Insurance Plan Sample

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 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.[insert] or by calling 1-800-[insert]. Important Questions Answers Why this Matters: $500 person / You must pay all the costs up to the deductible amount before this plan begins to pay for What is the overall $1,000 family covered services you use. Check your policy or plan document to see when the deductible deductible? Doesn’t apply to preventive care starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. Are there other Yes. $300 for prescription drug You must pay all of the costs for these services up to the specific deductible amount deductibles for specific coverage. There are no other before this plan begins to pay for these services. services? specific deductibles. Yes. For participating providers Is there an out–of– $2,500 person / $5,000 The out-of-pocket limit is the most you could pay during a coverage period (usually one pocket limit on my family year) for your share of the cost of covered services. This limit helps you plan for health expenses? For non-participating providers care expenses. $4,000 person / $8,000 family What is not included in Premiums, balance-billed the out–of–pocket charges, and health care this Even though you pay these expenses, they don’t count toward the out-of-pocket limit. limit? plan doesn’t cover. Is there an overall The chart starting on page 2 describes any limits on what the plan will pay for specific annual limit on what No. covered services, such as office visits. the plan pays? If you use an in-network doctor or other health care provider, this plan will pay some or all Does this plan use a Yes. See www.[insert].com or of the costs of covered services. Be aware, your in-network doctor or hospital may use an network of providers? call 1-800-[insert] for a list of out-of-network provider for some services. Plans use the term in-network, preferred, or participating providers. participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. Do I need a referral to No. You don’t need a referral to You can see the specialist you choose without permission from this plan. see a specialist? see a specialist. Are there services this Yes. Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan plan doesn’t cover? document for additional information about excluded services. Questions: Call 1-800-[insert] or visit us at www.[insert]. OMB Control Numbers 1545-2229, If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1210-0147, and 0938-1146 1 of 8 at www.[insert] or call 1-800-[insert] to request a copy. Corrected on May 11, 2012