25 For this purpose, family includes you and all eligible members of your family, including your Spouse and Eligible Dependent Child t hat are covered under the Plan. Deductible Carry - Over If a covered individual incurs charges during the last three months of a calendar year that are applied toward satisfaction of the deductible, those charges will also be a pplied toward the individual’s deductible for the next calendar year. Copayment A Copayment is the amount a participant must pay to his or her provider of service before benefits are payable by the Plan. The copayment shown in the Schedule of Benefits: • Ap plies to all covered medical charges unless otherwise stated; • Applies separately to each participant ; and • Applies separately for each visit, stay, procedure or item unless otherwise stated No charge will be subject to more than one copayment amount. Coi nsurance The coinsurance shown in the Schedule of Benefits i s the patient percentage of Covered Medical Charges for which you are responsible after the Plan’s payment ( e.g., if the Plan pays 90% of a covered service, your coinsurance is the remaining 10%). Your coinsurance: • Is generally payable when your provider bills you after submitting your claim to the Plan; • Does not include expenses not covered by the Plan ; and • Does not include your deductible or copayments (although these are included in your out - of - pocket limit explained later). Common Accident If you, your Spouse, and any of your Eligible Dependent Child ren incur covered medical charges as a result of injuries suffered in a common accident, only one deductible will be applied during each calendar y ear to those charges. If greater medical benefits would be paid in the absence of this provision, then this provision will not apply. Payment Percentage The Payment Percentage and the covered medical charges to which such Payment Percentage applies are sh own in the detailed Schedule of Benefits. The Payment Percentage applies after any applicable copayment amount has been met, and it is applied separately to each covered individual. Out - of - Pocket Limit The individual and family out - of - pocket limits are sh own in the Schedule of Benefits. A separate out - of - pocket limit for the Prescription Drug Coverage applies for benefits under the Plan. The out - of - pocket limit is the maximum amount a covered individual will have to pay for covered charges during a calenda r year. The out - of - pocket limit includes the deductible , copayments and coinsurance . When a covered individual’s cumulative out - of - pocket expenses in any calendar year reaches the applicable out - of - pocket limit shown in the Schedule of Benefits, all cover ed 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 e xceeds the amount of the family out - of - pocket limit

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