EFTA00316296.pdf

EFTA00316296 SOUTHERN TRUST COMPANY 6100 RED HOOK QUARTER,B-3 ST THOMAS V1 00802-0000 N e.01 teI r; i r§ i UnitedHealthcare i I) 21 ; •cr g 0 Cr t13 :Ft Ia; >002669 7080107 003082 E§ J.EPSTEIN 6100 RED HOOK QUARTER B-3 co s n, la ST THOMAS VI 00802-0000 5. yy 1C ELL 03082 7080107 0000 0002669 ono2,0.9 3519 716 EFTA00316297  Thank you for bong a UnitedHealexare Ineffibte We are proud to serve yOu. Your Unkeelealthcare health plan identification OD) Card a attathatt. Meade Chen yon card to be are all inforrnstiOn is ccerect. If not, please let us know by oiling the member number on the card. You may begin using your cord on your effective data. Remember to lake yOur ID card to yon aPPonffnentS and have i ready if you call us with quasions. Sign up for myuhc.come and download the UndedHeashcare Healthekles move Opp to find toots and infOrrnaban to help you manage your health and benefits at home and on the go. You can fnd network doctors. track and bey esueate coils. and more. You can even view. download or print a copy Of year ID Card. Wete here to help. If you have questions. reit rnyuhccom or call the toll-tree mentor phone number on year ID card. TTY users can dial lit TO/10 0c9t00 z00000 LOT000t 0000000 699Z00 Greens por Wok Linkocalmancsna Con to nun" urea de kleallicacal fleece de nlente0 de UntedllealliCre. pled lane mono a smacks we MOOR eivdare a Om, tea *is mat [E3 maxiable. Su Nava Ware de idanidlaiden we cfeanaaa pen ceoportionane cane melt. expanancie atm Santa Whoa% to lecture y eenefearae de Infamael5n Puma oarnatuar a mar eta flush Min inmeaatarYine el Mate Winder Vora de au commn. *Septa imag.b Itoralcamoft I neen.a.....0re. EFTA00316298 . EFTA00316299  349R0501060179002 UnitedHealthcard UnitedHealthcare 185 Asylum Street Cityplace I Hartford, CT 06103 December 14, 2016 G/GA272605IM SOUTHERN TRUST COMPANY 6100 RED HOOK QUARTER, (3-3 ST THOMAS, VI 008020000 Dear Customer: The Affordable Care Act requires all health plan issuers and group health plans to provide eligible enrollees with a Summary of Benefits and Coverage (SBC). The SBC provides you information to better understand your plan and allows you to compare coverage options. You are receiving this package due to one of the following plan coverage events that requires you to receive an SBC. • Upon application for coverage, • Prior to any material modification of your plan coverage, • Prior to your plan renewal, or • You are a special enrollee. If you are an Employer, you can find your group's SBC documents by logging into www.employereservices.com and select "Summary of Benefits and Coverage" under the Resources menu. For more information regarding this document, please visit uhc.com/summary or contact the Member Services number on the back of your ID card. Very truly yours, Christopher Hock Broker & Employer Operations UnitedHealthcare EFTA00316300 EFTA00316301  I UnitedHea'theme Choice Plus V6F /H9 Coverage Period: 01/01/2017 - 12/31/2017 Summary of Coverage: What this Plan Covers & What it Costs Coverage for: Employee/Family I Plan Type: POS 0 V. If you want more detail about your coverage and costs, you can ger the complete terms in the policy or plan document at wwv...welcometouhc.com or by calling 1-800-782-3740. A This is only a summary. _ A141 ti'. ..,r:in:i.::- , .. What is the overall Network: $0 YOU must pay all the costs up to the deductible amount before this pi..il begins to deductible? Non-Network: $500 Indiv / $1,000 Family pay for covered services you use. Check your policy or plan documem ;o see when Per calendar year. Does not apply to copays, the deductible starts over (usually, but not always, January 1st). See the chart prescription drugs, and services listed below as starting on page 2 for how much you pay for covered services after you meet the "No Charge". deductible. Are there other No. You don't have to meet deductibles for specific services, but see the chart starting deductibles for on page 2 for other costs for services this plan covers. specific services? Is there an Network: $2,500 Indiv I $5,000 Family The out-of-pocket limit is the most you could pay during a coverage period out-of- . ocket limitNon-Network: $5,000 Indiv I $10,000 Family (usually one year) for your share of the cost of covered services. This limit helps on my expenses? you plan for health care expenses. What is not included Premiums, balance-billed charges, health care this Even though you pay these expenses, they don't count toward the out-of-pocket in the out-of-pocket plan doesn't cover, penalties for failure to obtain limit? Pre-Notification for services , copays and prescription drugs. Is there an overall No. The chart starting on page 2 describes any limits on what the plan will pay former/fie annual limit on what covered services, such as office visits. the plan pays? Does this plan use a Yes. For a list of network providers, see If you use an in-network doctor or other health care provider, this plan will pay network of www.welcometouhc.com or call some or all of the costs of covered services. Be aware, your in-network doctor or • roviders? 