28 Comprehensive Medical Coverage The Plan will pay medical benefits as set forth in this SPD for covered medical charges incurred by you, your Spouse, or your Eligible Dependent Children while eligible for medical benefits under the Plan. Medical Benefit A Medical Benefit is the amount, if any, the Plan will pay for covered medical charges incurred by you, your Spouse, or your Eligible Dependent Child. The amount of a medical benefit is the amount the Claims Administrator calculates in the steps shown below: • The charges for which a claim is submitted to the Claims Administrator are tested against the covered medical charge definition. The submitted charges that meet all of the tests are the covered medical charges under the Plan. • Any copayment amount that applies to the charges is subtracted from the amount of covered medical charges. • If any part of the remaining amount exceeds an applicable benefit maximum, then that part is subtracted and the remainder is the amount of the medical benefit. Medically Necessary Charges Plan benefits are payable for charges incurred only to the extent the charges are for services, supplies and treatments that are Medically Necessary as defined under the terms of the Plan, and only up to the applicable maximum allowed for such benefits, services, or supplies under the terms of the Plan. Certain services are not subject to the Medically Necessary definition, as noted in the SPD. Deductible The deductible shown in the Schedule of Benefits: • Applies to all covered medical charges unless otherwise stated; • Applies separately to each participant during each calendar year; and • Must be accumulated during the applicable calendar year. No charge will be subject to more than one deductible amount. Only those charges to which a deductible applies will be applied to satisfy the applicable deductible. When a covered individual’s cumulative deductible in a calendar year reaches the individual deductible maximum amount as shown in the Schedule of Benefits, the deductible will be considered met in full, and no further deductible amounts will be applied to any charges incurred by the applicable participating individual in the applicable calendar year. Family Deductible Maximum When eligible covered individuals in your family have accumulated their individual deductible amounts in any calendar year that, when combined, reach the family deductible maximum amount as shown in the Schedule of Benefits, the family deductible will be considered met in full, and no further deductible
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