Why This Matters-Yes Answers

Insurance Company 1: Plan Option 1 Coverage Period: 1/1/2016 – 12/31/2016

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

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, [insert contact information]. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other bolded terms see the Glossary. You can view the Glossary at www.[insert].com or call 1-800-[insert] to request a copy.

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 1). The Common Medical Events chart below shows 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.
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 health care provider, this plan will pay some or all of the costs of covered services. Lesser coverage, or no coverage, may be available for out-of-network providers. Be aware, your in-network doctor or hospital may use another out-of-network provider for some services (such as lab work).
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.

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