Attachment 3_SFC SBC PHS HMO 2025

Description

Summary of Benefits and Coverage: What this Plan Covers and What You Pay for Covered Services Santa Fe County HMO Coverage Period: 01/01/2025 - 12/31/2025 Coverage for: Individual or Family | Plan Type: HMO 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. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-855-593-7737 or visit www.phs.org. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call 1-855-593-7737 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? Generally, you must pay all of the costs from providers up to the deductible amount before this plan $325 Single / $650 Two-person 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 family members / $975 Family meets the overall family deductible. Are there services covered before you meet your deductible? This plan covers some items & services even if you haven't met the deductible amount. But a Yes. Preventive care is covered copayment or coinsurance may apply. For example, this plan covers certain preventive care without before you meet your cost sharing and before you meet your deductible. See a list of covered preventive services at deductible. www.healthcare.gov/coverage/preventive-care-benefits. Are there other deductibles Yes. $50 Single $100 Twofor specific services? Person/Family You must pay all the Pharmacy costs up to the deductible amount before this plan begins to pay for covered services you use. What is the out-of-pocket limit for this plan? $3,500 Single/$7,000 Twoperson/$10,500 Family. The out of pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out of pocket limit until the overall family out of pocket limit has been met.