Summary of Benefits & Coverage

All private health plans must use this standard form. The information is laid out the same for every plan,
making it easier for you to compare.

Insurance Company 1: Plan Option 1 Coverage Period: 01/01/2014 – 12/31/2014 Didn’t get this form?
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Spouse | Plan Type: PPO You’re legally entitled to it (except if
it is a Medicare plan), so ask your
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 insurance company or benefits
document at www.[insert] or by calling 1-800-[insert]. manager for a copy.

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.
Worst-case scenario. Add together this
out-of-pocket limit and your annual $4,000 person / $8,000 family
premiums. This is the most you will have to What is not included in Premiums, balance-billed If there are hospitals or doctors you
pay in a year, no matter how much it costs 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. prefer, make sure they participate
overall. limit? plan doesn’t cover. with a plan before you select it. Using
Is there an overall providers outside your plan’s network
The chart starting on page 2 describes any limits on what the plan will pay for specific
annual limit on what No. can be very costly.
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.
The vast majority of plans cover all major Do I need a referral to No. You don’t need a referral to
medical services, but may still exclude You can see the specialist you choose without permission from this plan.
see a specialist? see a specialist.
certain things such as cosmetic surgery,
assisted reproductive treatments, or dental Are there services this Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan
Yes.
care for adults. 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.
Released on April 23, 2013 (corrected)

© 2014 Consumers Union. All rights reserved.

Insurance Company 1: Plan Option 1 Coverage Period: 01/01/2014 – 12/31/2014
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 Translation: the insurance company gets to
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 decide how much it will pay for out-of-net-
you haven’t met your deductible. work care. You’re responsible for the rest.
• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the It can be a lot.
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 Think about your own medical needs and
Services You May Need You Use a Limitations & Exceptions
Non-
Medical Event Participating look at the detail on pages 2-4 of the form
Participating
Provider to estimate what you can expect to pay for
Provider
those specific services.
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.

© 2014 Consumers Union. All rights reserved.

Insurance Company 1: Plan Option 1 Coverage Period: 01/01/2014 – 12/31/2014
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
Services You May Need You Use a Limitations & Exceptions
Non-
Medical Event Participating
Participating
Provider
Provider Expensive drugs live here. “Specialty
$10 copay/ Covers up to a 30-day supply (retail drugs,” many of which have to be injected,
If you need drugs to Generic drugs prescription (retail 40% coinsurance prescription); 31-90 day supply (mail tend to be for cancer, multiple sclerosis,
treat your illness or and mail order) order prescription) and other serious diseases. They can
condition 20% coinsurance cost thousands of dollars a month. If you
Preferred brand drugs (retail and mail 40% coinsurance –––––––––––none––––––––––– take one of these drugs, check the plan’s
More information order) formulary list of covered drugs, to make
about prescription 40% coinsurance sure it is covered.
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.

© 2014 Consumers Union. All rights reserved.

Insurance Company 1: Plan Option 1 Coverage Period: 01/01/2014 – 12/31/2014
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.)
Dental and vision coverage are important,
• Cosmetic surgery • Long-term care • Routine eye care (Adult) but not always included. Check to see if
you can buy separately.
• 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.

© 2014 Consumers Union. All rights reserved.

Insurance Company 1: Plan Option 1 Coverage Period: 01/01/2014 – 12/31/2014
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Spouse | Plan Type: PPO

Your Rights to Continue Coverage: You will see only information for individual
** Individual health insurance sample –   ** Group health coverage sample – or group coverage depending on what kind
you have.
 
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,
In case your plan denies a claim, here is
your state insurance department at [insert applicable State Employee Benefits Security Administration at 1-866-444-3272 where to start the process of appealing.
Department of Insurance contact information].   or www.dol.gov/ebsa, or the U.S. Department of Health and The new health care law gives consum-
Human Services at 1-877-267-2323 x61565 or ers more appeal rights than they used to
www.cciio.cms.gov. have, especially those who work for large
companies.
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].

Does this Coverage Provide Minimum Essential Coverage? Very handy indication if this coverage
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy [does/ meets minimum standards. Almost all will.
does not] provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage [does/does not] meet the minimum value standard for the benefits it provides. This is a different standard. If your employer
plan falls below it OR costs you more than
9.5% of your income, you may qualify for
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.–––––––––––––––––––––– financial help to purchase a plan from your
state Health Insurance Marketplace.
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.

© 2014 Consumers Union. All rights reserved.

Insurance Company 1: Plan Option 1 Coverage Period: 1/1/2014 – 12/31/2014
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)
This is a big deal. You may not be pregnant
These examples show how this plan might cover  Amount owed to providers: $7,540  Amount owed to providers: $5,400 or diabetic but these coverage examples
medical care in given situations. Use these  Plan pays $5,490  Plan pays $3,520 can help you compare how much of your
examples to see, in general, how much financial  Patient pays $2,050  Patient pays $1,880 health costs different plans are likely to
protection a sample patient might get if they are
pick up.
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.

© 2014 Consumers Union. All rights reserved.