Summary of BeneSBC 201of7SummaryofBenefitsandCoverageWhatthisPlanCoversWhatYouPayForCoveredServicesChoicePlusBUZU2VCoveragePeriodCoverageforEmployeeFamilyPlanTypePOSTheSummaryofBenefitsandCoverageS ID: 880260
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1 S umma r y of Bene fits and Coverage (
S umma r y of Bene fits and Coverage ( SBC) | 20 1of7SummaryofBenefitsandCoverage:WhatthisPlanCovers&WhatYouPayForCoveredServices ChoicePlusBUZU/2V CoveragePeriod:Coveragefor:Employee/Family|PlanType:POS TheSummaryofBenefitsandCoverage(SBC)docume
2 ntwillhelpyouchooseahealthplan TheSBCsho
ntwillhelpyouchooseahealthplan TheSBCshowsyouhowyouandtheplan wouldsharethecostforcoveredhealthcareservices.NOTE:Informationaboutthecostofthisplan (calledthepremium )willbeprovidedseparately.Thisisonlyasummary.Formoreinformationaboutyourcoverage,ort
3 ogetacopyofthecompletetermsofcoverage,vi
ogetacopyofthecompletetermsofcoverage,visitwww.welcometouhc.comorbycalling1-800-782-3740.Forgeneraldefinitionsofcommonterms,suchasallowed amount ,balance billing ,coinsurance ,copayment ,deductible ,provider ,orotherunderlined termsseetheGlossary.Yo
4 ucanviewtheGlossaryatwww.healthcare.gov/
ucanviewtheGlossaryatwww.healthcare.gov/sbc-glossaryorcall1-866-487-2365torequestacopy. WhyThisMatters: Whatistheoverall ?Network :$1,000Individual/$2,000Family :$5,000Individual/$10,000Percalendaryear.Generally,youmustpayallofthecostsfromproviders
5 uptothedeductible amountbeforethisplan b
uptothedeductible amountbeforethisplan beginstopay.Ifyouhaveotherfamilymembersonthe ,eachfamilymembermustmeettheirownindividualdeductible untilthetotalamountofdeductible expensespaidbyallfamilymembersmeetstheoverallfamily . Arethereservicescoveredbe
6 foreyoumeetyour Yes.Preventivecare andca
foreyoumeetyour Yes.Preventivecare andcategorieswithacopay arecoveredbeforeyoumeetyourdeductible Thisplan coverssomeitemsandservicesevenifyouhaven'tyetmetthedeductible amount.Butacopayment orcoinsurance mayapply.Forexample,thisplan certainpreventive
7 services withoutcost-sharing andbeforeyo
services withoutcost-sharing andbeforeyoumeetyour .Seealistofcoveredpreventiveservices atwww.healthcare.gov/coverage/preventive-care-benefits/. Arethereother specificservices? forspecificservices. Whatisthe limit forthisplan ?Network :$7,900Individu
8 al/$15,800Family :$15,000Individual/$30,
al/$15,800Family :$15,000Individual/$30,000Theout-of-pocket limit isthemostyoucouldpayinayearforcoveredservices.Ifyouhaveotherfamilymembersinthisplan ,theyhavetomeettheirown limits untiltheoverallfamilyout-of-pocket limit hasbeenmet. Whatisnotinclud
9 edintheout-of-pocket limit ?Premiums ,ba
edintheout-of-pocket limit ?Premiums ,balance-billing charges,healthcarethisplan doesn'tcoverandpenaltiesforfailuretoobtainpreauthorization forservices.Eventhoughyoupaytheseexpenses,theydon'tcounttowardtheout-of-pocket limit . Willyoupaylessifyouuse
10 anetwork provider Yes.Seewww.welcometouh
anetwork provider Yes.Seewww.welcometouhc.comorcall1-800-782-3740foralistofnetwork providers Thisplan usesaprovider network .Youwillpaylessifyouuseaprovider inthe network provider ,andyoumightreceiveabillfromaprovider forthedifferencebetweentheprovi
11 der's chargeandwhatyourplan pays(balance
der's chargeandwhatyourplan pays(balance billing) .Beaware,yournetwork provider mightuseanout-of-network provider forsomeservices(suchaslabwork).Checkwithyourprovider beforeyougetservices. Doyouneeda toseea Youcanseethespecialist youchoosewithoutare