Page 8 - QCS.19 Employee Benefits

r Covered Services Coverage Period: 02/01/2019 - 01/31/2020

Coverage for: Individual | Plan Type: PPO

u choose a health plan. The SBC shows you how you and the plan would
bout the cost of this plan (called the premium) will be provided separately.

opy of the complete terms of coverage, visit us at
general definitions of common terms, such as allowed amount, balance billing,
lossary. You can view the Glossary at www.dol.gov/ebsa/healthreform.com or call

ters:

must pay all of the costs from providers up to the deductible amount before this
pay.

rs some items and services even if you haven’t yet met the annual deductible
copayment or coinsurance mayapply. For example, this plan covers certain
vices without cost-sharing and before you meet your deductible. See a list of
ntive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.

to meet deductibles for specific services.

ket limit is the most you could pay in a year for covered services.

ou pay these expenses, they don’t count toward the out-of-pocket limit.

a provider network. You will pay less if you use a provider in the plan’s network.
e most if you use an out-of-network provider, and you might receive a bill from a
difference between the provider’s charge and what your plan pays (balance
are, your network provider might use an out-of-network provider for some services
ork). Check with your provider before you get services.
e specialist you choose without a referral.

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