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

What is the overall
deductible?

$

You must pay all the costs up to the deductible amount before this plan begins to pay for
covered services you use. Check your policy or plan document 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.

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.

Yes. $

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

Are there other
deductibles for specific
services?
Is there an out–of–
pocket limit on my
expenses?

Why this Matters:

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.

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

Yes. $

This plan will pay for covered services only up to this limit during each coverage 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. For a list of preferred
providers, see
www.[insert].com or call 1888-123-4567.

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. Be aware, your in-network doctor or hospital may use an
out-of-network provider for some services. Plans use the term in-network, preferred, or
participating for providers in their network. See the chart starting on page 2 for how this
plan pays different kinds of providers.

Do I need a referral to
see a specialist?
Are there services this
plan doesn’t cover?

Yes.
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.
Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan
document for additional 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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