2] per Covered Family Cash Deductible shown in the Schedule, We pay benefits for other Covered Charges incurred by any member of the covered family, less any Coinsurance, for the rest of that Calendar Year. [Note that Covered Charges applied to the [Tier 1] per Covered Family Cash Deductible also apply to this [Tier 2] per Covered Family Cash Deductible.)]

Family Deductible Limit. For Other than Single Coverage The per Member Cash Deductible is not applicable. This Contract has a family deductible limit of two per Covered Family Cash Deductibles for each Calendar YearDeductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once [Members] any combination of Members in a family meet meets the family Per Covered Family Cash Deductible shown in a Calendar Yearthe Schedule, We provide coverage pay benefits for other Covered Services and Supplies for all Members who are part Charges incurred by any member of the covered family, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. What We The Per Member and Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. In the case of single coverage, for a Member, the Maximum Out of Pocket is the annual maximum dollar amount that a member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per member Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. In the case of coverage which is based on other than single coverage, for a member, the per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the terms Per Member Maximum Out of this ContractPocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. In the case of coverage which is other than single coverage, for a Covered Family, the Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the Calendar Year.] [Please note: There are separate Cash Deductibles for [Tier 1] and [Tier 2] as shown on the Schedule of Insurance and Premium Rates.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network ProviderInsurance. The other is for treatment, services or supplies given by a [Tier 2] Network Provider. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 2] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 2] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider [as well as for treatment, services or and supplies given by a [Tier 1] Network Provider that are applied to the [Tier 11 and Tier 2] DeductibleCash Deductibles]. Each Cash Deductible is shown in the ScheduleSchedule of Services and Supplies. For Single Coverage Only: [Tier 1] Each Calendar Year, each Member You must have Covered Services and Supplies from a Charges that exceed the [Tier 1] Network Provider that exceed the per Member Cash Deductible before We pay any benefits to You for those types of Covered Services and Supplies to that Membercharges. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a The [Tier 1] Network Provider, per Member Cash Deductible is shown in the Schedule. The Cash Deductible cannot be met with Non-Covered Charges. Only Covered Charges incurred by You while covered by this Contract, insured can be used to meet this the Cash Deductible. Once the [Tier 1] per Member Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies Charges above the Cash Deductible amount incurred by that MemberYou, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. But all charges must be incurred while You are insured by this Policy. And what We pay is based on all the terms of this Policy including benefit limitations and exclusion provisions. For Single Coverage Only: [Tier 2] Each Calendar Year, the sum of the You must have Covered Services and Supplies for each Member from a [Tier 2] Network Provider and those from a [Tier 1] Provider must Charges that exceed the [Tier 2] per Member Cash Deductible before We pay any benefits to You for those charges. [Covered Charges applied to the [Tier 11 ] and per Member Cash Deductible also apply to this [Tier 2] Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the per Member for treatment, services or supplies from a [Tier 1Cash Deductible.] or a The [Tier 2] Network Provider, per Member Cash Deductible is shown in the Schedule. The Cash Deductible cannot be met with Non-Covered Charges. Only Covered Charges incurred by You while covered by this Contract, insured can be used to meet this the Cash Deductible. Once the [Tier 2] per Member Cash Deductible is met, We pay benefits for other such Covered Services and Supplies Charges above the Cash Deductible amount incurred by that MemberYou, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can But all charges must be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered You are insured by this Contract can be used to meet either Cash DeductiblePolicy. What And what We pay is based on all the terms of this ContractPolicy including benefit limitations and exclusion provisions. For Other than Single Coverage: [Tier 1] The [Tier 1] per Member Cash Deductible is not applicable. This Policy has a [Tier 1] per Covered Family Cash Deductible which applies in all instances where this Policy provides coverage that is not single only coverage. Once any combination of Members in a family meets the [Tier 1] per Covered Family Cash Deductible shown in the Schedule, We pay benefits for other Covered Charges incurred by any member of the covered family, less any Coinsurance, for the rest of that Calendar Year. For Other than Single Coverage: [Tier 2] The [Tier 2] per Member Cash Deductible is not applicable. This Policy has a [Tier 2] per Covered Family Cash Deductible which applies in all instances where this Policy provides coverage that is not single only coverage. Once any combination of Members in a family meets the [Tier 2] per Covered Family Cash Deductible shown in the Schedule, We pay benefits for other Covered Charges incurred by any member of the covered family, less any Coinsurance, for the rest of that Calendar Year. [Note that Covered Charges applied to the [Tier 1] per Covered Family Cash Deductible also apply to this [Tier 2] per Covered Family Cash Deductible.] (Use the above text if the The [Tier 1 deductible can be satisfied separately and allows Tier 2] Per Member and [Tier 1 and Tier 2] Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. For Single Coverage Only: [Tier 1] In the case of single coverage, for a Member, the [Tier 1] Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 1] per Member Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. For Single Coverage Only: [Tier 2] In the