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Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
Insurance Company 1: Plan Option 1

Coverage Period: 01/01/2022- 12/31/2022
Coverage for: Individual | 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

What is the overall
deductible?

$

Are there services
covered before you meet
your deductible?

Yes. [Insert: major categories]

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.

What is the out-of-pocket
limit for this plan?

$

The out-of-pocket limit is the most you could pay in a year for covered services. [For family
coverage, see instructions for additional applicable language.]

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

[Insert: major exceptions]

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Will you pay less if you
use a network provider?

Yes. See www.[insert].com or call
1-800-[insert] for a list of network
providers.

Do you need a referral to
see a specialist?

Yes.

Why This Matters:
Generally, you must pay all of the costs from providers up to the deductible amount before this
plan begins to pay. [For family coverage, see instructions for additional applicable
language.]
This plan covers some items and services even if you haven’t yet met the deductible amount.
But a copayment or coinsurance may apply. [For non-grandfathered plans, insert: "For
example, this plan covers certain preventive services without cost sharing and before you meet
your deductible. See a list of covered preventive services at
https://www.healthcare.gov/coverage/preventive-care-benefits/."]

This plan uses a provider network. You will pay less if you use a provider in the plan’s network.
You will pay the most if you use an out-of-network provider, and you might receive a bill from a
provider for the difference between the provider’s charge and what your plan pays (balance
billing). Be aware, your network provider might use an out-of-network provider for some services
(such as lab work). Check with your provider before you get services.
This plan will pay some or all of the costs to see a specialist for covered services but only if you
have a referral before you see the specialist.

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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.

(DT - OMB control number: 1545-0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration date: 5/31/2022)
(HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022)

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