Dean PPO Summary of Benefits & Coverage

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, deancare.com/healthinsurance/group-plans-for-employers/sample-group-certificates/ or call (800)-279-1301 (TTY: 711).

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 (800)-279-1301 (TTY: 711) to request a copy.

Coverage Period

Coverage Period: 7/1/2025-6/30/2026
Coverage for: Individual/Family
Plan Type: PPO

Important Questions	Answers	Why this Matters:
What is the overall deductible?	$100 / individual network $200 / family network $250 / individual out of-network $500 / family out-of network	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.
Are there services covered before you meet your deductible?	Yes. Preventive care and preventive prescriptions from network providers are covered before you meet your deductible.	This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles for specific services?	No.	You don’t have to meet deductibles for specific services
What is the out-of-pocket limit for this plan?	For network providers $4,600 individual / $9,200 family. For out of-network providers $6,900 individual / $13,800 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 limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit?	Premiums, balance billing charges, penalties for failure to obtain prior authorization, and health care this plan doesn‘t cover.	Even though you pay these expenses, they don‘t count toward the out-of-pocket limit.
Will you pay less if you use a network provider?	Yes. See deancare.com/find-adoc/ or call (800)-279-1301 (TTY: 711) for a list of network providers.	This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist?	No.	You can see the specialist you choose without a referral.

Common Medical Events and What You Will Pay

If you visit a health care provider's office or clinic

Services You May Need?	What You Will Pay: In Network (You will pay the least)	What You Will Pay: Out of Network (You will pay the most)	Limitations, Exceptions, & Other Important Information
Primary care visit to treat an injury or illness	$20 copay/visit and/or 0% coinsurance after deductible	20% coinsurance after deductible	No coverage for Chiropractic maintenance or long-term therapy.
Specialist visit	$20 copay/visit and/or 0% coinsurance after deductible	20% coinsurance after deductible	Infertility services are covered at 50% of $4,000 lifetime maximum.
Preventive care/ screening/immunization	No charge	20% coinsurance after deductible	Services under the Affordable Care Act (ACA) guidelines will be covered as preventive. Services may have a limit on number of visits and/or specific age requirements. For additional information please see the Preventive Services section in your Member Certificate. You may have to pay for services that are not preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Limited to one physical exam/year, unless additional visits are necessary.

Services You May Need?

What You Will Pay:

In Network (You will pay the least)

What You Will Pay:

Out of Network (You will pay the most)

Limitations, Exceptions, & Other Important Information

Primary care visit to treat an injury or illness

$20 copay/visit and/or 0% coinsurance after
deductible

20% coinsurance after
deductible

No coverage for Chiropractic maintenance or long-term therapy.

Specialist visit

$20 copay/visit and/or
0% coinsurance after
deductible

20% coinsurance after
deductible

Infertility services are covered at 50% of $4,000 lifetime maximum.

Preventive care/ screening/immunization

No charge

20% coinsurance after
deductible

Services under the Affordable Care Act (ACA) guidelines will be covered as preventive. Services may have a limit on number of visits
and/or specific age requirements. For
additional information please see the
Preventive Services section in your Member
Certificate. You may have to pay for services
that are not preventive. Ask your provider if the
services needed are preventive. Then check
what your plan will pay for. Limited to one
physical exam/year, unless additional visits are
necessary.

If you have a test

Services You May Need?	What You Will Pay: In Network (You will pay the least)	What You Will Pay: Out of Network (You will pay the most)	Limitations, Exceptions, & Other Important Information
Diagnostic test (x-ray, blood work)	0% coinsurance after deductible	20% coinsurance after deductible	Certain covered diagnostic tests and/or imaging may require written prior authorization from us. Failure to obtain prior authorization for services will result in a penalty of 50% of the allowed amount, up to a $500 maximum per occurrence.
Imaging (CT/PET scans, MRIs)	0% coinsurance after deductible	20% coinsurance after deductible	Certain covered diagnostic tests and/or imaging may require written prior authorization from us. Failure to obtain prior authorization for services will result in a penalty of 50% of the allowed amount, up to a $500 maximum per occurrence.

Services You May Need?

What You Will Pay:

In Network (You will pay the least)

What You Will Pay:

Out of Network (You will pay the most)

Limitations, Exceptions, & Other Important Information

Diagnostic test (x-ray, blood work)

0% coinsurance after
deductible

20% coinsurance after
deductible

Certain covered diagnostic tests and/or imaging may require written prior authorization from us. Failure to obtain prior authorization for services will result in a penalty of 50% of the allowed amount, up to a $500 maximum per occurrence.