case of single coverage, for a Member, the [Tier 2] Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. [All per Member Cash Deductible plus Coinsurance and Copayments applied to the [Tier 1] per Member Maximum Out of Pocket also apply to this [Tier 2] per Member Maximum Out of Pocket.] Once the [Tier 2] per Member Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. For Other than Single Coverage: [Tier 1] In the case of coverage which is other than single coverage, for a Member, the [Tier 1] per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as [Tier 1] per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in benefit a Calendar Year. Once the [Tier 1] per Member Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 1] Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. In the case of coverage which is other than single coverage, for a Covered Family, the [Tier 1] Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as [Tier 1] per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 1] per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 1 1] Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the Calendar Year. For Other than Single Coverage: [Tier 2] In the case of coverage which is other than single coverage, for a Member, the [Tier 2] per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as [Tier 2] per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 2] per Member Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 2] Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. [Note that amounts applied to the [Tier 1] per Member Maximum Out of Pocket also apply to this [Tier 2] per Member Maximum Out of Pocket.] In the case of coverage which is other than single coverage, for a Covered Family, the [Tier 2] Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as [Tier 2] per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 2] per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 2] Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the Calendar Year. [Note that amounts applied to the [Tier 1] per Covered Family Maximum Out of Pocket also apply to this [Tier 2] per Covered Family Maximum Out of Pocket.]] [Members] are entitled to receive the benefits in the following sections when Medically Necessary and Appropriate, subject to the payment by [Members] of applicable copayments [Cash Deductible,][or Coinsurance] as stated in the applicable Schedule of Services and Supplies and is also applied toward subject to the satisfaction terms, conditions and limitations of this Contract. Read the Tier 2 deductibleentire Contract to determine what treatment, services and supplies are limited or excluded.)

Family Deductible Limit. For Other than Single Coverage The per Member Cash Deductible is not applicable. This Contract has a family deductible limit of two per Covered Family Cash Deductibles for each Calendar YearDeductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once [Members] any combination of Covered Persons in a family meet meets the family Per Covered Family Cash Deductible shown in a Calendar Yearthe Schedule, We provide coverage pay benefits for other Covered Services and Supplies for all Members who are part Charges incurred by any member of the covered family, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. What We pay is based on all the terms Maximum Out of this Contract.] [Please notePocket: There The Per Member and Per Covered Family Maximum Out of Pocket amounts are separate Cash Deductibles for [Tier 1] and [Tier 2] as shown on the Schedule of Insurance and Premium Rates.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider. Each Cash Deductible is shown in the Schedule. Each In the case of single coverage, for a Member, the Maximum Out of Pocket is the annual maximum dollar amount that a member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per member Maximum Out of Pocket has been met during a Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash no further Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, Copayments will be required for such Member for the rest of that the Calendar Year. Each In the case coverage which is other than single coverage, for a member, the per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per Member Maximum Out of Pocket has been met during a Calendar Year, each Member must have Covered Services and Supplies from a [Tier 2] Network Provider that exceed the Cash no further Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 2] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, Copayments will be required for such Member for the rest of that the Calendar Year. Neither In the [Tier 1] nor case of coverage which is other than single coverage, for a Covered Family, the [Tier 2] Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as per Covered Family Cash Deductible can be plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per Covered Family Maximum Out of Pocket has been met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] [The [Tier 1] Deductible is for treatment, services or supplies given by during a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider as well as for treatment, services or supplies given by a [Tier 1] Network that are applied to the [Tier 1] Deductible. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash no further Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, Copayment will be required for members of the covered family for the rest of that the Calendar Year. Each Calendar Year, the sum of the Covered Services and Supplies for each Member from a [Tier 2] Network Provider and those from a [Tier 1] Provider must exceed the [Tier 2] Cash Deductible before We pay benefits for [Tier 1] and [Tier 2] Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] or a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] (Use [Members] are entitled to receive the above text if benefits in the Tier 1 deductible can be satisfied separately following sections when Medically Necessary and allows a Member Appropriate, subject to be the payment by [Members] of applicable copayments [Cash Deductible,][or Coinsurance] as stated in benefit for further Tier 1 Covered the applicable Schedule of Services and Supplies and is also applied toward subject to the satisfaction terms, conditions and limitations of this Contract. Read the Tier 2 deductibleentire Contract to determine what treatment, services and supplies are limited or excluded.)

