Summary of Benefits Coverage

The SBC shows you how you and the plan would share the cost for covered health care services. [...] Premiums, balance-billed charges, payments for What is not included in the services subject to a maximum once you reach Even though you pay these expenses, they don’t count toward the out-of-pocket out-of-pocket limit? the maximum, any amounts you owe in addition to your copayment for covered services, and limit. [...] This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. [...] Formulary Specialty drugs (retail) 30% coinsurance Not covered Tier 4 & 5 (mail order) Not covered Not covered Facility fee (e.g., ambulatory surgery center) 20% coinsurance Not covered ---none--- If you have Physician Visits $10 copay/visit Not covered ---none--- outpatient surgery Surgeon fees 10% coinsurance (cutting) Not covered (cutting) ---none--- 10% coinsurance (non-cutting) Not covered (n. [...] 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.