Situation

CHOICE PLUS

NETWORK

CHOICE PLUS

NON-NETWORK

Out-of-Pocket Maximum (OOPM)

The annual Out-of-Pocket Maximum is the most you pay each Calendar Year year for Covered Health Services.

If your eligible out-of-pocket expenses in a Calendar Year year exceed the annual maximum, the Plan pays 100% of Eligible Expenses for Covered Health Services through the end of the Calendar Year.

$1,500 per Covered Person per calendar year, not to exceed $3,000 for all Covered Persons in a family.

The following costs will never apply to the Out-of-Pocket Maximum:

●  Any charges for non-

Covered Health Services.

●  The amount of any

reduced Benefits if you don't notify us as described in the section titled Notification Requirements.

$2,800 per Covered Person per calendar year, not to exceed $5,600 for all Covered Persons in a family.

The following costs will never apply to the Out-of-Pocket Maximum:

●  Any charges for non-

Covered Health Services.

●  The amount of any

reduced Benefits if you don't notify us as described in the section titled Notification Requirements.

Out of Network Benefits

When Covered Health Services are received from non-Network providers, Eligible Expenses are determined based on either:

Fee(s) that are negotiated with the provider.

Available data resources of competitive fees in that geographic area.

NOTE:

If care is received from a non-network physician, facility, or other health care professional you will incur greater financial expense compared to an in-network provider. Your plan only pays a portion of those charges and it is your responsibility to pay the remainder. You are required to pay the amount that exceeds the allowable amount, which could be significant, and that amount does not apply to the Out-of-Pocket Maximum. We recommend you ask the non-network physician or health care professional about their billed charges before you receive care.

Maximum Plan Benefit

The Lifetime Maximum Benefit is the most the Plan will pay for Benefits during the entire period you are enrolled in this Plan.

No Maximum Plan Benefit

$1,000,000 per Covered Person.