Page 17 - QCS.19 SPD - HSA

Out-of-Pocket Limit

The Out-of-Pocket Limit is the maximum you pay per Calendar Year for the Annual Deductible and Coinsurance.
Once you reach the Out-of-Pocket Limit, Benefits are payable at 100% of Allowed Amounts during the rest of that
Calendar Year. The Out-of-Pocket Limit applies to Covered Health Care Services as indicated in this Schedule of
Benefits, including Covered Health Care Services provided under Section 5, Prescription Drug Products.
Details about the way in which Allowed Amounts are determined appear in the definition of "Allowed Amounts" in
Section 15, Glossary.
The Out-of-Pocket Limit does not include any of the following and, once the Out-of-Pocket Limit has been
reached, you still will be required to pay the following:

· any charges for non-Covered Health Care Services.

· charges that are not covered due to failure to meet prior authorization requirements.

· charges that exceed Allowed Amounts.
Network Non-Network

Out-of-Pocket Limit $6,550 per Covered Person, not to $11,400 per Covered Person, not to
exceed $13,100 for all Covered exceed $22,800 for all Covered
Persons in a family. Persons in a family.

The Out-of-Pocket Limit includes the The Out-of-Pocket Limit includes the
Annual Deductible. Annual Deductible.

Page 12 Section 4 - Schedule of Benefits
HSA - 2017