Family Deductible Limit. For Other than Single Coverage The per Member Cash Deductible is not applicable. This Contract has a family deductible limit of two per Covered Family Cash Deductibles for each Calendar YearDeductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once [Members] any combination of Members in a family meet meets the family Per Covered Family Cash Deductible shown in a Calendar Yearthe Schedule, We provide coverage pay benefits for other Covered Services and Supplies for all Members who are part Charges incurred by any member of the covered family, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. What We The Per Member and Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. In the case of single coverage, for a Member, the Maximum Out of Pocket is the annual maximum dollar amount that a member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per member Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. In the case of coverage which is based on other than single coverage, for a member, the per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the terms Per Member Maximum Out of this ContractPocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. In the case of coverage which is other than single coverage, for a Covered Family, the Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the Calendar Year.] [Please note: There are separate Cash Deductibles for [Tier 1] and [Tier 2] as shown on the Schedule of Insurance and Premium Rates.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network ProviderInsurance. The other is for treatment, services or supplies given by a [Tier 2] Network Provider. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 2] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 2] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider [as well as for treatment, services or and supplies given by a [Tier 1] Network Provider that are applied to the [Tier 11 and Tier 2] DeductibleCash Deductibles]. Each Cash Deductible is shown in the ScheduleSchedule of Services and Supplies. For Single Coverage Only: [Tier 1] Each Calendar Year, each Member You must have Covered Services and Supplies from a Charges that exceed the [Tier 1] Network Provider that exceed the per Member Cash Deductible before We pay any benefits to You for those types of Covered Services and Supplies to that Membercharges. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a The [Tier 1] Network Provider, per Member Cash Deductible is shown in the Schedule. The Cash Deductible cannot be met with Non-Covered Charges. Only Covered Charges incurred by You while covered by this Contract, insured can be used to meet this the Cash Deductible. Once the [Tier 1] per Member Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies Charges above the Cash Deductible amount incurred by that MemberYou, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. But all charges must be incurred while You are insured by this Contract. And what We pay is based on all the terms of this Contract including benefit limitations and exclusion provisions. For Single Coverage Only: [Tier 2] Each Calendar Year, the sum of the You must have Covered Services and Supplies for each Member from a [Tier 2] Network Provider and those from a [Tier 1] Provider must Charges that exceed the [Tier 2] per Member Cash Deductible before We pay any benefits to You for those charges. [Covered Charges applied to the [Tier 11 ] and per Member Cash Deductible also apply to this [Tier 2] Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the per Member for treatment, services or supplies from a [Tier 1Cash Deductible.] or a The [Tier 2] Network Provider, per Member Cash Deductible is shown in the Schedule. The Cash Deductible cannot be met with Non-Covered Charges. Only Covered Charges incurred by You while covered by this Contract, insured can be used to meet this the Cash Deductible. Once the [Tier 2] per Member Cash Deductible is met, We pay benefits for other such Covered Services and Supplies Charges above the Cash Deductible amount incurred by that MemberYou, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can But all charges must be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered You are insured by this Contract can be used to meet either Cash DeductibleContract. What And what We pay is based on all the terms of this ContractContract including benefit limitations and exclusion provisions. For Other than Single Coverage: [Tier 1] The [Tier 1] per Member Cash Deductible is not applicable. This Contract has a [Tier 1] per Covered Family Cash Deductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once any combination of Members in a family meets the [Tier 1] per Covered Family Cash Deductible shown in the Schedule, We pay benefits for other Covered Charges incurred by any member of the covered family, less any Coinsurance, for the rest of that Calendar Year. For Other than Single Coverage: [Tier 2] The [Tier 2] per Member Cash Deductible is not applicable. This Contract has a [Tier 2] per Covered Family Cash Deductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once any combination of Members in a family meets the [Tier 2] per Covered Family Cash Deductible shown in the Schedule, We pay benefits for other Covered Charges incurred by any member of the covered family, less any Coinsurance, for the rest of that Calendar Year. [Note that Covered Charges applied to the [Tier 1] per Covered Family Cash Deductible also apply to this [Tier 2] per Covered Family Cash Deductible.] (Use the above text if the The [Tier 1 deductible can be satisfied separately and allows Tier 2] Per Member and [Tier 1 and Tier 2] Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. For Single Coverage Only: [Tier 1] In the case of single coverage, for a Member, the [Tier 1] Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 1] per Member Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. For Single Coverage Only: [Tier 2] In the case of single coverage, for a Member, the [Tier 2] Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. [All per Member Cash Deductible plus Coinsurance and Copayments applied to the [Tier 1] per Member Maximum Out of Pocket also apply to this [Tier 2] per Member Maximum Out of Pocket.] Once the [Tier 2] per Member Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. For Other than Single Coverage: [Tier 1] In the case of coverage which is other than single coverage, for a Member, the [Tier 1] per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as [Tier 1] per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in benefit a Calendar Year. Once the [Tier 1] per