Copayments and Coinsurance The Copayment or Coinsurance for each covered Service is shown in the “Benefit Summary.” Copayments or Coinsurance are due when you receive the Service. You are not responsible for paying any amount over the Allowed Amount for Services received from a Non-Participating Provider at a Participating Facility. Out-of-Pocket Maximum There is a maximum to the total dollar amount of Deductible, Copayment and Coinsurance that you must pay for covered Services that you receive within the same Year under this or any other evidence of coverage with the same Group number printed on this EOC. If you are the only Member in your Family, then you must meet the self-only Out-of-Pocket Maximum. If there is at least one other Member in your Family, then you must each meet the individual Family Member Out-of-Pocket Maximum, or your Family must meet the Family Out-of-Pocket Maximum, whichever occurs first. Each individual Family Member Out-of-Pocket Maximum amount counts toward the Family Out-of- Pocket Maximum amount. The Out-of-Pocket Maximum amounts are shown in the “Benefit Summary.” All Deductibles, Copayments and Coinsurance amounts count toward the Out-of-Pocket Maximum unless otherwise indicated. After you reach the Out-of-Pocket Maximum, you are not required to pay Copayments and Coinsurance for these Services for remainder of the Year. Member Services can provide you with the amount you have paid toward your Out-of-Pocket Maximum. The following amounts do not count toward the Out-of-Pocket Maximum and you will continue to be responsible for these amounts even after the Out-of-Pocket Maximum is satisfied:  Payments for Services that are not covered under this EOC.  Payments that you make because you exhausted (used up) your benefit allowance, or because we already covered the benefit maximum amount or the maximum number of days or visits for a Service.  Payments for vision hardware for Members age 19 and older.  Payments for hearing aid Services.  Amounts recovered from a liability claim against another party subject to reimbursement under the “Injuries or Illnesses Alleged to be Caused by Other Parties or Covered by No-fault Insurance” section. BENEFIT DETAILS The Services described in this “Benefit Details” section are covered only if all the following conditions are satisfied, and will not be retrospectively denied:  You are a Member on the date you receive the Services.  A Participating Provider determines that the Services are Medically Necessary.  The Services are provided, prescribed, authorized, or directed by a Participating Provider except where specifically noted to the contrary in this EOC.  You receive the Services from a Participating Provider, Participating Facility, or from a Participating Skilled Nursing Facility, except where specifically noted to the contrary in this EOC.  You receive prior authorization for the Services, if required under “Prior and Concurrent Authorization and Utilization Review” in the “How to Obtain Services” section. All Services are subject to the coverage requirements described in this “Benefit Details” section. Some Services are subject to benefit-specific exclusions and/or limitations and eligibility provisions, which are listed, when applicable, in each benefit section. A broader list of exclusions and limitations that apply to all benefits is provided under the “Benefit Exclusions and Limitations” section. EWCLGHDHP1983ACT0124 39 WAPEBB-CD-ACT