Summary of Benefits and Coverage

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: [See Instructions]

: Coverage for: | Plan Type:

T he 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?	$
Are there services covered before you meet your deductible?
Are there other deductibles for specific services?	$
What is the out-of-pocket limit for this plan?	$
What is not included in the out-of-pocket limit?
Will you pay less if you use a network provider?
Do you need a referral to see a specialist?

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event	Services You May Need	What You Will Pay		Limitations, Exceptions, & Other Important Information
		Network Provider (You will pay the least)	Out-of-Network Provider (You will pay the most)
If you visit a health care provider’s office or clinic	Primary care visit to treat an injury or illness
	Specialist visit
	Preventive care/screening/ immunization
If you have a test	Diagnostic test (x-ray, blood work)
	Imaging (CT/PET scans, MRIs)
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.[insert].com	Generic drugs
	Preferred brand drugs
	Non-preferred brand drugs
	Specialty drugs
If you have outpatient surgery	Facility fee (e.g., ambulatory surgery center)
	Physician/surgeon fees
If you need immediate medical attention	Emergency room care
	Emergency medical transportation
	Urgent care
If you have a hospital stay	Facility fee (e.g., hospital room)
	Physician/surgeon fees
If you need mental health, behavioral health, or substance abuse services	Outpatient services
	Inpatient services
If you are pregnant	Office visits
	Childbirth/delivery professional services
	Childbirth/delivery facility services
If you need help recovering or have other special health needs	Home health care
	Rehabilitation services
	Habilitation services
	Skilled nursing care
	Durable medical equipment
	Hospice services
If your child needs dental or eye care	Children’s eye exam
	Children’s glasses
	Children’s dental check-up

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: [insert State, HHS, DOL, and/or other applicable agency contact information]. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318- 2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: [insert applicable contact information from instructions].

Does this plan provide Minimum Essential Coverage? [Yes/No]

Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet the Minimum Value Standards? [Yes/No/Not Applicable]

If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al [insert telephone number].

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa [insert telephone number].

Chinese (中文): 如果需要中文的帮助, 请拨打这个号码[insert telephone number].

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' [insert telephone number].

Pennsylvania Dutch (Deitsch): Fer Hilf griege in Deitsch, ruf [insert telephone number] uff.

Samoan (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni [insert telephone number].

Carolinian (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye [insert telephone number].

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Chamorro (Chamoru): Para un ma ayuda gi finu Chamoru, å’gang [insert telephone number].

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 1210-0147 with expiration date of 05/31/2025.  Group health plans are to provide applicants, enrollees, policyholders, and certificate holders a summary of benefits and coverage (SBC) explanation that accurately describes the benefits and coverage under the plan or coverage. The responses to this information collection are mandatory.  The time required to complete this information collection is estimated to average 1 minute per response, including the time to review instructions, gather the necessary data, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this information collection, please write to: U.S. Department of Labor, Employee Benefits Security Administration, Office of Research and Analysis, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0147.

About these Coverage Examples:

T his is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby

(9 months of in-network pre-natal care and a hospital delivery)

• The plan’s overall deductible $

 Specialist [cost sharing] $

 Hospital (facility) [cost sharing] %

 Other [cost sharing] %

This EXAMPLE event includes services like:

Specialist office visits (prenatal care)

Childbirth/Delivery Professional Services

Childbirth/Delivery Facility Services

Diagnostic tests (ultrasounds and blood work)

Specialist visit (anesthesia)

Total Example Cost	$12,700
In this example, Peg would pay:
Cost Sharing
Deductibles	$
Copayments	$
Coinsurance	$
What isn’t covered
Limits or exclusions	$
The total Peg would pay is	$

Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition)

• The plan’s overall deductible $

 Specialist [cost sharing] $

 Hospital (facility) [cost sharing] %

 Other [cost sharing] %

This EXAMPLE event includes services like:

Primary care physician office visits (including disease education)

Diagnostic tests (blood work)

Prescription drugs

Durable medical equipment (glucose meter)

Total Example Cost	$5,600
In this example, Joe would pay:
Cost Sharing
Deductibles	$
Copayments	$
Coinsurance	$
What isn’t covered
Limits or exclusions	$
The total Joe would pay is	$

Mia’s Simple Fracture

(in-network emergency room visit and follow up care)

• The plan’s overall deductible $

 Specialist [cost sharing] $

 Hospital (facility) [cost sharing] %

 Other [cost sharing] %

This EXAMPLE event includes services like:

Emergency room care (including medical supplies)

Diagnostic test (x-ray)

Durable medical equipment (crutches)

Rehabilitation services (physical therapy)

Total Example Cost	$2,800
In this example, Mia would pay:
Cost Sharing
Deductibles	$
Copayments	$
Coinsurance	$
What isn’t covered
Limits or exclusions	$
The total Mia would pay is	$

The plan would be responsible for the other costs of these EXAMPLE covered services.

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(OMB control number: 1210-0147/Expiration date: 05/31/2025)