† HSA Qualified High Deductible Plan

2) When an individual member of a family unit has paid an amount of Deductible and Copayments for the Calendar Year equal to the Individual Out-of-Pocket Maximum, no further Copayments will be due for Covered Services (except infertility services) for the remainder of that Calendar Year. The remaining family members will continue to pay the applicable Copayment until the member satisfies the Individual Out-of-Pocket Maximum or until the family, as a whole, meets the Family Out-of-Pocket Maximum.

4) Copayments for supplemental benefits (Assisted Reproductive Technologies, Chiropractic Services, Adult Vision, ect.) do not apply to the annual out-of-pocket maximum.

13) The Family Deductible is an embedded deductible. When an individual member of a family unit satisfies the Individual Deductible for the Calender Year, no further Deductible will be required for that individual member for the remainder of the Calender Year. The remaining family members will continue to pay full member charges for services that are subject to the deductible until the member satisfites the Individual Deductible or until the family, as a whole, meets the Family Deductible.