Summary of Benefits and Coverage Completed Example

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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services	Coverage Period: 01/01/2025 – 12/31/2025
Insurance Company 1: Plan Option 1	Coverage for: Family | Plan Type: PPO


Important Questions
Answers
Why This Matters:
What is the overall deductible?
$500 / individual or $1,000 / family
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.
Are there services covered before you meet your deductible?
Yes. Preventive care and primary care services are covered before you meet your 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/.
Are there other deductibles for specific services?
Yes. $300 for prescription drug coverage and $300 for occupational therapy services. There are no other specific deductibles.
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?
For network providers $2,500 individual / $5,000 family; for out- of-network providers $4,000 individual / $8,000 family
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.
What is not included in the out-of-pocket limit?
Copayments for certain services, premiums, balance-billing charges, and health care this plan doesn’t cover.
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.
	

Common Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other 
Important Information


Network Provider 
(You will pay the least)
Out-of-Network Provider (You will pay the most)

If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness
$35 copay/office visit and 20% coinsurance for other outpatient services; deductible does not apply
40% coinsurance
None

Specialist visit
$50 copay/visit
40% coinsurance
Preauthorization is required. If you don't get preauthorization, benefits could be reduced by 50% of the total cost of the service.

Preventive care/screening/
immunization
No charge
40% coinsurance
You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood work)
$10 copay/test
40% coinsurance
None

Imaging (CT/PET scans, MRIs)
$50 copay/test
40% coinsurance

If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at [www.insert.com]
Generic drugs (Tier 1)
$10 copay/prescription (retail & mail order)
40% coinsurance
Covers up to a 30-day supply (retail subscription); 31-90 day supply (mail order prescription).

Preferred brand drugs (Tier 2)
$30 copay/prescription (retail & mail order)
40% coinsurance


Non-preferred brand drugs (Tier 3)
40% coinsurance
60% coinsurance


Specialty drugs (Tier 4)
50% coinsurance
70% coinsurance

If you have outpatient surgery
Facility fee (e.g., ambulatory surgery center)
$100/day copay
40% coinsurance
Preauthorization is required. If you don't get preauthorization, benefits could be reduced by 50% of the total cost of the service.

Physician/surgeon fees
20% coinsurance
40% coinsurance
50% coinsurance for anesthesia.
If you need immediate medical attention
Emergency room care
20% coinsurance
20% coinsurance
None

Emergency medical transportation
20% coinsurance
20% coinsurance


Urgent care
$30 copay/visit
40% coinsurance

If you have a hospital stay
Facility fee (e.g., hospital room)
20% coinsurance
40% coinsurance
Preauthorization is required. If you don't get preauthorization, benefits could be reduced by 50% of the total cost of the service.

Physician/surgeon fees
20% coinsurance
40% coinsurance
50% coinsurance for anesthesia.
If you need mental health, behavioral health, or substance abuse services
Outpatient services
$35 copay/office visit and 20% coinsurance for other outpatient services
40% coinsurance
None

Inpatient services
20% coinsurance
40% coinsurance

If you are pregnant
Office visits
20% coinsurance
40% coinsurance
Cost sharing does not apply for preventive services. Depending on the type of services, a coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).

Childbirth/delivery professional services
20% coinsurance
40% coinsurance


Childbirth/delivery facility services
20% coinsurance
40% coinsurance

If you need help recovering or have other special health needs
Home health care
20% coinsurance
40% coinsurance
60 visits/year

Rehabilitation services
20% coinsurance
40% coinsurance
60 visits/year. Includes physical therapy, speech therapy, and occupational therapy.

Habilitation services
20% coinsurance
40% coinsurance


Skilled nursing care
20% coinsurance
40% coinsurance
60 visits/calendar year

Durable medical equipment
20% coinsurance
40% coinsurance
Excludes vehicle modifications, home modifications, exercise, and bathroom equipment.

Hospice services
20% coinsurance
40% coinsurance
Preauthorization is required. If you don't get preauthorization, benefits could be reduced by 50% of the total cost of the service.
If your child needs dental or eye care
Children’s eye exam
$35 copay/visit
Not covered
Coverage limited to one exam/year.

Children’s glasses
20% coinsurance
Not covered
Coverage limited to one pair of glasses/year.

Children’s dental check-up
No charge
Not covered
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
    • Dental care (Adult)
    • Infertility treatment
    • Long-term care
    • Non-emergency care when traveling outside the U.S.
    • Private-duty nursing
    • Routine eye care (Adult)
    • Routine foot care

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
    • Acupuncture (if prescribed for rehabilitation purposes)
    • Bariatric surgery
    • Chiropractic care
    • Hearing aids
    • Weight loss programs
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.
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.
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].
Pennsylvania Dutch (Deitsch): Fer Hilf griege in Deitsch, ruf [insert telephone number] uff.
Samoan (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni [insert telephone number].
Carolinian (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye [insert telephone number].
Chamorro (Chamoru): Para un ma ayuda gi finu Chamoru, å’gang [insert telephone number].
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 0.02 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.
About these Coverage Examples:



    • The plan’s overall deductible 	$500
    • Specialist copayment	$50
    • Hospital (facility) coinsurance	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)
Total Example Cost
$12,700
In this example, Peg would pay:
Cost Sharing
Deductibles
$500
Copayments
$200
Coinsurance
$1,800
What isn’t covered
Limits or exclusions
$60
The total Peg would pay is
$2,560

    • The plan’s overall deductible 	$500
    • Specialist copayment	$50
    • Hospital (facility) coinsurance	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)
Total Example Cost
$5,600
In this example, Joe would pay:
Cost Sharing
Deductibles*
$800
Copayments
$900
Coinsurance
$100
What isn’t covered
Limits or exclusions
$20
The total Joe would pay is
$1,820

    • The plan’s overall deductible 	$500
    • Specialist copayment	$50
    • Hospital (facility) coinsurance	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
$2,800
In this example, Mia would pay:
Cost Sharing
Deductibles*
$500
Copayments
$200
Coinsurance
$400
What isn’t covered
Limits or exclusions
$0
The total Mia would pay is
$1,100

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.