Explanation of Benefits: Payments Summary for Eliza N Bruington

School: Coral Springs High School - Course: ACCOUNTING TAXATION - Subject: Accounting

THIS IS NOT A BILL Individual Claim Report EXPLANATION OF BENEFITS Plan Holder: ANDREW BRUINGTON (ID # ANI061937213019) Benefit Plan Year: 08/01/2021 - 08/01/2022 Notice Date: 10/12/2021 P.O. Box 100121Columbia, SC 29202-3121 ANDREW BRUINGTON644 NW 48TH AVEPLANTATION, FL 33317 WE'RE HERE! Write:Member Services P. O. Box 100121 Columbia, SC 29202-3121 Web:Log on towww.MyHealthToolkitFL.com Toll-free:800-830-1501 (Monday - Friday, 8:00 a.m. - 8:00 p.m. EST) PAYMENTS SUMMARY for ELIZA N BRUINGTONClaim 10/07/2021 Your health care providers' charges $350.10 Amountyou saved $295.32 Total amountyour plan paid$27.93 AMOUNT YOU MAY OWE OR HAVE PAID PROVIDER(S)$26.85 FamilyDeductibleOut-of-Pocket $6,000.00 Maximum$10,000.00 Maximum$5,941.99$58.01RemainingApplied$9,941.99$58.01RemainingApplied DeductibleOut-of-Pocket Each covered individual hasa deductible that appliestoward the familydeductible. Once the familydeductible is met, all deductibles are met. The most you could pay during a benefit plan year for your share of the cost of covered services. Member(s) ELIZA N BRUINGTON DeductibleOut-of-Pocket $3,000.00$2,973.15$26.85MaximumRemainingApplied$5,000.00$4,973.15$26.85Maximum Remaining Applied IN-NETWORK BENEFITS AT-A-GLANCE 0004195 000000 0001 of 0004

Individual Claim Report: EXPLANATION OF BENEFITS Plan Holder:ANDREW BRUINGTON(ID # ANI061937213019) Page 2 of 8GETTING THE MOST FROM YOUR PLAN Network Providers Save You Money Your health plan pays a higher percentage when you use in-network providers. You can easily locate in-network providers by using the Doctor/Hospital Finder. Order ID Cards Online Lost your ID card? Need one for your student going to college? It is simple to order it online. Just visit My Health Toolkit(R). Other Insurance Do you or any family members have other medical insurance? You can update your information today by visiting My Health Toolkit(R). OUT-OF-NETWORK BENEFITS AT-A-GLANCEDeductibleOut-of-Pocket MaximumAppliedRemainingMaximumAppliedRemaining FAMILY$12,000.00$0.00$12,000.00$20,000.00$0.00$20,000.00 ELIZA N BRUINGTON$6,000.00$0.00$6,000.00$10,000.00$0.00$10,000.00 DeductibleEach covered individual has a deductible that applies toward the family deductible. Once the family deductible is met, all deductibles are met. Out-of-PocketThe most you could pay during a benefit plan year for your share of the cost of covered services. Avoid the spread of germsGerms cause the transmissionof colds, flu and COVID-19. Theycan spread through the air orfrequently touched surfaces.Create healthy habitsTake steps to keep yourself and othershealthy this cold and flu season. Washyour hands, avoid people who are sick,and stay home if you don't feel well.Don't forget your flu shot Experts recommend that everyone ages 6 months and older get a flu shot each year. The vaccine prevents millions of flu cases annually