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 Amounts Medical Benefits Type of Service Plan Pays In - Network Plan Pays Out - of - Network PHYSICIAN SERVICES Primary Care Physician Office Visit 100% after $ 30 copay /visit 50% after deductible Specialist Office Visit 100% after $ 50 copay /visit 50% after deductible Surgical Professional Fees (inpatient) Surgeon, Assistant Surgeon, Anesthesiologist 30 % after deductible 50% after deductible Inpatient Hospital Visit 30 % after deductible 50% after deductible Observation Visit 30 % after deductible 50% after deductible Urgent Care Physician Visit 30 % after deductible 50% after deductible Emergency Room Physician Visit 30 % after deductible 30% after deductible; 50% after deductible if not a true emergency Financial In - Network Out - of - Network Lifetime Maximum No Lifetime Maximum No Lifetime Maximum Deductible (per calendar year – includes 4 th quarter carryover) Individual $ 850 $3,000 Family $ 1,70 0 $ 6 ,000 Out - of - Pocket Limit (per calendar year – cross accumulate in - and out - of - network – includes deductible, coinsurance and copayments) . Individual $ 6 , 6 00 $ 13,000 Family $1 3 , 2 00 $ 26 ,000