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. Annual Deductible Annual Deductible without Wellness incentive: Enrollee pays $250 per Enrollee per calendar year or $750 per Family Unit per calendar year; or Annual Deductible with Wellness incentive: Subscriber Enrollee pays $125 per calendar year; dependent Enrollees pay $250 per calendar year or $625 per Family Unit per calendar year Prescription Drug Enrollee pays $100 per Enrollee per calendar year or $300 per Family Unit per calendar Deductible year Coinsurance Plan Coinsurance: Enrollee pays nothing Lifetime Maximum No lifetime maximum on covered Essential Health Benefits Medical Out-of- Limited to a maximum of $3,000 per Enrollee or $6,000 per Family Unit per calendar year pocket Limit 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, Outpatient Pharmacy Drug Deductible, Outpatient Pharmacy Copayments, and Outpatient Pharmacy coinsurance, charges for non-Covered Services Prescription Drug Limited to a maximum of $2,000 per Enrollee or $8,000 per Family Unit per calendar year Out-of-pocket Limit The following Out-of-pocket Expenses apply to the Out-of-pocket Limit: Prescription Drug Deductible, Copayments and coinsurance 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 which apply to the medical Out-of-Pocket limit, charges for non-Covered Services Pre-existing Condition No pre-existing condition waiting period Waiting Period PEBB_VA_2024 12