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 the maximum, any amounts you owe in addition Even though you pay these expenses, they don’t count toward the out-of-pocket out-of-pocket limit? to your copayment for covered services, and limit. [...] You will pay the most if you use an out-of-network provider, and you Will you pay less if you use a network provider? or call 1-800-776-4672 for a list of network might receive a bill from a provider for the difference between the provider’s charge providers. [...] attention Urgent care $45 copay/visit; deductible does not apply 50% coinsurance ---none--- Facility fee (e.g., hospital room) 30% coinsurance 50% coinsurance ---none--- If you have a Physician Visits $45 copay/visit; deductible does hospital stay not apply 50% coinsurance ---none--- Surgeon fee 30% coinsurance (cutting) 50% coinsurance (cutting) ---none--- 30% coinsurance (non-cutting) 50% coinsu. [...] 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.