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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services <br />HealthPartners:$2400-100% HSA Gold SE Open Access Coverage for: Single/Family | Plan Type: PPO <br /> <br /> <br />1 of 6 <br /> <br />PSBC-SL313-230101-E <br />79888MN0250142-00 <br /> <br /> <br />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 <br />share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. <br />This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-800-883-2177 or visit us at <br />www.healthpartners.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment , deductible, provider, or other <br />underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc -glossary or call 1-800-883-2177 to request a copy. <br /> <br />Important Questions Answers Why This Matters: <br />What is the overall <br />deductible? <br />In-network: $2,400 Individual/ $4,800 <br />Family <br />Out-of -network: $10,000 Individual/ <br />$20,000 Family <br />Generally, you must pay all of the costs from providers up to the deductible, amount <br />before this plan begins to pay. If you have other family members on the plan, the overall <br />family deductible must be met before the plan begins to pay. <br />Are there services covered <br />before you meet your <br />deductible? <br />Yes,some preventive care services are <br />covered before you meet your <br />deductible. <br />This plan covers some items and services even if you haven’t yet met the deductible. <br />amount. But a copayment or coinsurance may apply. For example, this plan covers <br />certain preventive s ervices without cost-sharing and before you meet your deductible. <br />See a list of covered preventive services at <br />https://www.healthcare.gov/coverage/preventive-care-benefits/. <br />Are there other deductibles <br />for specific services? <br />There are no other specific <br />deductibles. You don't have to meet deductibles for specific services. <br />What is the out-of-pocket <br />limit for this plan? <br />In-network medical/pharmacy: $2,400 <br />Individual/$4,800 Family <br />Out-of -network medical/pharmacy: <br />$30,000 Individual/$60,000 Family <br />The out -of -pocket limit is the most you could pay in a year for covered services. If you <br />have other family members in this plan, the overall family out -of -pocket limit must be <br />met. <br /> <br />Coverage beginning on or after 1/1/2023