1 Schedule of Benefits The Plan provides the following levels of coverage. Please do not rely on these tables alone to determine your benefits . Important coverage details, limitations, exclusions and definitions that may affect claims for you, your Spouse, and your Eligible Dependent Children are found later in this SPD. Cost - Sharing Am ounts Medical Benefits Type of Service Plan Pays In - Network Plan Pays Out - of - Network PHYSICIAN SERVICES Primary Care Physician Office Visit 100% after $25 copay /visit 50% after deductible Specialist Office Visit 100% after $40 copay /visit 50% after deductible Surgical Professional Fees (inpatient) Surgeon, Assistant Surgeon, Anesthesiologist 100% after $350 facility copay 50% after deductible Inpatient Hospital Visit 100% after $350 facility copay 50% after deductible Observation Visit 100% after $350 facility copay 50% after deductible Urgent Care Physician Visit 100% after $50 facility copay 50% after deductible Financial In - Network Out - of - Network Lifetime Maximum No Lifetime Maximum No Lifetime Maximum Deductible (per calendar year – includes 4 th quarter carryover) Individual $0 $3,000 Family $0 $9,000 Out - of - Pocket Limit (per calendar year – cross accumulate in - and out - of - network – includes deductible, coinsurance and copayments) . Individual $4,000 $13,000 Family $10,000 $39,000