 Deductible take-over. Payments that were counted toward your deductible under your prior group health coverage if all of the following requirements are met: • This group health coverage with Kaiser replaces the Group’s prior group health coverage. • Your prior group health coverage was not with us or with any Kaiser Foundation Health Plan. • You were covered under Group’s prior group health coverage on the day before the effective date of this EOC. • The payments were for Services you received during the period of 12 months or less that occurred between January 1 and your effective date of coverage under this EOC. • The payments were for Services that we would have covered under this EOC if you had received them as a Member during the term of this EOC. • We would have counted the payments toward your Deductible under this EOC if you had received the Services as a Member during the term of this EOC. 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: EWCLGDED1983ACT0124 38 WAPEBB-CL-ACT