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. T his 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? |
No. |
You will have to meet the deductible before the plan pays for any services. |
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. |
File Type | application/msword |
Author | DOL Comments |
Last Modified By | Department of Treasury |
File Modified | 2016-04-05 |
File Created | 2016-04-05 |