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Plan Year 2021

Summation of Household Grid

Calendar Year	Deductible Summation By Year	Coinsurance Summation By Year	OOP Sum Ded Plus Coins Summation By Year

Per Family Member Grid

Calendar Year	First Name	Last Name	Relationship	Deductible	Coinsurance	OOP Sum Ded Plus Coinsurance

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Plan Year 2022

Summation of Household Grid

Calendar Year	Deductible Summation By Year	Coinsurance Summation By Year	OOP Sum Ded Plus Coins Summation By Year

Per Family Member Grid

Calendar Year	First Name	Last Name	Relationship	Deductible	Coinsurance	OOP Sum Ded Plus Coinsurance