1-800-782.3740. hospital may use an out-of-network provider for some services. Plans use the term in-network preferred, or participating for . roviders in their network. See the chart starting on page 2 for how this plan pays different kinds of roviders. Do I need a referral No. You can see the s . ecialist you choose without permission from this plan. to see a specialist? Are there services Yes. Some of the services this plan doesn't cover are listed on page 5. See your policy or this plan doesn't plan document for additional information about excluded services. cover? Questions: Ca111-800-782-3740 or visit us at www.welcometouhc.com. If you aren't clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or www.dol.gov/ebsa/healthreform or cal11-866-487-2365 to request a copy. V6F 1 of 8 EFTA00316302  EFTA00316303 • Copavments arc fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. A • Coinsurance isyour share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan's allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven't met your deductible. • The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an our-of-network hospital charges S1,500 for an overnight stay and the allowed amount is 51,000, you may have to pay the $500 difference. (This is called balance Wilkie.) • This plan may encourage you to use network providers by charging you lower deductibles, copavments and coinsurance amounts. Common Your Cost If Your Cost If Medical Event Services You May Need You Use a You Use a Limitations & Exceptions Network Non-Network Provider Provider If you visit a Primary care visit to treat an $20 copay per 20% co-ins, after If you receive services in addition to office visit, adclition.LI health care injury or illness visit ded copays, deductibles, or co-ins may apply. provider's office or clinic Specialist visit $30 copay per 20% co-ins, after If you receive services in addition to office visit, additional visit ded copays, deductibles, or co-ins may apply. Other practitioner office visit $20 copay per 20% co-ins, after Cost Share applies for only Manipulative (Chiropractic) Services visit ded and is limited to 20 visits per policy period. Pre-Notification required for non-network or benefit reduces to 50% of allowed. Preventive No Charge Not Covered No coverage non-Network. care/screening/immunizati- Includes preventive health services specified in the health care on reform law. If you have a test Diagnostic test (x-ray, blood No Charge 20% co-ins, after None work) ded Imaging (CT/PET scans, $200 copay per 20% co-ins, after None MRIs) service ded 2 of 8  Common Services You May Need Your Cost If Your Cost If Limit • t. Medical Event You Use a You Use a Network Non-Network Provider Provider If you need drugs Tier 1 - Your Lowest-Cost Retail: $10 copay Retail: $10 copay Provider means pharmacy for purposes of this section. to treat your Option Mail-Order $25 Retail: Up to a 31 day supply. 6006LT090TCSOS6bE illness or copay Mail-Order: Up to a 90 day supply. condition Tier 2 - Your Midrange-Cost Retail: $30 copay Retail: $30 copay You may need to obtain certain drugs, including certain specialty Option Mail-Order $75 drugs, from a pharmacy designated by us. More information Certain drugs may have a Pre-Notification requirement or may copay about prescription result in a higher cost. drug coverage is Tier 3 - Your Highest-Cost Retail: $50 copay Retail: $50 copay If you use a non-Network Pharmacy (including a mail order available at Option Mail-Order $125 pharmacy), you may be responsible for any amount over the www.wekometouh- copay allowed amount. c.com. Tier 4 (if applicable) - Not applicable Not applicable You may be required to use a lower-cost drug(s) prior to Additional High-Cost benefits under your policy being available for certain prescribed Options drugs. See the website listed for information on drugs covered by your plan. Not all drugs are covered. Tier 1 contraceptives are covered at No Charge. Growth Hormone Therapy : 30% co-ins, ded does not apply. If you have Facility fee (e.g., ambulatory No Charge 20% co-ins, after $250 outpatient surgery per occurrence deductible applies prior outpatient surgery surgery center) ded to the Annual Deductible. Physician/surgeon fees No Charge 20% co-ins, after None ded If you need Emergency room services $200 copay per $200 copay per None immediate visit visit medical attention Emergency medical No Charge No Charge None transportation Urgent care S75 copay per 20% oo-ins, after If you receive services in addition to urgent care, additional visit ded copays, deductibles, or co-ins may apply. If you have a Facility fee (e.g., hospital No Charge 20% co-ins, after Pre-Notification required for non-network or benefit reduces to hospital stay room) ded 50% of allowed. $500 Inpatient Stay per occurrence deductible applies prior to the Annual Deductible. 