SBC Disclosure

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2025 – 12/31/2025

I nsurance Company 1: AI/AN Limited Cost Sharing Coverage for: Individual + Spouse | 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 at Indian Health Care Provider (IHCP) or with IHCP referral at non-IHCP; or $500 individual / $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?	$0 at IHCP or with IHCP referral at non-IHCP; or 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.

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

Common Medical Event Common	Services You May Need		What You Will Pay		Limitations, Exceptions, & Other Important Information
		Indian Health Care Provider (IHCP) (You will pay the least)	Non-IHCP In-Network Provider (You will pay more)	Non-IHCP 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	No charge	$35 copay/office visit and 20% coinsurance for other outpatient services; deductible does not apply	40% coinsurance	Cost sharing waived at non-IHCP with IHCP referral. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
	Specialist visit	No charge	$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. Cost sharing waived at non-IHCP with IHCP referral. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
	Preventive care/ screening/ immunization	No charge	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)	No charge	$10 copay/test	40% coinsurance	Cost sharing waived at non-IHCP with IHCP referral. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
	Imaging (CT/PET scans, MRIs)	No charge	$50 copay/visit	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	No charge	$10 copay/prescription (retail & mail order)	40% coinsurance	*See Section [X]. Cost sharing waived at non-IHCP with IHCP referral. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
	Preferred brand drugs	No charge	$30 copay/prescription (retail & mail order)	40% coinsurance
	Non-preferred brand drugs	No charge	40% coinsurance	60% coinsurance
	Specialty drugs	No charge	50% coinsurance	70% coinsurance
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	No charge	$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. Cost sharing waived at non-IHCP with IHCP referral. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
	Physician/surgeon fees	No charge	20% coinsurance	40% coinsurance	50% coinsurance for anesthesia. Cost sharing waived at non-IHCP with IHCP referral. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
If you need immediate medical attention	Emergency room care	No charge	20% coinsurance	20% coinsurance	Cost sharing waived at non-IHCP with IHCP referral. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
	Emergency medical transportation	No charge	20% coinsurance	20% coinsurance
	Urgent care	No charge	$30 copay/visit	40% coinsurance
If you have a hospital stay	Facility fee (e.g., hospital room)	No charge	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. Cost sharing waived at non-IHCP with IHCP referral. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
	Physician/surgeon fees	No charge	20% coinsurance	40% coinsurance	50% coinsurance for anesthesia. Cost sharing waived at non-IHCP with IHCP referral. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
If you need mental health, behavioral health, or substance abuse services	Outpatient services	No charge	$35 copay/office visit and 20% coinsurance for other outpatient services	40% coinsurance	Cost sharing waived at non-IHCP with IHCP referral. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
	Inpatient services	No charge	20% coinsurance	40% coinsurance
If you are pregnant	Office visits	No charge	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). Cost sharing waived at non-IHCP with IHCP referral. If an out- of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
	Childbirth/delivery professional services	No charge	20% coinsurance	40% coinsurance
	Childbirth/delivery facility services	No charge	20% coinsurance	40% coinsurance
If you need help recovering or have other special health needs	Home health care	No charge	20% coinsurance	40% coinsurance	60 visits/year. Cost sharing waived at non-IHCP with IHCP referral. If an out- of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
	Rehabilitation services	No charge	20% coinsurance	40% coinsurance	60 visits/year. Includes physical therapy, speech therapy, and occupational therapy. Cost sharing waived at non-IHCP with IHCP referral. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
	Habilitation services	No charge	20% coinsurance	40% coinsurance
	Skilled nursing care	No charge	20% coinsurance	40% coinsurance	60 visits/calendar year. Cost sharing waived at non-IHCP with IHCP referral. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
	Durable medical equipment	No charge	20% coinsurance	40% coinsurance	Excludes vehicle modifications, home modifications, exercise, and bathroom equipment. Cost sharing waived at non-IHCP with IHCP referral. If an out- of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
	Hospice services	No charge	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. Cost sharing waived at non-IHCP with IHCP referral. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
If your child needs dental or eye care	Children’s eye exam	No charge	$35 copay/visit	Not covered	Coverage limited to one exam/year. Cost sharing waived at non-IHCP with IHCP referral. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
	Children’s glasses	No charge	20% coinsurance	Not covered	Coverage limited to one pair of glasses/year. Cost sharing waived at non-IHCP with IHCP referral. If an out- of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).
	Children’s dental check-up	No charge	No charge	Not covered	Cost sharing waived at non-IHCP with IHCP referral. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).

[* For more information about limitations and exceptions, see the plan or policy document at [www.insert.com].]

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.)
Abortion (except in cases of rape, incest, or when the life of the mother is endangered) 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].

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 0.02 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:

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

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

• 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	$0
Copayments	$0
Coinsurance	$0
What isn’t covered
Limits or exclusions	$0
The total Peg would pay is	$0

Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition)

• 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	$0
Copayments	$0
Coinsurance	$0
What isn’t covered
Limits or exclusions	$0
The total Joe would pay is	$0

Mia’s Simple Fracture

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

• 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	$0
Copayments	$0
Coinsurance	$0
What isn’t covered
Limits or exclusions	$0
The total Mia would pay is	$0

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: These numbers assume the patient received care from an IHCP provider or with IHCP referral at a non-IHCP. If you receive care from a non-IHCP provider without a referral from an IHCP your costs may be higher.

The plan would be responsible for the other costs of these EXAMPLE covered services.

(OMB control number: 0938-1146/Expiration date: 05/31/2026) Page 1 of 38