This is only a summary.If you wantmore detail about your coverage and costs, you can get the complete terms in the policy or plan document at
MedMutual.com/SBC or by calling 800.315.3137.
ImportantQuestions / Answers / WhyThisMatters:Whatis theoverall deductible? / $2,500/single,$5,000/family Network
$4,000/single,$8,000/family
Non-Network
Doesn't apply to coinsurance, copays and network preventive care / Youmust pay all the costs up to the deductibleamount before this plan begins to pay for covered services you use. Check your policy or plan document to see whenthe deductiblestarts over (usually, but not always, January 1st). Seethe chart starting on page 2 for howmuch you pay for covered services after you meet the deductible.
Arethereotherdeductibles forspecific services? / No / Youdon’t have to meet deductiblesfor specific services, but see the chart starting on page 2 for other costs for services this plan covers.
Is thereanout-of-pocketlimit onmy expenses? / Yes, CoinsuranceLimit:
$2,500/single,$5,000/family Network
$3,500/single,$7,000/family
Non-Network
Out-of-pocketLimit:
$6,600/single,$13,200/family Network Unlimited/single,Unlimited/family Non-Network / The out-of-pocketlimitis the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. The coinsurance limit is included in the out-of-pocketlimit.
Whatisnotincludedin the out-of-pocketlimit? / Premiums,balance-billed charges and health care this plan doesn't cover. / Even though you pay these expenses, they don’t count towardthe out–of–pocketlimit.
Is therean overallannuallimit onwhat theinsurerpays? / No / The chart starting on page 2 describes any limits on whatthe plan will pay for specificcovered services, such as office visits.
Doesthis plan use anetwork ofproviders? / Yes, SeeMedMutual.com/SBCor call
800.315.3137 for a list of participating providers. / If you use an in-networkdoctor or other health care provider,this plan will pay some or all of the costs of covered services. Beaware,your in-networkdoctor or hospital may use an out-of-network providerfor some services. Plans use the term in-network, preferred,or participating for providersin their network. Seethe chart starting on page 2 for howthis plan pays different kinds of providers.
DoI need a referraltosee a specialist? / No / Youcan see the specialistyou choose without permission from this plan.
Arethereservices this plan doesn'tcover? / Yes / Some of the services this plan doesn’t cover are listed on page 5. Seeyour policy or plan document for additional information about excludedservices.
•Copaymentsare fixed dollar amounts (forexample, $15) you pay for covered health care, usually whenyou receive the service.
•Coinsuranceis your share of the costs of a covered service, calculated as a percent of the allowedamountfor the service. Forexample, if the plan's allowedamountfor an overnight hospital stay is $1,000, your coinsurancepayment 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 allowedamount.If an out-of-network providercharges more than the allowed
amount,you may have to pay the difference. Forexample, if an out-of-networkhospital charges $1,500 for an overnight stay and the allowedamountis
$1,000, you may have to pay the $500 difference. (This is called balancebilling.)
•This plan may encourage you to use Network providersby charging you lowerdeductibles,copaymentsand coinsuranceamounts.
