Attachment 4_SFC SBC PHS PPO 2025

Description

Summary of Benefits and Coverage: What this Plan Covers and What You Pay for Covered Services Santa Fe County PPO Coverage Period: 01/01/2025 - 12/31/2025 Coverage for: Individual or Family | Plan Type: PPO 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 What is the overall deductible? Are there services covered before you meet your deductible? Answers In-network: $500 Individual / $1,000 Double / $1,500 Family Out-of-network: $2,800 Individual / $5,600 Double / $8,400 Family 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 family members meets the overall family 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 In-network: $3,500 Individual / $7000 2-party / $10,500 Family What is the out-of-pocket Out-of-network: $7,000 limit for this plan? Individual / $14000 2-party / $21,000 Family What is not included in the out-of-pocket limit? Why This Matters: Premiums, balance billing charges, health care this plan doesn't cover, and penalty amounts. You must pay all the Pharmacy costs up to the deductible amount before this plan begins to pay for covered services you use.