Welfare Summary Plan Description

5.3 ANNUAL OUT-OF-POCKET LIMIT

The Annual Out-of-Pocket Limit is the maximum amount of Covered Expenses each Participant pays each calendar year. Once Participants have reached their Annual Out-of-Pocket Limit, Covered Expenses during the remainder of that calendar year are payable at 100%. The calendar year deductible is included in the Annual Out-of-Pocket Limit.

The following expenses are not applied toward the Out-of-Pocket Limit:

  • An expense reduced because it is in excess of the Usual, Reasonable and Customary charge;
  • An expense for a non-covered service; or
  • Any expenses under Prescription Drug, Hearing Loss, Vision Care, or Dental Care Benefits.

For Eligible Employees and their Dependents for Preferred Provider Expenses

The Annual Out-of-Pocket Limit for each Eligible Employee for Preferred Provider Expenses is $3,800 during a calendar year. The family Annual Out-of-Pocket Limit for Preferred Provider Expenses is $7,600 during a calendar year.

For Eligible Employees and their Dependents for Non-Preferred Provider Expenses

The Annual Out-of-Pocket Limit for each Eligible Employee for Non-Preferred Provider Expenses is $7,600 during a calendar year. The family Annual Out-of-Pocket Limit for Non-Preferred Provider Expenses is $15,200 during a calendar year.