CommonMedical EventServices YouMay NeedYourCostIfYouUse aYourCostIfYouUseaLimitationsand ExceptionsNetworkProviderNon-NetworkProvider
Ifyou visit a healthcare provider'sofficeorclinic / Primarycare visit to treat an injury or illness / $30 copay/visit / 35% coinsurance / ------none------
Specialist visit / $30 copay/visit / 35% coinsurance / ------none------
Other practitioneroffice visit
(Chiropractic) / 15% coinsurance / 35% coinsurance / (12 visits per benefit period)
Other practitioneroffice visit
(Acupuncture) / NotCovered / Excluded Service
Preventivecare/ screening/
immunization / Nocharge / 35% coinsurance / ------none------
Ifyou have a test / Diagnostic test (x-ray) / 15% coinsurance / 35% coinsurance / ------none------
Diagnostic test (blood work) / 15% coinsurance / 35% coinsurance / ------none------
Imaging (CT/PETscans, MRIs) / 15% coinsurance / 35% coinsurance / ------none------
CommonMedical EventServices YouMay NeedYourCostIfYouUse aYourCostIfYouUseaLimitationsand Exceptions
NetworkProviderNon-NetworkProvider
Ifyou need drugstotreat yourillness orcondition
More informationabout prescriptiondrug coverageis available at MedMutual.com/SBC / Generic copay -retail /Rx / $8 / Does NotApply / Covers up to a 30-day supply
Generic copay -home delivery /Rx / $20 / Does NotApply / Covers up to a 90-day supply
Formularycopay -retail /Rx / $20 / Does NotApply / ------none------
Formularycopay -home delivery /Rx / $50 / Does NotApply / ------none------
Non-Formularycopay -retail /Rx / $40 / Does NotApply / ------none------
Non-Formularycopay -home delivery /Rx / $100 / Does NotApply / ------none------
Ifyou have outpatient surgery / Facility fee (e.g., ambulatory surgery center) / 15% coinsurance / 35% coinsurance / ------none------
Physician/surgeonfees (Outpatient) / 15% coinsurance / 35% coinsurance / ------none------
Ifyou need immediate medical attention / Emergencyroom services / $115 copay/visit / ------none------
Emergencymedical transportation / 15% coinsurance / 35% coinsurance / ------none------
Urgentcare / $30 copay/visit / 35% coinsurance / ------none------
Ifyou have a hospitalstay / Facility fee (e.g., hospital room) / 15% coinsurance / 35% coinsurance / ------none------
Physician/ surgeon fee (inpatient) / 15% coinsurance / 35% coinsurance / ------none------
Ifyou have mental health, behavioralhealth,or substanceabuse needs / Mental/Behavioralhealth outpatient services / Benefits paid based on correspondingmedical benefits / ------none------
Mental/Behavioralhealth inpatient services / Benefits paid based on correspondingmedical benefits / ------none------
Substance use disorderoutpatient services (alcoholism) / Benefits paid based on correspondingmedical benefits / ------none------
Substance use disorderoutpatient services (drug use) / Benefits paid based on correspondingmedical benefits / ------none------
Substance use disorderinpatient services (alcoholism) / Benefits paid based on correspondingmedical benefits / ------none------
Substance use disorderinpatient services (drug use) / Benefits paid based on correspondingmedical benefits / ------none------
CommonMedical EventServices YouMay NeedYourCostIfYouUse aYourCostIfYouUseaLimitationsand Exceptions
NetworkProviderNon-NetworkProvider
Ifyou arepregnant / Prenatal and postnatal care / 15% coinsurance / 35% coinsurance / ------none------
Deliveryand all inpatient services / 15% coinsurance / 35% coinsurance / ------none------
Ifyou need help recovering orhave otherspecial health needs / Home health care / 15% coinsurance / 35% coinsurance / ------none------
Rehabilitation services (Physical
Therapy) / 15% coinsurance / 35% coinsurance / (40 visits per benefit period, combined with Occupational Therapy)
Habilitation services (Occupational
Therapy) / 15% coinsurance / 35% coinsurance / (40 visits per benefit period, combined with Physical Therapy)
Habilitation services (Speech
Therapy) / 15% coinsurance / 35% coinsurance / (20 visits per benefit period)
Skilled nursing care / 15% coinsurance / 35% coinsurance / ------none------
Durable medical equipment / 15% coinsurance / 35% coinsurance / ------none------
Hospice service / 15% coinsurance / 35% coinsurance / (180 days per lifetime)
Ifyourchild needs dentalor eye care / Eye exam (Child) / Nocharge / 35% coinsurance / ------none------
Glasses / NotCovered / Excluded Service
Dental check-up (Child) / NotCovered / Excluded Service
ExcludedServices &OtherCoveredServices:
Services YourPlanDoesNOTCover(Thisisn'ta completelist.Checkyourpolicy orplan documentforotherexcludedservices.)
•Acupuncture
•Cosmetic Surgery
•Dental check-up (Child)
•Dental Care(Adult)
•Glasses
•Hearing Aids
•Infertility Treatment
•Long-TermCare
•Non-emergencycare whentraveling outside the
U.S.
•Routine Eye Care(Adult)
•Routine Foot Care
•Weight Loss Programs
Other CoveredServices (Thisisn'ta completelist.Checkyourpolicy orplan documentforothercoveredservices and yourcosts forthese services.)
