Insurance Company 1: Plan Option 1 Coverage Period: 01/01/2013 – 12/31/2013 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Spouse | Plan Type: PPO Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts. Your Cost If Your Cost If Common You Use a You Use a Medical Event Services You May Need Participating Non- Limitations & Exceptions Provider Participating Provider Primary care visit to treat an injury or illness $35 copay/visit 40% coinsurance –––––––––––none––––––––––– If you visit a health Specialist visit $50 copay/visit 40% coinsurance –––––––––––none––––––––––– care provider’s office 20% coinsurance 40% coinsurance or clinic Other practitioner office visit for chiropractor for chiropractor –––––––––––none––––––––––– and acupuncture and acupuncture Preventive care/screening/immunization No charge 40% coinsurance If you have a test Diagnostic test (x-ray, blood work) $10 copay/test 40% coinsurance –––––––––––none––––––––––– Imaging (CT/PET scans, MRIs) $50 copay/test 40% coinsurance –––––––––––none––––––––––– Questions: Call 1-800-[insert] or visit us at www.[insert]. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 2 of 8 at www.[insert] or call 1-800-[insert] to request a copy.