Summary of Benefits and Coverage

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: Family | 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 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

What is the overall
deductible?

$500/Individual or $1,000/family

Are there services
covered before you meet
your deductible?

Yes. Preventive care and primary
care services are covered before
you meet your deductible.

Are there other
deductibles for specific
services?

Yes. $300 for prescription drug
coverage and $300 for
occupational therapy services.
For network providers $2,500
individual / $5,000 family; for outof-network providers $4,000
individual / $8,000 family
Copayments for certain services,
premiums, balance-billing
charges, and health care this plan
doesn’t cover.

What is the out-of-pocket
limit for this plan?
What is not included in
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.

Do you need a referral to
see a specialist?

Yes.

Why This Matters
Generally, you must pay all of the costs from providers up to the deductible amount before this
plan begins to pay. If you have other family members on the plan, each family member must
meet their own individual deductible until the total amount of deductible expenses paid by all
family members meets the overall family deductible.
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 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/.
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. If you have other
family members in this plan, they have to meet their own out-of-pocket limits until the overall
family out-of-pocket limit has been met.
Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
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.
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.

(DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date:
5/31/2022)(HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022)

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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common Medical Event

If you visit a health care
provider’s office or clinic

If you have a test
If you need drugs to treat
your illness or condition
More information about
prescription drug coverage
is available at
www.[insert].com
If you have outpatient
surgery
If you need immediate
medical attention
If you have a hospital
stay

What You Will Pay:
Limitations, Exceptions, & Other
Network Provider
Out-of-Network Provider
Services You May Need
Important Information
(You will pay the least) (You will pay the most)
$35 copay/office visit and
Primary care visit to treat an injury 20% coinsurance for other
40% coinsurance
None
or illness
outpatient services;
deductible does not apply
Preauthorization is required. If you don't
get preauthorization, benefits could be
Specialist visit
$50 copay/visit
40% coinsurance
reduced by 50% of the total cost of the
service.
You may have to pay for services that
Preventive
aren’t preventive. Ask your provider if
No charge
40% coinsurance
care/screening/immunization
the services you need are preventive.
Then check what your plan will pay for.
Diagnostic test (x-ray, blood work) $10 copay/test
40% coinsurance
None
Imaging (CT/PET scans, MRIs)
$50 copay/test
40% coinsurance
$10 copay/prescription
Generic drugs (Tier 1)
40% coinsurance
(retail & mail order)
Covers up to a 30-day supply (retail
$30 copay/prescription
Preferred brand drugs (Tier 2)
40% coinsurance
subscription); 31-90 day supply (mail
(retail & mail order)
order prescription).
Non-preferred brand drugs (Tier 3) 40% coinsurance
60% coinsurance
Specialty drugs (Tier 4)
50% coinsurance
70% coinsurance
Preauthorization is required. If you don't
Facility fee (e.g., ambulatory
get preauthorization, benefits could be
$100/day copay
40% coinsurance
surgery center)
reduced by 50% of the total cost of the
service.
Physician/surgeon fees
20% coinsurance
40% coinsurance
50% coinsurance for anesthesia.
Emergency room care
20% coinsurance
20% coinsurance
Emergency medical transportation 20% coinsurance
20% coinsurance
None
Urgent care
$30 copay/visit
40% coinsurance
Preauthorization is required. If you don't
get preauthorization, benefits could be
Facility Fee (e.g., hospital room)
20% coinsurance
40% coinsurance
reduced by 50% of the total cost of the
service.

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Common Medical Event
If you have a hospital
stay
If you need mental
health, behavioral health,
or substance abuse
services

If you are pregnant

If you need help
recovering or have other
special needs

If your child needs dental
or eye care

Services You May Need
Physician/surgeon fees

What You Will Pay
Network Provider
Out-of-Network Provider
(You will pay the least)
(You will pay the most)
20% coinsurance

40% coinsurance

Inpatient services

$35 copay/office visit and
20% coinsurance for
other outpatient services
20% coinsurance

