Minimum Value 6500

Medical Benefits

This form is a benefit highlight representing a brief description of the coverage available. Additional covered services, exclusions and limitations exist. Specific services including inpatient hospital, maternity and outpatient surgery are subject to precertification.

Annual Deductible/Out-of-Pocket Maximum

$6,500 individual / $13,000 family

The out-of-pocket maximum refers to covered services only. Specific services, including emergency and hospital services, are subject to reference-

based pricing (see definition below) and patients may be billed beyond the out-of-pocket maximum for these services.

Preventative/Wellness

Covered 100%

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Primary Care/Specialist Visits

$50

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Urgent Care

Covered 100% after deductible is met

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Emergency Services (excludes ambulance)

Reference-Based Pricing after deductible is met

Reference-Based Pricing (see definition below)

Diagnostic Services including Labs, X-Rays and other Imaging

Covered 100% after deductible is met

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Inpatient Hospital Services including Physician Fees

Reference-Based Pricing after deductible is met

Reference-Based Pricing (see definition below)

Outpatient Hospital Services

Not Covered

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All additional covered services

Covered 100% after deductible is met

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Telemedicine

Included

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Reference-based pricing reimburses providers using a percentage of Medicare coverage as the reference point for the reimbursement total. The MV 6500 plan pays up to 125% of the Medicare allowable coverage for applicable services. Patients will be responsible for paying any remaining balance beyond the provider reimbursement total. For additional information regarding reference-based pricing, please contact a SBMA representative at 1.888.505.7724 option 2.