Page 11 - QCS.19 SPD - HSA
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Annual Deductible

            The Annual Deductible is the Allowed Amount you must pay each Calendar Year for Covered Health Care
            Services before you are eligible to begin receiving Benefits. There are separate Network and Out-of-Network
            Annual Deductibles for this Plan. The amounts you pay toward your Annual Deductible accumulate over the
            course of the Calendar Year.

            Copayment

            A Copayment (Copay) is the amount you pay each time you receive certain Covered Health Care Services. The
            Copay is a flat dollar amount and is paid at the time of service or when billed by the provider. Copays do not count
            toward the Annual Deductible, but do count towards the Out-of-Pocket Limit. If the Allowed Amount is less than
            the Copay, you are only responsible for paying the Allowed Amounts and not the Copay.
            Coinsurance

            Coinsurance is the percentage of Allowed Amounts that you are responsible for paying. Coinsurance is a fixed
            percentage that applies to certain Covered Health Care Services after you meet the Annual Deductible.

            Out-of-Pocket Limit

            The annual Out-of-Pocket Limit is the most you pay each calendar year for Covered Health Care Services. There
            are separate Network and Out-of-Network Out-of-Pocket Limits for this Plan. If your eligible out-of-pocket
            expenses in a calendar year exceed the annual limit, the Plan pays 100% of Allowed Amounts for Covered Health
            Care Services through the end of the calendar year.
            The following table identifies what does and does not apply toward your Network and Out-of-Network Out-of-
            Pocket Limits:


                                                                   Applies to the      Applies to the Out-
                   Plan Features                                  Network Out-of-      of-Network Out-of-
                                                                   Pocket Limit?         Pocket Limit?
                   Payments toward the Annual Deductible       Yes                    Yes
                   Coinsurance Payments                        Yes                    Yes

                   Charges   for  non-Covered   Health   Care  No                     No
                   Services
                   Charges that exceed Allowed Amounts         No                     No
































            Page 6                                                                     Section 3 - How the Plan Works
                                                                                                     HSA - 2017
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