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

Insurance Company 1: AI/AN Zero 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	See the Common Medical Events chart below for your costs for services this plan covers.
Are there services covered before you meet your deductible?	Yes.	This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply.
Are there other deductibles for specific services?	No.	You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan?	Not Applicable.	This plan does not have an out-of-pocket limit on your expenses.
What is not included in the out-of-pocket limit?	Not Applicable.	This plan does not have an out-of-pocket limit on your expenses.
Will you pay less if you use a network provider?	Not Applicable.	This plan does not use a provider network. You can receive covered services from any provider.
Do you need a referral to see a specialist?	No.	You can see the specialist you choose without a referral.

		What You Will Pay		Limitations, Exceptions, & Other Important Information
Common Medical Event	Services You May Need	Indian Health Care Provider (IHCP) (You will pay the least)	Non-IHCP 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	No charge	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	No charge	Preauthorization is required. If you don't get preauthorization, benefits could be reduced by 50% of the total cost of the service. 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	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	No charge	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	No charge
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	No charge	Covers up to a 30-day supply (retail subscription); 31-90 day supply (mail order prescription). 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	No charge
	Non-preferred brand drugs	No charge	No charge
	Specialty drugs	No charge	No charge
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)	No charge	No charge	Preauthorization is required. If you don't get preauthorization, benefits could be reduced by 50% of the total cost of the service. 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	No charge	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	No charge	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	No charge
	Urgent care	No charge	No charge
If you have a hospital stay	Facility fee (e.g., hospital room)	No charge	No charge	Preauthorization is required. If you don't get preauthorization, benefits could be reduced by 50% of the total cost of the service. 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	No charge	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	No charge	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	No charge
If you are pregnant	Office visits	No charge	No charge	Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). 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	No charge
	Childbirth/delivery facility services	No charge	No charge
If you need help recovering or have other special health needs	Home health care	No charge	No charge	60 visits/year. 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	No charge	60 visits/year. Includes physical therapy, speech therapy, and occupational therapy. 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	No charge
	Skilled nursing care	No charge	No charge	60 visits/calendar year. 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	No charge	Excludes vehicle modifications, home modifications, exercise, and bathroom equipment. 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	No charge	Preauthorization is required. If you don't get preauthorization, benefits could be reduced by 50% of the total cost of the service. 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	No charge	Coverage limited to one exam/year. 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	No charge	Coverage limited to one pair of glasses/year. 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	If an out-of-network provider charges more than the allowed amount, you may have to pay the difference (balance billing).

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.

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

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 $0

• Specialist copayment $0

• Hospital (facility) coinsurance 0%

• Other coinsurance 0%

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 $0

• Specialist copayment $0

• Hospital (facility) coinsurance 0%

• Other coinsurance 0%

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 $0

• Specialist copayment $0

• Hospital (facility) coinsurance 0%

• Other coinsurance 0%

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

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

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