Plan Payment Percentages/Out-of-Pocket Maximums

Regardless of the following provisions, any covered medical expenses that a family member incurs for non-surgical TMJ treatment, chiropractic care, or non-precertified or out-of-network TMJ/jaw surgery will ONLY be payable at the regular Plan payment percentages (80% or 70%) or, if a special limitation applies, at the percentage stated on the Schedule of Benefits. Any amounts you pay out-of-pocket as your percentage shares for these types of treatment do NOT apply to any individual or family out-of-pocket maximums, and expenses for these treatments will NOT be paid at 100% if your out-of-pocket maximum has been met.

After satisfaction of the individual or family calendar year deductible during a year (and after satisfaction of any applicable hospital certification noncompliance deductibles or emergency room deductibles), the Plan pays the payment percentage shown on the Schedule of Benefits for the covered medical expenses a person incurs during that year UNTIL the individual or family out-of-pocket maximum is met.

Individual Out-of-Pocket Maximum - Once the amounts of your out-of-pocket payments for your 20% and 30% co-pay shares of most covered medical expenses incurred during a calendar year total $1,500 ($1,125 for persons who are eligible for Medicare), the Plan will pay 100% of the covered medical expenses you incur during the remainder of that year.

Family Out-of-Pocket Maximum - If the amounts paid out-of-pocket for you and your family's 20% and 30% co-pay shares of most covered medical expenses incurred during a calendar year total $3,000, the Plan will pay 100% of the covered medical expenses incurred by you and your covered family members during the remainder of that year.

No Carry-Over - Amounts accumulated toward an out-of-pocket maximum during a year do not carry over to the next year.

Exception - If a covered person is admitted to a hospital during one year and the hospital confinement continues without interruption into the next year while the person is continuously eligible, the covered medical expenses incurred for and in connection with that confinement will be considered incurred on the hospital admission date. This means that all of the expenses incurred during both years for that hospital stay will count as though they had been incurred during the year in which the admission occurred. If the person has already met his out-of-pocket maximum during that year, or if he meets his out-of-pocket maximum during that hospital stay, the Plan will pay 100% of the rest of the covered medical expenses incurred during that hospital stay, even if some of the expenses are actually incurred during the second year. Any covered expenses that are not related to the continuing hospital confinement are not covered under this exception and will not be paid at 100% unless and until the out-of-pocket maximum for the second year has been met.

Amounts That Don't Count Toward Meeting Out-of-Pocket Maximums - Any out-of-pocket payments you make for the following do not count toward any individual or family maximum out-of-pocket maximums:

Expenses for non-surgical TMJ treatment, chiropractic care, hearing care and non-precertified or out-of-network TMJ/jaw surgery will NOT be paid at 100% even if your out-of-pocket maximum has been met.