IV. Benefits Details Benefits are subject to all provisions of the EOC. Enrollees are entitled only to receive benefits and services that are Medically Necessary and clinically appropriate for the treatment of a Medical Condition as determined by KFHPWA’s medical director and as described herein. All Covered Services are subject to case management and utilization management. “Case management” means a care management plan developed for an Enrollee whose diagnosis requires timely coordination. Annual Deductible Individual Only Coverage: Subscriber pays $1,600 per calendar year for Subscriber only coverage Family Coverage: Enrollee pays $3,200 per Family Unit per calendar year for family coverage Coinsurance Plan Coinsurance: Enrollee pays 10% of the Allowed Amount Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Out-of-pocket Limit Limited to a maximum of $5,100 per calendar year for Subscriber or $10,200 per Family Unit per calendar year for family coverage The following Out-of-pocket Expenses apply to the Out-of-pocket Limit: All Cost Shares for Covered Services The following expenses do not apply to the Out-of-pocket Limit: Premiums, charges for services in excess of a benefit, charges in excess of Allowed Amount, charges for non- Covered Services Pre-existing Condition No pre-existing condition waiting period Waiting Period PEBB HMOHSA 2024 12