Summary of Benefits and Coverage

Health Plan Name: Insurance Company 1
What This Plan Covers & What it Costs

Policy Period: 9/15/2010 - 9/14/2011
Coverage for: Individual | Plan Type: HMO

This is not a policy. You can get the policy at www.insurancecompany.com/HMO1500 or by calling 1-800-XXX-XXXX.
A policy has more detail about how to use the plan and what you and your insurer must do. It also has more detail about your coverage and costs.
Important Questions

Answers

Why This Matters:

What is the premium?

$

The premium is the amount paid for health insurance. This is only an estimate based on
information you’ve provided. After the insurer reviews your application, your actual premium may be higher or your application may be denied.

What is the overall
deductible?

$

You must pay all the costs up to the deductible amount before this health insurance plan
begins to pay for covered services you use. Check your policy to see when the deductible
starts over (usually, but not always, January 1st). See the chart starting on page 2 for how
much you pay for covered services after you meet the deductible.

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.

Is there an out–of–pocket
limit on my expenses?

Yes. $

The out-of-pocket limit is the most you could pay during a policy period for your share of
the cost of covered services. This limit helps you plan for health care expenses.

What is not included in
the out–of–pocket limit?

Even though you pay these expenses, they don’t count toward the out-of-pocket limit. So,
a longer list of expenses means you have less coverage.

Is there an overall annual
limit on what the insurer
pays?

Yes. $

This plan will pay for covered services only up to this limit during each policy period, even
if your own need is greater. You’re responsible for all expenses above this limit. The chart
starting on page 2 describes specific coverage limits, such as limits on the number of office
visits.

Does this plan use a
network of providers?

Yes.

If you use an in-network doctor or other health care provider, this plan will pay some or all
of the costs of covered services. Plans use the term in-network, preferred, or participating
for providers in their network.

Do I 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 the plan’s permission before you see the specialist.

Are there services this
plan doesn’t cover?

Yes.

Some of the services this plan doesn’t cover are listed on page 3.

Questions: Call 1-800-XXX-XXXX or visit us at www.insurancecompany.com
If you aren’t clear about any of the terms used in this form, see the Glossary at www.insuranceterms.gov.

FINAL (pg1 - YES), 11/16/10

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