Health & Security Plan > SPD > Additional OutofPocket Expenses

Summary Plan Description

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" 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.