Why This Matters-No Answers

Insurance Company 1: Plan Option 1 Coverage Period: 1/1/2016 – 12/31/2016

S ummary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual | Plan Type: PPO

This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, [insert contact information]. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other bolded terms see the Glossary. You can view the Glossary at www.[insert].com or call 1-800-[insert] to request a copy.

Important Questions	Answers	Why this Matters:
What is the overall deductible?	$	See the Common Medical Events chart below for your costs for services this plan covers.
Are there other deductibles for specific services?	No.	You don’t have to meet deductibles for specific services.
Is there an out-of-pocket limit on my expenses?	No.	There’s no limit on how much you could pay during a coverage period for your share of the cost of covered services.
What is not included in the out-of-pocket limit?	This plan has no out-of-pocket limit.	Not applicable because there’s no out-of-pocket limit on your expenses.
Does this plan use a network of providers?	No.	This plan treats providers the same in determining payment for the same services.
Do I need a referral to see a specialist?	No. To see a specialist, you don’t need a referral from this plan.	You can see the specialist you choose without getting permission from this plan.

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