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:

You must pay all the costs up to the deductible amount before this plan begins to pay for
What is the overall $500 person / covered services you use. Check your policy or plan document to see when the deductible
deductible? $1,000 family starts over (usually, but not always, January 1st). See the chart starting on page 2 for how
Doesn’t apply to preventive care 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
Yes. See www.[insert].com or of the costs of covered services. Be aware, your in-network doctor or hospital may use an
Does this plan use a
call 1-800-[insert] for a list of out-of-network provider for some services. Plans use the term in-network, preferred, or
network of providers?
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 Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan
Yes.
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
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
Services You May Need Non- Limitations & Exceptions
Medical Event Participating
Participating
Provider
Provider
Primary care visit to treat an injury or illness $35 copay/visit 40% coinsurance –––––––––––none–––––––––––
Specialist visit $50 copay/visit 40% coinsurance –––––––––––none–––––––––––
If you visit a health
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
Diagnostic test (x-ray, blood work) $10 copay/test 40% coinsurance –––––––––––none–––––––––––
If you have a test
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.
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
Services You May Need Non- Limitations & Exceptions
Medical Event Participating
Participating
Provider
Provider
$10 copay/ Covers up to a 30-day supply (retail
If you need drugs to Generic drugs prescription (retail 40% coinsurance prescription); 31-90 day supply (mail
treat your illness or and mail order) order prescription)
condition 20% coinsurance
Preferred brand drugs (retail and mail 40% coinsurance –––––––––––none–––––––––––
More information order)
about prescription 40% coinsurance
drug coverage is Non-preferred brand drugs (retail and mail 60% coinsurance –––––––––––none–––––––––––
available at www. order)
[insert].
Specialty drugs 50% coinsurance 70% coinsurance –––––––––––none–––––––––––

If you have Facility fee (e.g., ambulatory surgery center) 20% coinsurance 40% coinsurance –––––––––––none–––––––––––
outpatient surgery Physician/surgeon fees 20% coinsurance 40% coinsurance –––––––––––none–––––––––––
If you need Emergency room services 20% coinsurance 20% coinsurance –––––––––––none–––––––––––
immediate medical Emergency medical transportation 20% coinsurance 20% coinsurance –––––––––––none–––––––––––
attention Urgent care 20% coinsurance 40% coinsurance –––––––––––none–––––––––––
If you have a Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance –––––––––––none–––––––––––
hospital stay Physician/surgeon fee 20% coinsurance 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 3 of 8
at www.[insert] or call 1-800-[insert] to request a copy.
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
Services You May Need Non- Limitations & Exceptions
Medical Event Participating
Participating
Provider
Provider
$35 copay/office
visit and 20%
Mental/Behavioral health outpatient services 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 visit and 20%
Substance use disorder outpatient services 40% coinsurance –––––––––––none–––––––––––
coinsurance other
outpatient services
Substance use disorder inpatient services 20% coinsurance 40% coinsurance –––––––––––none–––––––––––
Prenatal and postnatal care 20% coinsurance 40% coinsurance –––––––––––none–––––––––––
If you are pregnant
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–––––––––––
Eye exam $35 copay/ visit Not Covered Limited to one exam per year
If your child needs
Glasses 20% coinsurance Not Covered Limited to one pair of glasses per year
dental or eye care
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.
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

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

Cosmetic surgery Long-term care Routine eye care (Adult)

Dental care (Adult) Non-emergency care when traveling outside Routine foot care
the U.S.
Infertility treatment
Private-duty nursing

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.)

Acupuncture (if prescribed for rehabilitation Chiropractic care Most coverage provided outside the United
purposes) States. See www.[insert]
Hearing aids
Bariatric surgery Weight loss programs

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 5 of 8
at www.[insert] or call 1-800-[insert] to request a copy.
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 Rights to Continue Coverage:

** Individual health insurance sample – ** Group health coverage sample –

Federal and State laws may provide protections that allow you If you lose coverage under the plan, then, depending upon the
to keep this health insurance coverage as long as you pay your circumstances, Federal and State laws may provide protections
premium. There are exceptions, however, such as if: that allow you to keep health coverage. Any such rights may be
OR
limited in duration and will require you to pay a premium,
You commit fraud which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights
The insurer stops offering services in the State to continue coverage may also apply.
You move outside the coverage area For more information on your rights to continue coverage,
For more information on your rights to continue coverage, contact the plan at [contact number]. You may also contact your
contact the insurer at [contact number]. You may also contact state insurance department, the U.S. Department of Labor,
your state insurance department at [insert applicable State Employee Benefits Security Administration at 1-866-444-3272
Department of Insurance contact information]. or www.dol.gov/ebsa, or the U.S. Department of Health and
Human Services at 1-877-267-2323 x61565 or
www.cciio.cms.gov.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For
questions about your rights, this notice, or assistance, you can contact: [insert applicable contact information from instructions].

