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January lst, a new deductible amount is required. However,covered expenses incurred in, and applied toward the <br /> deductible in October, November and December will be applied to the deductible in the next Calendar Year as well as <br />� the cunent Calendar Year. <br /> NETWORK PROVIDERS NON-NETWORK <br /> PROVIDERS <br /> MAXIMUM LIFETIlVIE <br /> BENEFIT AMOL]NT $2,000,000 <br /> Annual Restoration.A certain <br /> amount will automatically be <br /> restored to your Lifetime <br /> maximum each year.This <br /> amount will be$1,000 or the <br /> amount you have received in <br /> benefits for that benefit period, <br /> whichever is less. <br /> Note: The maximums listed below are the total for Network and Non-Network expenses.For <br /> example,if a maximum of 60 days is listed twice under a service,the Calendar Year maximum <br /> is 60 days total which may be split between Network and Non-Network providers. <br /> DEDUCTIBLE,PER <br /> CALENDAR YEAR <br /> Per Covered Person $100 er benefit riod $200 er benefit eriod <br /> Per Famil Unit Three individual deductibles Three individual deductibles <br /> Note: Expenses incurred by you for Covered Services rendered by a Network Provider which <br /> are applied to the Network Provider program deductible will also be applied to the Non- <br /> Network program deductible.Expenses incurred by you for Covered Services by a Non- <br /> Network Provider which are applied to the Non-Network program deductible will also be <br /> applied toward the Network provider program deductible. <br /> MAXII�ZUM OUT-OF- <br /> POCKET AMOUNT,PER <br /> CALENDAR YEAR <br /> Per Covered Person $1,000 er benefit eriod $5,000 er benefit riod <br /> Per Famil Unit Three individual out-of- ocket Three individual out-of- ocket <br /> The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are <br /> reached, at which time the Plan will pay 100%of the remainder of Covered Charges for the rest of the <br /> Calendar Year unless stated otherwise. <br /> The following charges do not apply toward the out-of-pocket maximum. <br /> Outpatient mental treatment charges <br /> Inpatient mental treatment charges <br /> Outpatient substance abuse treatment charges <br /> Inpatient substance abuse treatment charges <br /> Jaw joint/TMJ charges <br /> Covered char es with a se arate dollar maximum <br /> COVERED SERVICES NETWORK PROVIDERS NON-NETWORK <br /> PROVIDERS <br /> Emergency Room/Accident 100%,deductible waived for the 100% of the maximum allowance <br /> Benefit initial dia nosis for the initial dia osis <br /> Hospital Services <br /> Room and Board 90% after deductible 70% after deductible <br /> the semi rivate room rate the semi rivate room rate <br /> Intensive Care Unit 90% after deductible 70%after deductible <br /> Hos ital's ICU Char e Hos ital's ICU Char e <br /> Skilled Nursing Facility 90% after deductible 70%after deductible <br /> the facility's semiprivate room the facility's semiprivate room <br /> rate rate <br /> 12 <br />