Summary of Benefits and Coverage: Coverage Period: 01/01/202 – 12/31/202 HMSA Individual Metallic Gold HMO Coverage for:Plan Type:

The SBC shows you how you and the plan would share the cost for covered health care services. [...] See Will you pay less if you might receive a bill from a provider for the difference between the provider’s charge or call 1-800-776-4672 for a list of network use a network provider? and what your plan pays (balance billing). [...] Common Medical Services You May Need What You Will Pay Limitations, Exceptions, & Other Event Network Provider Out-of-Network Provider Important Information (You will pay the least) (You will pay the most) Primary care visit to treat an injury $15 copay/visit; deductible Not covered ---none--- or illness does not apply $30 copay/visit; deductible Specialist visit Not covered ---none--- does not ap. [...] If you visit a health $15 copay/visit; deductible care provider’s Psychologist Not covered ---none--- does not apply office or clinic $15 copay/visit; deductible Nurse Practitioner Not covered ---none--- does not apply Preventive care (Well Child No charge; deductible does not Age and frequency limitations may Not covered Physician Visit) apply apply. [...] 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.