SBC disclosure

Health Plan Name: Insurance Company 1 Coverage Period: 1/1/2013 – 12/31/2013

S ummary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: PPO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.[insert] or by calling 1-800-[insert].

Important Questions	Answers		Why this Matters:
What is the overall deductible?	$	You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.
Are there other deductibles for specific services?	Yes. $	You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.
Is there an out–of–pocket limit on my expenses?	Yes. $	The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.
What is not included in the out–of–pocket limit?		Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
Is there an overall annual limit on what the plan pays?	Yes. $	This plan will pay for covered services only up to this limit during each coverage period, even if your own need is greater. You’re responsible for all expenses above this limit. The chart starting on page 2 describes specific coverage limits, such as limits on the number of office visits.
Does this plan use a network of providers?	Yes. For a list of preferred providers, see www.[insert].com or call 1-888-123-4567.	If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.
Do I need a referral to see a specialist?	Yes.	This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan’s permission before you see the specialist.
Are there services this plan doesn’t cover?	Yes.	Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan document for additional information about excluded services.

Q

2 of [#]

uestions: Call 1-800-[insert]or visit us at www.[insert].com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary

at www.[insert] or call 1-800-[insert] to request a copy.