Additional
Out-of-Pocket Expenses
In
addition to the annual deductible, copayment and coinsurance expenses discussed
above, each individual is responsible for the following expenses:
- Expenses
that exceed the “usual, customary and reasonable” charges as
determined by this plan.
- Expenses
for services or supplies not medically necessary.
- Expenses
for services or supplies not covered under this plan.
- Expenses
not covered as a result of a benefit reduction under the medical review
program.
- Expenses
which exceed benefit maximums.
- Expenses
which exceed vision and dental scheduled amounts.
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