Use the following information to determine the costs to you and/or to the insurance company for the following occurrences:

1) You have $300 Per-person Wellness Benefit.

2) You have a $750 Individual Deductible and your family

(spouse and child) has a $750 Family Deductible.

3) You have a $4,000 annual Maximum Family Out-of-

Pocket expense provision.

4) Once you have met your Individual or Family Deductible,

your insurance will pay 80% of the expenses and you will

pay 20% as your co-pay.

Unless the occurrence is a Wellness expense, you and/or your family have to meet their deductibles first before insurance will pay anything.