Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
Coverage Period: 01/01/2027 through 12/31/2027Coverage for: Family | Plan Type: HMO
The 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.
| Important Questions | Answers | Why This Matters: |
|---|---|---|
| What is the overall ? | $4,500 individual / $9,000 family | Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. |
| What is the for this plan? | $9,200 individual / $18,400 family | The out-of-pocket limit is the most you could pay in a year for covered services. |
| Will you pay less if you use a ? | Yes. See www.example.com or call 1-800-000-0000 for a list of network providers. | You will pay less if you use a provider in the plan's network. |
| Do you need a to see a specialist? | Yes. | This plan will pay some or all of the costs to see a specialist only if you have a referral before you see the specialist. |
Questions: Call 1-800-000-0000 or visit us at www.example.com.Page 1 of 8
