Summary of Benefits and Coverage: Coverage Period: 01/01/202 – 12/31/202 HMSA: Catastrophic PlanCoverage for:Plan Type: The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wou

Tier 4 & 5 (mail order) Not covered Not covered Facility fee (e.g., ambulatory No charge No charge ---none--- surgery center) First 3 primary care provider office visits: $35 copay/visit; If you have deductible does not apply outpatient Physician Visits No charge ---none--- surgery All remaining physician visits: No charge No charge (cutting) No charge (cutting) ---none--- Surgeon fees No charge (. [...] Urgent care No charge No charge ---none--- If you have a Facility fee (e.g., hospital room) No charge No charge ---none--- 4 of 8 2021 CATASTROPHIC PLAN . [...] No charge No charge pregnant services Maternity care may include Childbirth/delivery facility tests and services described elsewhere in the No charge No charge services SBC (i.e. [...] recovering or have other No charge (DME) No charge (DME) special health needs No charge (PT/OT outpatient) No charge (PT/OT outpatient) Services may require preauthorization. [...] Does this Coverage Meet the Minimum Value Standard? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.