Imaging (CT/PET scans, MRIs)

0% coinsurance after
deductible

20% coinsurance after
deductible

If you need drugs to treat your illness or condition

Services You May Need?	What You Will Pay: In Network (You will pay the least)	What You Will Pay: Out of Network (You will pay the most)	Limitations, Exceptions, & Other Important Information
Generic	$6 copay /prescription (retail); Mail order maintenance prescriptions, a 90-day supply for 2 copays.	50% coinsurance /prescription (retail)	None
Preferred brand drugs	$15 copay /prescription (retail); Mail order maintenance prescriptions, a 90-day supply for 3 copays.	50% coinsurance /prescription (retail)	None
Non-preferred brand drugs	$30 copay /prescription (retail); Mail order maintenance prescriptions, a 90-day supply for 3 copays.	Not Covered (retail and mail order)	None
Specialty drugs	50% coinsurance for infertility drugs / prescription (retail)	Not Covered (retail and mail order)	None

If you have outpatient surgery

Services You May Need?	What You Will Pay: In Network (You will pay the least)	What You Will Pay: Out of Network (You will pay the most)	Limitations, Exceptions, & Other Important Information
Facility fee (e.g., ambulatory surgery center)	0% coinsurance after deductible	20% coinsurance after If you have outpatient deductible	Outpatient hospital services require a written prior authorization from us. Failure to obtain prior authorization for services will result in a penalty of 50% of the allowed amount, up to a $500 maximum per occurrence.
Physician/surgeon fees	0% coinsurance after deductible	20% coinsurance after If you have outpatient deductible	Outpatient hospital services require a written prior authorization from us. Failure to obtain prior authorization for services will result in a penalty of 50% of the allowed amount, up to a $500 maximum per occurrence.

Services You May Need?

What You Will Pay:

In Network (You will pay the least)

What You Will Pay:

Out of Network (You will pay the most)

Limitations, Exceptions, & Other Important Information

Facility fee (e.g., ambulatory
surgery center)

0% coinsurance after
deductible

20% coinsurance after
If you have outpatient deductible

Outpatient hospital services require a written prior authorization from us. Failure to obtain
prior authorization for services will result in a
penalty of 50% of the allowed amount, up to a
$500 maximum per occurrence.

Physician/surgeon fees

0% coinsurance after
deductible

20% coinsurance after
If you have outpatient deductible

If you need immediate medical attention

Services You May Need?	What You Will Pay: In Network (You will pay the least)	What You Will Pay: Out of Network (You will pay the most)	Limitations, Exceptions, & Other Important Information
Emergency room care	$150 copay/visit and/or 0% coinsurance after deductible	$150 copay/visit and/or 0% coinsurance after in-network deductible	Copay is waived if admitted for observation or inpatient.
Emergency medical transportation	0% coinsurance after deductible	0% coinsurance after innetwork deductible	None
Urgent care	$20 copay/visit and/or 0% coinsurance after deductible	$20 copay/visit and/or 0% coinsurance after in-network deductible	None

Services You May Need?

What You Will Pay:

In Network (You will pay the least)

What You Will Pay:

Out of Network (You will pay the most)

Limitations, Exceptions, & Other Important Information

Emergency room care

$150 copay/visit and/or 0% coinsurance after
deductible

$150 copay/visit and/or 0% coinsurance after in-network
deductible

Copay is waived if admitted for observation or
inpatient.

Emergency medical transportation

0% coinsurance after
deductible

0% coinsurance after innetwork
deductible

None

Urgent care

$20 copay/visit and/or
0% coinsurance after
deductible

$20 copay/visit and/or 0%
coinsurance after in-network
deductible

None

If you have a hospital stay

Services You May Need?	What You Will Pay: In Network (You will pay the least)	What You Will Pay: Out of Network (You will pay the most)	Limitations, Exceptions, & Other Important Information
Facility fee (e.g., hospital room)	0% coinsurance after deductible	20% coinsurance after deductible	Inpatient hospital services require a written prior authorization from us. Failure to obtain prior authorization for services will result in a penalty of 50% of the allowed amount, up to a $500 maximum per occurrence.
Physician/surgeon fees	0% coinsurance after deductible	20% coinsurance after deductible	Inpatient hospital services require a written prior authorization from us. Failure to obtain prior authorization for services will result in a penalty of 50% of the allowed amount, up to a $500 maximum per occurrence.

Services You May Need?

What You Will Pay:

In Network (You will pay the least)

What You Will Pay:

Out of Network (You will pay the most)

Limitations, Exceptions, & Other Important Information

Facility fee (e.g., hospital room)

0% coinsurance after
deductible

20% coinsurance after
deductible

Inpatient hospital services require a written prior authorization from us. Failure to obtain prior authorization for services will result in a penalty of 50% of the allowed amount, up to a $500 maximum per occurrence.

Physician/surgeon fees

0% coinsurance after
deductible

20% coinsurance after
deductible

If you need mental health, behavioral health, or substance abuse services

Services You May Need?	What You Will Pay: In Network (You will pay the least)	What You Will Pay: Out of Network (You will pay the most)	Limitations, Exceptions, & Other Important Information
Outpatient services	$20 copay/office visit 0% coinsurance after deductible for other outpatient services	20% coinsurance after deductible	None
Inpatient services	0% coinsurance after deductible	20% coinsurance after deductible	Inpatient mental health services require a written prior authorization from us. Failure to obtain prior authorization for services will result in a penalty of 50% of the allowed amount, up to a $500 maximum per occurrence.

Services You May Need?

