Page 33 - USUI Benefit Book

deductible amount. out-of-pocket limit. plan pays 1 of 8 SBC000004111460
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call 1-888-605-2566. For
Coverage Period: Beginning on or after 01/01/2019
general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary.
Coverage for: Individual/Family | Plan Type: PPO

Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/covera

family members meets the overall family deductible. overall family out-of-pocket limit has been met. You can see the specialist you choose without a referral.

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. bill from a provider
This plan Are there services covered before Yes. Preventive care services are covered But a copayment or coinsurance may apply. For example, this plan covers certain preventive

Out-of-Network $500 Individual/ $1,000 Family $13,200 Individual/ $26,400 Family
Usui International Corporation

Answers
PPO Premium Plan, Rx 1 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-888-605-2566 to request a copy. In-Network $200 Individual/ $400 Family before you meet your deductible. No. $5,000 Individual/ $10,000 Family Premiums, balance-billing charges, any pharmacy penalty and health care this plan Yes. For a list of n

Important Questions What is the overall deductible? you meet your deductible? Are there other deductibles for What is the out-of-pocket limit for (May include a coinsurance What is not included in the out-of- Will you pay less if you use a Do you need a referral to see a Group Number 71505-1001-011

specific services? pocket limit? network provider?

this plan? maximum) specialist?