Member Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 1] Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. In the case of coverage which is other than single coverage, for a Covered Family, the [Tier 1] Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as [Tier 1] per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 1] per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 1 1] Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the Calendar Year. For Other than Single Coverage: [Tier 2] In the case of coverage which is other than single coverage, for a Member, the [Tier 2] per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as [Tier 2] per Covered Services Family Cash Deductible plus Coinsurance and Supplies Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 2] per Member Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 2] Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. [Note that amounts applied to the [Tier 1] per Member Maximum Out of Pocket also apply to this [Tier 2] per Member Maximum Out of Pocket.] In the case of coverage which is other than single coverage, for a Covered Family, the [Tier 2] Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as [Tier 2] per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 2] per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 2] Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the Calendar Year. [Note that amounts applied to the [Tier 1] per Covered Family Maximum Out of Pocket also apply to this [Tier 2] per Covered Family Maximum Out of Pocket.]] If a Member receives emergency services at a Hospital or independent freestanding emergency department, the Member’s liability for services rendered by an out-of-network Provider is limited to the network level copayment, deductible, coinsurance and maximum out-of-pocket. The Member cannot be balance billed for the services. Except as stated below, the Member’s liability for post-stabilization emergency services is also applied toward limited to the satisfaction of the Tier 2 network level copayment, deductible, coinsurance and maximum out-of-pocket.)

Family Deductible Limit. For Other than Single Coverage The per Member Cash Deductible is not applicable. This Contract has a family deductible limit of two per Covered Family Cash Deductibles for each Calendar YearDeductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once [Members] any combination of Members in a family meet meets the family Per Covered Family Cash Deductible shown in a Calendar Yearthe Schedule, We provide coverage pay benefits for other Covered Services and Supplies for all Members who are part incurred by any member of the covered family, less any applicable Coinsurance or Copayments[copayment or] Coinsurance, for the rest of that Calendar [Calendar] [Plan] Year. What We pay is based on all the terms Maximum Out of this Contract.] [Please notePocket: There The Per Member and Per Covered Family Maximum Out of Pocket amounts are separate Cash Deductibles for [Tier 1] and [Tier 2] as shown on the Schedule of Insurance and Premium Rates.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider. Each Cash Deductible is shown in the Schedule. Each In the case of single coverage, for a Member, the Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a [Calendar] [Plan] Year. Once the Per Member Maximum Out of Pocket has been met during a [Calendar] [Plan] Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the [Calendar] [Plan] Year. In the case coverage which is other than single coverage, for a Member, the per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a [Calendar] [Plan]Year. Once the Per Member Maximum Out of Pocket has been met during a Calendar Year, each Member no further Deductible or Coinsurance or Copayments will be required for such Covered Person for the rest of the [Calendar][Plan] Year. In the case of coverage which is other than single coverage, for a Covered Family, the Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must have pay as per Covered Services Family Cash Deductible plus Coinsurance and Supplies from Copayments for all covered services and supplies in a [Tier 1Calendar] Network Provider that exceed [Plan] Year. Once the Cash Deductible before We pay benefits for those types Per Covered Family Maximum Out of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from Pocket has been met during a [Tier 1Calendar] Network Provider[Plan] Year, while no further Deductible or Coinsurance or Copayment will be required for members of the covered by family for the rest of the [Calendar] [Plan] Year.] The Contractholder who purchased this ContractContract may have purchased it to replace a plan the Contractholder had with some other carrier. The Member may have incurred charges for covered services and supplies under the Contractholder's old plan before it ended. If so, can these charges will be used to meet this Cash Deductible. Once the Contract’s Cash Deductible if: the charges were incurred during the [Calendar] [Plan] Year in which this Contract starts or during the 90 days preceding the effective date, whichever is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, greater period; this Contract would have provided coverage for the rest of that Calendar Year. Each Calendar Year, each charges if this Contract had been in effect: the Member must have Covered Services and Supplies from a [Tier 2] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred was covered by the Member for treatment, services or supplies from a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 2] Covered Services old plan when it ended and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by enrolled in this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of its Effective Date; and this Contract.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider as well as for treatment, services or supplies given by a [Tier 1] Network that are applied to the [Tier 1] Deductible. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Each Calendar Year, the sum Contract takes effect immediately upon termination of the Covered Services and Supplies for each Member from a [Tier 2] Network Provider and those from a [Tier 1] Provider must exceed the [Tier 2] Cash Deductible before We pay benefits for [Tier 1] and [Tier 2] Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] or a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contractprior plan.] (Use the above text if the Tier 1 deductible can be satisfied separately and allows a Member to be in benefit for further Tier 1 Covered Services and Supplies and is also applied toward the satisfaction of the Tier 2 deductible.)

