Summary of Benefits and Coverage

Health Plan Name: Insurance Company 1
Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 1/1/2013 – 12/31/2013
Coverage for: Individual | Plan Type: PPO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan
document at www.[insert] or by calling 1-800-[insert].
Important Questions

Answers

Why this Matters:

What is the overall
deductible?

$

See the chart starting on page 2 for your costs for services this plan covers.

Are there other
deductibles for specific
services?

No.

You don’t have to meet deductibles for specific services, but see the chart starting on page
2 for other costs for services this plan covers.

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

No.

There’s no limit on how much you could pay during a coverage period for your share of
the cost of covered services.

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

This plan has no out–of–
pocket limit.

Not applicable because there’s no out–of–pocket limit on your expenses.

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

No.

The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits.

Does this plan use a
network of providers?

No.

This plan treats providers the same in determining payment for the same services.

Do I need a referral to
see a specialist?

No.

You can see the specialist you choose without permission from this plan.

Are there services this
plan doesn’t cover?

No.

See your policy or plan document for information about excluded services.

Questions: Call 1-800-[insert] or visit us at www.[insert].com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.[insert] or call 1-800-[insert] to request a copy.

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