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 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 $35 copay/office Mental/Behavioral health outpatient services visit and 20% 40% coinsurance –––––––––––none––––––––––– coinsurance other If you have mental outpatient services health, behavioral Mental/Behavioral health inpatient services 20% coinsurance 40% coinsurance –––––––––––none––––––––––– health, or substance $35 copay/office abuse needs Substance use disorder outpatient services visit and 20% 40% coinsurance –––––––––––none––––––––––– coinsurance other outpatient services Substance use disorder inpatient services 20% coinsurance 40% coinsurance –––––––––––none––––––––––– If you are pregnant Prenatal and postnatal care 20% coinsurance 40% coinsurance –––––––––––none––––––––––– Delivery and all inpatient services 20% coinsurance 40% coinsurance –––––––––––none––––––––––– Home health care 20% coinsurance 40% coinsurance –––––––––––none––––––––––– If you need help Rehabilitation services 20% coinsurance 40% coinsurance –––––––––––none––––––––––– recovering or have Habilitation services 20% coinsurance 40% coinsurance –––––––––––none––––––––––– other special health Skilled nursing care 20% coinsurance 40% coinsurance –––––––––––none––––––––––– needs Durable medical equipment 20% coinsurance 40% coinsurance –––––––––––none––––––––––– Hospice service 20% coinsurance 40% coinsurance –––––––––––none––––––––––– If your child needs Eye exam $35 copay/ visit Not Covered Limited to one exam per year dental or eye care Glasses 20% coinsurance Not Covered Limited to one pair of glasses per year Dental check-up No Charge Not Covered Covers up to $50 per year 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 4 of 8 at www.[insert] or call 1-800-[insert] to request a copy.