Family Deductible Limit. For Other than Single Coverage The per Member Cash Deductible is not applicable. This Contract has a family deductible limit of two per Covered Family Cash Deductibles for each Calendar YearDeductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once [Members] any combination of Covered Persons in a family meet meets the family Per Covered Family Cash Deductible shown in a Calendar Yearthe Schedule, We provide coverage pay benefits for other Covered Services and Supplies for all Members who are part Charges incurred by any member of the covered family, less any applicable Coinsurance or CopaymentsCoinsurance, for the rest of that Calendar Year. What We pay is based on all the terms The Per Member and Per Covered Family Maximum Out of this Contract.] [Please note: There Pocket amounts are separate Cash Deductibles for [Tier 1] and [Tier 2] as shown on the Schedule of Insurance and Premium Rates.] [The [Tier 1] Deductible is for treatment, services or supplies given by a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider. Each Cash Deductible is shown in the Schedule. Each In the case of single coverage, for a Member, the Maximum Out of Pocket is the annual maximum dollar amount that a member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per member Maximum Out of Pocket has been met during a Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash no further Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, Copayments will be required for such Member for the rest of that the Calendar Year. Each In the case coverage which is other than single coverage, for a member, the per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per Member Maximum Out of Pocket has been met during a Calendar Year, each Member must have Covered Services and Supplies from a [Tier 2] Network Provider that exceed the Cash no further Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 2] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, Copayments will be required for such Member for the rest of that the Calendar Year. Neither In the [Tier 1] nor case of coverage which is other than single coverage, for a Covered Family, the [Tier 2] Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as per Covered Family Cash Deductible can be plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per Covered Family Maximum Out of Pocket has been met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] [The [Tier 1] Deductible is for treatment, services or supplies given by during a [Tier 1] Network Provider. The other is for treatment, services or supplies given by a [Tier 2] Network Provider as well as for treatment, services or supplies given by a [Tier 1] Network that are applied to the [Tier 1] Deductible. Each Cash Deductible is shown in the Schedule. Each Calendar Year, each Member must have Covered Services and Supplies from a [Tier 1] Network Provider that exceed the Cash no further Deductible before We pay benefits for those types of Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such [Tier 1] Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, Copayment will be required for members of the covered family for the rest of that the Calendar Year. Each Calendar Year, the sum of the Covered Services and Supplies for each Member from a [Tier 2] Network Provider and those from a [Tier 1] Provider must exceed the [Tier 2] Cash Deductible before We pay benefits for [Tier 1] and [Tier 2] Covered Services and Supplies to that Member. Only Covered Services and Supplies incurred by the Member for treatment, services or supplies from a [Tier 1] or a [Tier 2] Network Provider, while covered by this Contract, can be used to meet this Cash Deductible. Once the Cash Deductible is met, We pay benefits for other such Covered Services and Supplies above the Cash Deductible incurred by that Member, less any applicable Coinsurance or Copayments, for the rest of that Calendar Year. Neither the [Tier 1] nor the [Tier 2] Cash Deductible can be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered by this Contract can be used to meet either Cash Deductible. What We pay is based on all the terms of this Contract.] (Use [Members] are entitled to receive the above text if benefits in the Tier 1 deductible can be satisfied separately following sections when Medically Necessary and allows a Member Appropriate, subject to be the payment by [Members] of applicable copayments [Cash Deductible,][or Coinsurance] as stated in benefit for further Tier 1 Covered the applicable Schedule of Services and Supplies and is also applied toward subject to the satisfaction terms, conditions and limitations of this Contract. Read the Tier 2 deductibleentire Contract to determine what treatment, services and supplies are limited or excluded.)