Summary of Benefits and Coverage

Health Plan Name: Insurance Company 1
What This Plan Covers & What it Costs

Policy Period: 9/15/2010 - 9/14/2011
Coverage for: Individual | Plan Type: HMO

This is not a policy. You can get the policy at www.insurancecompany.com/HMO1500 or by calling 1-800-XXX-XXXX.
A policy has more detail about how to use the plan and what you and your insurer must do. It also has more detail about your coverage and costs.
Important Questions

Answers

Why This Matters:

What is the premium?

$

The premium is the amount paid for health insurance. This is only an estimate based on
information you’ve provided. After the insurer reviews your application, your actual premium may be higher or your application may be denied.

What is the overall
deductible?

$

See the chart starting on page 2 for your other costs for services this plan covers.

Are there other
deductibles for specific
services?

No.

Because you don’t have to meet deductibles for specific services, this plan starts to cover
costs sooner.

Is there an out–of–pocket
limit on my expenses?

No.

There’s no limit on how much you could pay during a policy period for your share of the
cost of covered services.

What is not included in
the out–of–pocket limit?

This plan has no out-of-pocket
limit.

Not applicable because there’s no out-of-pocket limit on your expenses.

Is there an overall annual
limit on what the insurer
pays?

No.

The chart starting on page 2 describes any limits on what the insurer will pay for specific
covered services, such as office visits.

Does this plan use a
network of providers?

No.

The providers you choose won’t affect your costs.

Do I need a referral to see
a specialist?

No.

You can see the specialist you choose without permission from this plan.

Are there services this
plan doesn’t cover?

No.

This plan also covers many common health care services listed on page 3.

Questions: Call 1-800-XXX-XXXX or visit us at www.insurancecompany.com
If you aren’t clear about any of the terms used in this form, see the Glossary at www.insuranceterms.gov.

FINAL (pg1 - NO), 11/16/10

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