Page 7 - QCS.19 Employee Benefits

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

Plan P25003060e : 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 $2,500 /individual network Generally, you
deductible? plan begins to p
$5,000 /family network or
$5,000 /individual out-of-network

$10,000 /family out-of-network
Copayments and coinsurance
don’t count toward the deductible.

Are there services Yes. Preventive care services are This plan cover
covered before you meet covered before you meet your amount. But a c
your deductible? deductible. preventive servi
covered preven
Are there other No.
deductibles for specific You don’t have
services? For network providers $5,000
individual / $10,000 family; for out- The out-of-pock
What is the out-of-pocket of-network providers $10,000
limit for this plan? individual / $20,000 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