•BariatricSurgery•ChiropracticCare•Private-DutyNursing
YourRightstoContinueCoverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage.Any such rights may be limited in duration and will require you to pay a premium,which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.
Formore information on your rights to continue coverage, contact the plan at 800.315.3137.Youmay also contact your state insurance department, the U.S.Department of Labor, Employee Benefits SecurityAdministrationat 866.444.3272 or the U.S.Department of Health and Human Servicesat 877.267.2323 X61565 or
YourGrievanceand AppealsRights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appealor file a grievance.Forquestions about your rights, this notice, or assistance, you can contact: the plan at 800.315.3137.
Doesthis CoverageProvideMinimum EssentialCoverage?
The AffordableCareAct requiresmost people to have health care coverage that qualifies as “minimum essential coverage.”This plan orpolicy does provideminimum essential coverage.
Doesthis CoverageMeet theMinimum ValueStandard?
The AffordableCareAct establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarialvalue). This health coverage
does meet theminimum value standardforthebenefitsitprovides.
------Tosee examples ofhow this plan might cover costsforsample medical situations,see the next page------
Aboutthese CoverageExamples:
These examples show howthis plan might cover medical care in given situations. Use these examples to see, in general, howmuch financial protection a sample patient might get if they are covered under different plans.
This is
nota cost estimator.
Don’t use these examples to
estimate your actual costs under this plan. The actual care you receive will be different from these examples,
and the cost of that care will also be different.
Seethe next page for important information about these examples.
Havinga baby
(normaldelivery)
n Amountowed toproviders:$7,540
n PlanPays $4,130
n PatientPays $3,410
Samplecare costs:
PatientPays:
ManagingType 2 diabetes
(routine maintenance of
a well-controlledcondition)
n Amountowed toproviders:$5,400
n PlanPays $4,760
n PatientPays $640
Samplecare cost:
Prescriptions / $2,900Medical Equipment and Supplies
Office Visits and Procedure
Education
Laboratorytests Vaccines, other preventive / $1,300
$700
$300
$100
$100
Total$5,400
PatientPays:
These numbers assume that the patient does not use an
HRAor FSA.If you participate in an HRAor FSAand use it to pay for out-of-pocketexpenses, then your costs may be lower. Formore information about your HRAor FSA,please contact your employer group.
QuestionsandanswersaboutCoverageExamples:
Whataresome ofthe assumptionsbehindthe CoverageExamples?
•Costs don’t include premiums.
•Sample care costs are based on national averages supplied by the U.S.Department of Health and Human Services,and aren’t specific to a particulargeographic area or health plan.
•Patient’s condition was not an excluded or preexisting condition.
•All services and treatments started and ended in the same coverage period.
•There are no other medical expenses for any member covered under this plan.
•Out-of-pocketexpenses are based only on treating the condition in the example.
•The patient received all care from in-network providers.If the patient had received care from out-of-network providers,costs would have been higher.
Whatdoes a CoverageExample show?
Foreach treatment situation, the Coverage Example helps you see how deductibles, copayments,and coinsurancecan add up. It
also helps you see whatexpenses might be left
up to you to pay because the service or treatment isn’t covered or payment is limited.
DoestheCoverageExample predictmy own care needs?
No.Treatmentsshown are just examples.
The care you would receive for this condition could be different, based on
your doctor’s advice, your age, howserious your condition is, and many other factors.
DoestheCoverageExample predictmy futureexpenses?
No.Coverage Examples are notcost
estimators. Youcan’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your owncosts will be different depending on
the care you receive, the prices your
providerscharge, and the reimbursement your health plan allows.
CanI use CoverageExamples tocompareplans?
Yes.When you look at the Summariesof
Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box on each example. The smaller that number, the more coverage the plan provides.
Arethereothercosts I should considerwhen comparing plans?
Yes. Animportant cost is the premium
you pay. Generally, the loweryour
premium,the more you’ll pay in out-of-pocket costs, such as copayments,
deductibles, and coinsurance. You
should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements(FSAs)or health reimbursementaccounts (HRAs)
that help you pay out-of-pocketexpenses.