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Select Coverage

Deductibles and Coinsurance Maximums for Medical Services

IN-NETWORK OUT-OF-

$500

NETWORK $1,000

$1,000

$2,000

$2,000

$3,000

Individual Calendar Year Medical Deductible Family Calendar Year Medical Deductible Individual Medical Coinsurance Maximum Individual Prescription Drug Deductible

$50

Individual Calendar Year Medical Deductible The calendar year medical deductible is the amount of covered medical expense a participant must pay each year before the Plan begins to pay its share of covered medical expense. Once the calendar year deductible is met, the Plan pays a percentage of the allowable charge for covered medical expenses.

The initial $500 of covered medical expense will apply to both the in and out-of-network deductible. After the initial $500 has been applied, only services rendered by a non-participating provider will be applied to the additional $500 out-of-network deductible.

The following expenses do not count towards the calendar year medical deductible:

Prescription drug deductible Expenses in excess of the allowable charge Expenses in excess of Plan maximum limits Services not considered medically necessary

Prescription drug co-payments Utilization review penalties Private room co-payment Services not covered by the Plan

Emergency room co-payment

Family Calendar Year Medical Deductible Once a family has paid the family medical deductible in a calendar year, all covered participants in that family will be considered to have satisfied their individual medical deductibles for that calendar year. The family medical deductible also applies when both husband and wife are covered separately as enrollees and both are enrolled in Select Coverage. No individual family member may contribute more than $500 to the in-network family medical deductible or more than $1,000 to the out-of-network family medical deductible.

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