25 Out - of - Pocket Limit The individual and family out - of - pocket limits are shown in the Schedule of Benefits. A separate out - of - pocket limit for the Prescription Drug Coverage applies for benefits under the Plan. The ou t - of - pocket limit is the maximum amount a cover ed individual will have to pay for covered charges during a calendar year. The out - of - pocket limit includes copayments a s well as the coinsurance paid for prescription drugs . When a covered individual’s cumul ative out - of - pocket expenses in any calendar year reaches the applicable out - of - pocket limit shown in the Schedule of Benefits, all covered charges for the covered individual will be paid by the Plan at 100% for the remaining months of that calendar year. When your covered family members have accumulated individual out - of - pocket amounts in any calendar year that, when combined, equals or exceeds the amount of the family out - of - pocket limit shown in the Schedule of Benefits, all further covered charges for all covered family members will be paid by the Plan at 100% for the remaining months of that calendar year. For this purpose, the term family includes you, your Spouse, and your Eligible Dependent Children who are covered under the Plan. The above provisi ons do not apply to charges that exceed Usual, Customary and Reasonable (UCR) charges, charges that exceed Plan benefit limitations, or charges for services that are excluded under the terms of the Plan. Out - of - Network Services This Plan does not cover ser vices obtained out of network. Any amounts you pay for out - of - netw ork ser vices will not count toward the out - of - pocket limit. Lifetime Maximum The Plan does not impose an overall lifetime dollar maximum. However, there are limits that may apply for some ty pes of visits, and/or a limit on the number of days permitted for the ben efit under the terms of the Plan. In addition, there may be dollar limits applicable to certain benefits as described in this SPD.

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