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The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
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 underlined 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?
$ 
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. [For family coverage, see instructions for additional applicable language.]
Are there services covered before you meet your deductible?
Yes. [Insert: major categories]
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. [For non-grandfathered plans insert: “For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.]
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.
What is the out-of-pocket limit for this plan?
$
The out-of-pocket limit is the most you could pay in a year for covered services. [For family coverage, see instructions for additional applicable language.]
What is not included in
the out-of-pocket limit?
[Insert: major exceptions]
Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
Will you pay less if you use a network provider?
Yes. See www.[insert].com or call 1-800-[insert] for a list of network providers.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you 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 a referral before you see the specialist.