SBC Disclosure

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
Insurance Company 1: Plan Option 1

Coverage Period: 01/01/2022-12/31/2022
Coverage for: Individual | Plan Type: PPO

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?

$0

See the Common Medical Events chart below for your costs for services this plan
covers.

Are there services
covered before you meet
your deductible?
Are there other
deductibles for specific
services?
What is the out-of-pocket
limit for this plan?
What is not included in
the out-of-pocket limit?

No.
No.
Not Applicable.

You will have to meet the deductible before the plan pays for any services.

You don’t have to meet deductibles for specific services.
This plan does not have an out-of-pocket limit on your expenses.

Not Applicable.

This plan does not have an out-of-pocket limit on your expenses.

Will you pay less if you
use a network provider?

Not Applicable.

This plan does not use a provider network. You can receive covered services from any
provider.

Do you need a referral to
see a specialist?

No.

You can see the specialist you choose without a referral.

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valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is
estimated to average XXX hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
OMB control number: 0938--1146
Expiration Date: XX/20XX

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