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

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 6 of 8
at www.[insert] or call 1-800-[insert] to request a copy.
Insurance Company 1: Plan Option 1 Coverage Period: 1/1/2011 – 12/31/2011
Coverage Examples Coverage for: Individual + Spouse | Plan Type: PPO

About these Coverage Having a baby Managing type 2 diabetes

(normal delivery) (routine maintenance of
Examples: a well-controlled condition)
These examples show how this plan might cover  Amount owed to providers: $7,540  Amount owed to providers: $5,400
medical care in given situations. Use these  Plan pays $5,490  Plan pays $3,520
examples to see, in general, how much financial  Patient pays $2,050  Patient pays $1,880
protection a sample patient might get if they are
covered under different plans. Sample care costs: Sample care costs:
Hospital charges (mother) $2,700 Prescriptions $2,900
Routine obstetric care $2,100 Medical Equipment and Supplies $1,300
Hospital charges (baby) $900 Office Visits and Procedures $700
This is Anesthesia $900 Education $300
not a cost Laboratory tests $500 Laboratory tests $100
estimator. Prescriptions $200 Vaccines, other preventive $100
Don’t use these examples to Radiology $200 Total $5,400
estimate your actual costs Vaccines, other preventive $40
under this plan. The actual Total $7,540 Patient pays:
care you receive will be Deductibles $800
different from these Patient pays: Copays $500
examples, and the cost of Deductibles $700 Coinsurance $500
that care will also be Copays $30 Limits or exclusions $80
different. Coinsurance $1320 Total $1,880
See the next page for Limits or exclusions $0
important information about Total $2,050 Note: These numbers assume the patient is
these examples. participating in our diabetes wellness
program. If you have diabetes and do not
participate in the wellness program, your
costs may be higher. For more information
about the diabetes wellness program, please
contact: [insert].

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 7 of 8
at www.[insert] or call 1-800-[insert] to request a copy.
Insurance Company 1: Plan Option 1 Coverage Period: 1/1/2011 – 12/31/2011
Coverage Examples Coverage for: Individual + Spouse | Plan Type: PPO

Questions and answers about the Coverage Examples:

What are some of the What does a Coverage Example Can I use Coverage Examples
assumptions behind the show? to compare plans?
Coverage Examples? For each treatment situation, the Coverage
Example helps you see how deductibles,
Yes. When you look at the Summary of
Costs don’t include premiums. Benefits and Coverage for other plans,
copayments, and coinsurance can add up. It
Sample care costs are based on national you’ll find the same Coverage Examples.
also helps you see what expenses might be left
averages supplied by the U.S. When you compare plans, check the
up to you to pay because the service or
Department of Health and Human “Patient Pays” box in each example. The
treatment isn’t covered or payment is limited.
Services, and aren’t specific to a smaller that number, the more coverage
particular geographic area or health plan. the plan provides.
The patient’s condition was not an Does the Coverage Example
excluded or preexisting condition. predict my own care needs? Are there other costs I should
All services and treatments started and
ended in the same coverage period.  No. Treatments shown are just examples. consider when comparing
The care you would receive for this plans?
There are no other medical expenses for
condition could be different based on your
any member covered under this plan.
doctor’s advice, your age, how serious your Yes. An important cost is the premium
Out-of-pocket expenses are based only you pay. Generally, the lower your
condition is, and many other factors.
on treating the condition in the example. premium, the more you’ll pay in out-of-
The patient received all care from in- pocket costs, such as copayments,
network providers. If the patient had Does the Coverage Example deductibles, and coinsurance. You
received care from out-of-network predict my future expenses? should also consider contributions to
providers, costs would have been higher. accounts such as health savings accounts
 No. Coverage Examples are not cost (HSAs), flexible spending arrangements
estimators. You can’t use the examples to (FSAs) or health reimbursement accounts
estimate costs for an actual condition. They (HRAs) that help you pay out-of-pocket
are for comparative purposes only. Your expenses.
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
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 8 of 8
at www.[insert] or call 1-800-[insert] to request a copy.