SCHEDULE OF BENEFITS

All Plan payments, deductibles, maximums and limitations apply to each person separately except where stated otherwise.

Benefits for Eligible

day of a disability due to an accidental injury. For an illness, benefits start on the earlier of the first day of an inpatient hospital stay or the eighth day of disability.

After satisfying your deductible, the Plan will typically pay the following percentages. (Note: See below for exceptions.)

The out-of-pocket maximum is the most you will pay for covered services under the Plan each calendar year. Noncovered services and expenses for hearing care, dental and vision care do not apply toward your out-of-pocket maximum.