SBC Disclosure

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

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Coverage Period: [See Instructions]

Coverage for: | Plan Type:

T he 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.

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21244-1850.

(OMB control number: 0938-1146/Expiration date: 05/31/2026) Page 1 of 1