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?	$	See the chart starting on page 2 for your costs for services this plan covers.
Are there other deductibles for specific services?	No.	You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.
Is there an out–of–pocket limit on my expenses?	No.	There’s no limit on how much you could pay during a coverage 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 plan pays?	No.	The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.
Does this plan use a network of providers?	No.	This plan treats providers the same in determining payment for the same services.
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.	See your policy or plan document for 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.