Page 20 - QCS.19 Employee Benefits

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For

Plan HP28503060 : All Savers Alternate Funding

The Summary of Benefits and Coverage (SBC) document will help you
share the cost for covered health care services. NOTE: Information ab

This is only a summary. For more information about your coverage, or to get a co
https://www.myallsavers.com/MyAllSavers/Plan or by calling 1-800-291-2634. For
coinsurance, copayment, deductible, provider, or other underlined terms see the Gl
1-800-291-2634 to request a copy.

Important Questions Answers Why This Matt

What is the overall $2,850 /individual network Generally, you
deductible? plan begins to p
$5,700 /family network or
$5,700 /individual out-of-network If you have othe
individual dedu
$11,400 /family out-of-network meets the over
Copayments and coinsurance
don’t count toward the deductible.

Are there services Yes. Preventive care services are This plan cover
amount. But a c
covered before you meet covered before you meet your preventive servi
covered preven
your deductible? deductible.
You don’t have
Are there other No.
deductibles for specific The out-of-pock
services? For network providers $6,550 If you have oth
individual / $13,100 family; for out-of-pocket li
What is the out-of-pocket out-of-network providers $11,400
limit for this plan? individual / $22,800 family

What is not included in Premiums, balance-billed charges,
the out-of-pocket limit?
and health care this plan doesn’t Even though yo
cover.

Will you pay less if you Yes. See www.myallsavers.com This plan uses
use a network provider? You will pay the
or call 1-800-291-2634 for a list of
network providers. provider for the
billing). Be awa
(such as lab wo

Do you need a referral to No. You can see the