Page 11 - QCS.19 SPD - PPO

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?

Copays Yes Yes
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
PPO - 2017