29 amounts will be applied to any charges incurred in the applicable calendar year by any of the applicable covered individuals in your family. The result of this rule is that some covered individuals in your family may fully satisfy their individual deductible amount before receiving benefits under the Plan (except for Preventive Services with no applicable deductible amount and no cost sharing), while other covered individuals may end up having to satisfy only a portion of their applicable individual deductible amount because collectively between those members the entire family deductible amount is met in full. For this purpose, family includes you and all eligible members of your family, including your Spouse and Eligible Dependent Child that 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 applied 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: • Applies 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. Coinsurance The coinsurance referenced in the Schedule of Benefits is 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 Children incur covered medical charges as a result of injuries suffered in a common accident, only one deductible will be applied during each calendar year to those charges. If greater medical benefits would be paid in the absence of this provision, then this provision will not apply.

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