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|[pic] |This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.[insert] or by calling 1-800-[insert]. |

|Important Questions |Answers |Why this Matters: |
|What is the overall deductible? |$ | |
|Are there other |$ | |
|deductibles for specific services? | | |
|Is there an out–of–pocket limit on my |$ | |
|expenses? | | |
|What is not included in | | |
|the out–of–pocket limit? | | |
|Is there an