What You Will Pay:

In Network (You will pay the least)

What You Will Pay:

Out of Network (You will pay the most)

Limitations, Exceptions, & Other Important Information

Outpatient services

$20 copay/office visit
0% coinsurance after
deductible for other
outpatient services

20% coinsurance after
deductible

None

Inpatient services

0% coinsurance after
deductible

20% coinsurance after
deductible

Inpatient mental health services require a written prior authorization from us. Failure to
obtain prior authorization for services will result
in a penalty of 50% of the allowed amount, up
to a $500 maximum per occurrence.

If you are pregnant

Services You May Need?	What You Will Pay: In Network (You will pay the least)	What You Will Pay: Out of Network (You will pay the most)	Limitations, Exceptions, & Other Important Information
Office visits	0% coinsurance after deductible	20% coinsurance after deductible	Home or intentional out of hospital deliveries are not covered. Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).
Childbirth/delivery professional services	0% coinsurance after deductible	20% coinsurance after deductible	Home or intentional out of hospital deliveries are not covered. Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).
Childbirth/delivery facility services	0% coinsurance after deductible	20% coinsurance after deductible	Home or intentional out of hospital deliveries are not covered. Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound).

Services You May Need?

What You Will Pay:

In Network (You will pay the least)

What You Will Pay:

Out of Network (You will pay the most)

Limitations, Exceptions, & Other Important Information

Office visits

0% coinsurance after
deductible

20% coinsurance after
deductible

Home or intentional out of hospital deliveries are not covered. Cost sharing does not apply
for preventive services. Depending on the type
of services, a copayment, coinsurance, or
deductible may apply. Maternity care may
include tests and services described
elsewhere in the SBC (i.e., ultrasound).

Childbirth/delivery professional services

0% coinsurance after
deductible

20% coinsurance after
deductible

Childbirth/delivery facility services

0% coinsurance after
deductible

20% coinsurance after
deductible

If you need help recovering or have other special health needs

Services You May Need?	What You Will Pay: In Network (You will pay the least)	What You Will Pay: Out of Network (You will pay the most)	Limitations, Exceptions, & Other Important Information
Home health care	0% coinsurance after deductible	20% coinsurance after deductible	60 visits/contract period. Services for home health require a written prior authorization from us. Failure to obtain a prior authorization for services will result in a penalty of 50% of the allowed amount, up to a $500 maximum per occurrence.
Rehabilitation services	0% coinsurance after deductible	20% coinsurance after deductible	Inpatient Rehabilitation Care - 90 days/contract period. Physical, Occupational and Speech Therapy - 60 visits/contract period. Services for custodial care are a policy exclusion. Services for rehabilitation care and Physical, Occupational and Speech Therapy require a written prior authorization from us. Failure to obtain prior authorization for services will result in a penalty of 50% of the allowed amount, up to a $500 maximum per occurrence.
Habilitation services	0% coinsurance after deductible	20% coinsurance after deductible	Habilitative therapies - 60 visits/contract period. Services for custodial care are a policy exclusion. Habilitation services require written prior authorization from us. Failure to obtain prior authorization for services will result in a penalty of 50% of the allowed amount, up to a $500 maximum per occurrence.
Skilled nursing care	0% coinsurance after deductible	20% coinsurance after deductible	30 days/confinement. Services for skilled nursing require a written prior authorization from us. Failure to obtain prior authorization for services will result in a penalty of 50% of the allowed amount, up to a $500 maximum per occurrence.
Durable medical equipment	0% coinsurance after deductible	50% coinsurance after deductible; not subject to out-of-pocket maximum	Durable medical equipment as stated in our medical policies requires prior authorization from us. Failure to obtain prior authorization for services will result in a penalty of 50% of the allowed amount, up to a $500 maximum per occurrence.
Hospice services	0% coinsurance after deductible	20% coinsurance after deductible	Services for hospice require a written prior authorization from us. Failure to obtain prior authorization for services will result in a penalty of 50% of the allowed amount, up to a $500 maximum per occurrence.

If your child needs dental or eye care

Services You May Need?	What You Will Pay: In Network (You will pay the least)	What You Will Pay: Out of Network (You will pay the most)	Limitations, Exceptions, & Other Important Information
Children’s eye exam	$20 copay/visit and/or 0% coinsurance after deductible	20% coinsurance after deductible	None
Children’s glasses	Not Covered	Not Covered	None
Children’s dental check-up	Not Covered	Not Covered	None

Services You May Need?

What You Will Pay:

In Network (You will pay the least)

What You Will Pay:

Out of Network (You will pay the most)

Limitations, Exceptions, & Other Important Information

Children’s eye exam

$20 copay/visit and/or
0% coinsurance after
deductible

20% coinsurance after
deductible

None

Children’s glasses

Not Covered

None

Children’s dental check-up

Not Covered

None

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Dean PPO Summary of Benefits & Coverage

Coverage Period

Common Medical Events and What You Will Pay

If you visit a health care provider's office or clinic

If you have a test

If you need drugs to treat your illness or condition

If you have outpatient surgery

If you need immediate medical attention

If you have a hospital stay

If you need mental health, behavioral health, or substance abuse services

If you are pregnant

If you need help recovering or have other special health needs

If your child needs dental or eye care

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