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?

$

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.]

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/.]

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.

$

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.]

[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.

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?

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