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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

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.

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.

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