Office visits

20% coinsurance

40% coinsurance

20% coinsurance

40% coinsurance

20% coinsurance
20% coinsurance

40% coinsurance
40% coinsurance

Rehabilitation services

20% coinsurance

40% coinsurance

Habilitation services
Skilled nursing care

20% coinsurance
20% coinsurance

40% coinsurance
40% coinsurance

Durable medical equipment

20% coinsurance

40% coinsurance

Hospice services

20% coinsurance

40% coinsurance

Children’s eye exam

$35 copay/visit

Not covered

Children’s glasses

20% coinsurance

Not covered

Children’s dental checkups

No charge

Not covered

Outpatient services

Childbirth/delivery professional
services
Childbirth/delivery facility services
Home health care

40% coinsurance

Limitations, Exceptions, & Other
Important Information
50% coinsurance for anesthesia
None

40% coinsurance
Cost sharing does not apply to certain
preventive services. Depending on the
type of services, coinsurance may
apply. Maternity care may include tests
and services described elsewhere in
the SBC (i.e. ultrasound).
60 visits/year
60 visits/year. Includes physical
therapy, speech therapy, and
occupational therapy.
60 visits/calendar year
Excludes vehicle modifications, home
modifications, exercise, and bathroom
equipment.
Preauthorization is required. If you don't
get preauthorization, benefits could be
reduced by 50% of the total cost of the
service.
Coverage limited to one exam/year.
Coverage limited to one pair of
glasses/year.
None

Excluded Services & Other Covered Services
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Cosmetic Surgery
• Long Term Care
• Routine eye care (Adult)
• Dental Care
• Routine Foot Care
• Non-emergency care when traveling outside
the
U.S.
• Infertility Treatment
• Private Duty Nursing
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Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Chiropractic Care
• Weight Loss Programs
• Acupuncture (if prescribed for rehabilitation
purposes)
• Hearing Aids
• Bariatric Surgery
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: [insert State, HHS, DOL, and/or other applicable agency contact information]. Other coverage options may be available to you too, including buying
individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call
1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or
assistance, contact: [insert applicable contact information from instructions].
Does this plan provide Minimum Essential Coverage? [Yes/No]
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? [Yes/No/Not Applicable]
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
[Spanish (Español): Para obtener asistencia en Español, llame al [insert telephone number].]
[Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa [insert telephone number].]
[Chinese (中文): 如果需要中文的帮助，请拨打这个号码[insert telephone number].]
[Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' [insert telephone number].]
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a 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 0.08 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.

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About these Coverage Examples
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on
the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and
coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note
these coverage examples are based on self-only coverage.

Peg is Having a Baby

Managing Joe’s Type 2 Diabetes

Mia’s Simple Fracture

(9 months of in-network pre-natal care and a
hospital delivery)

(a year of routine in-network care of a wellcontrolled condition)

(in-network emergency room visit and follow up
care)

 The plan's overall deductible
$500
 Specialist copayment
$50
 Hospital (facility) [cost sharing]
20%
 Other coinsurance
20%
This EXAMPLE event includes services
like: Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services Diagnostic
tests (ultrasounds and blood work)
Specialist visit (anesthesia)

 The plan's overall deductible
$500
 Specialist copayment
$50
 Hospital (facility) [cost sharing]
20%
 Other coinsurance
20%
This EXAMPLE event includes services
like: Primary care physician office visits
(including disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)

 The plan's overall deductible
$500
 Specialist copayment
$50
 Hospital (facility) [cost sharing]
20%
 Other coinsurance
20%
This EXAMPLE event includes services
like: Emergency room care (including medical
supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)

Total Example Cost

Total Example Cost

Total Example Cost

In this example, Peg would pay:
Cost Sharing
Deductibles
Copayments
Coinsurance
What isn’t covered
Limits or exclusions
The total Peg would pay is

$12,700

$500
$300
$2,300
$60
$3,160

In this example, Joe would pay:
Cost Sharing
Deductibles
Copayments
Coinsurance
What isn’t covered
Limits or exclusions
The total Joe would pay is

$5,600

$800
$1,200
$300
$60
$2,360

In this example, Mia would pay:
Cost Sharing
Deductibles
Copayments
Coinsurance
What isn’t covered
Limits or exclusions
The total Mia would pay is

$2,800

$700
$50
$300
$0
$1,050

Note: These numbers assume the patient does not participate in the plan’s wellness program. If you participate in the plan’s wellness program, you may be able to
reduce your costs. For more information about the wellness program, please contact: [insert].
*Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?” row above.
[The plan would be responsible for the other costs of these EXAMPLE covered services.]
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