Additional Out-Of-Pocket Expenses

In addition to the annual deductible, copayment and coinsurance expenses discussed above, you are responsible for the following expenses. Each individual covered under the plan is responsible for these out-of-pocket expenses.

• Expenses that exceed the "usual, customary and reasonable" charge 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 (non-Medicare individuals only).
• Expenses that exceed benefit maximums.
• Expenses covered by Medicare even if the Medicare-eligible individual is not enrolled in Medicare.
• Expenses for services or supplies from any provider received outside the United States. This applies for dates of service on or after January 1, 2012 for retirees and dependents who are on or who are eligible for Medicare.