Page 17 - QCS.19 SPD - PPO

Out-of-Pocket Limit

The Out-of-Pocket Limit is the maximum you pay per Calendar Year for the Annual Deductible, Copayments 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 13, Prescription Drug.

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 Out-of-Network

Out-of-Pocket Limit $5,000 per Covered Person, not to $10,000 per Covered Person, not to
exceed $10,000 for all Covered exceed $20,000 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
PPO - 2017