3 of 8 IIII11111I1IIIIIIIIII1IIIIIIlH111111 IIIIII EFTA00316304  EFTA00316305 Common Medical Eve t. Services You May Need Your Cost If You Use a Your Cost If You Use a 4 Network Non-Network Provider Provider Physician surgeon fee No Charge 20% co-ins, after None ded If you have mental Mental/Behavioral health $30 copay per 20% co-ins, after Limited to 20 visits per policy period (combined with Outpatient health, behavioral outpatient services visit ded Substance use). health, or Pre-Notification required for certain services for non-network substance abuse or benefit reduces to 50% of allowed. needs Mental/Behavioral health No Charge 20% co-ins, after Limited to 30 days per policy period (combined with Inpatient inpatient services ded Substance use). Pre-Notification required for non-network or benefit reduces to 50% of allowed. Substance use disorder $30 copay per 20% co-ins, after Limited to 20 visits per policy period (combined with Outpatient outpatient services visit ded Mental health). Pre-Notification required for certain services for non-network or benefit reduces to 50% of allowed. Substance use disorder No Charge 20% co-ins, after Limited to 30 days per policy period (combined with Inpatient inpatient services ded Mental health). Pre-Notification required for non-network or benefit reduces to 50% of allowed. If you are Prenatal and postnatal care No Charge 20% co-ins, after Additional copays, deductibles, or co-ins may apply depending pregnant ded on services rendered. Delivery and all inpatient No Charge 20% co-ins, after Inpatient Notification may apply. services ded $500 Inpatient Stay per occurrence deductible applies prior to the Annual Deductible. If you need help Home health care No Charge 20% co-ins, after Limited to 60 visits per policy period. recovering or have ded Pre-Notification required for non-network or benefit reduces to other special 50% of allowed. health needs Rehabilitation services $20 copay per 20% co-ins, after Depending on the type of therapy, there is a limit of 20-36 visits outpatient visit ded per policy period. Habilitative services Not Covered Not Covered No coverage for Habilitative services. Skilled nursing care No Charge 20% co-ins, after Limited to 60 days per policy period (combined with Inpatient ded Rehabilitation). Pre-Notification required for non-network or benefit reduces to 50% of allowed. 4 of 8  Durable medical equipment No Charge 20% co-ins, after Covers I per type of DME (including repair/replace) every 3 ded years. 5006LT090TGS0216tE Pre-Notification required for non-network DME. over $1000 or no coverage. Hospice service No Charge 20% co-ins, after Inpatient Pre-Notification required for non-network or benefit ded reduces to 50% of allowed. If your child needs Eye exam $20 copay per Not Covered Limited to 1 exam every 2 years. dental or eye care visit No coverage non-Network. Glasses Not Covered Not Covered No coverage for Glasses. Dental check-up Not Covered Not Covered No coverage for Dental check-up. Excluded Services & Other Covered Services: Services Your Plan Does NOT cover (This isn't a complete list. Check your policy or plan document for other excluded services.) • Acupuncture • Bariatric Surgery • Cosmetic Surgery • Dental Care (Adult/Child) • Glasses • Habilitation services • Infertility Treatment • Long-Term Care • Non-emergency care when • Private-Duty Nursing traveling outside the U.S. • Routine Foot Care • Weight Loss Proitrams Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) • Chiropractic care • Hearing aids • Routine eye care (Adult) Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 1-866-747-1019. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact the Employee Benefits Security Administration at 1-866-444-3272or vnvw.dolgov/ebsa/healthreform or the United States Virgin Islands Division of Banking and Insurance at 340-774-7166 or 5 of 8 IIIIIIIIIIIIIIIIIIIII1 EFTA00316306  EFTA00316307 wwwItg.gov.vi/division-of-banking-and-insurance.html. Additionally, a consumer assistance program can help you file your appeal. Contact U.S. Virgin Islands Division of Banking and Insurance at 340-773-6459 or visit www.ltg.gov.vi. Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage." This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Espanol): Para obtener asistencia en Espaliol, flame al 1-800-782-3740 Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-782-3740 Chinese (n): APMIIRWriotreilM, illfacjatftlal 1-800-782-3740 Navajo Pine): Dinek'ehgo shika at' ohwol ninisingo, kwiijigo holne' 1-800-782-3740 To see examples ofbow this plan migbi towr cosisfora sample medicalsithalion, see the next page. 6 of 8  unitedllealtheare Choice Plus V6F /H9 Coverage Period: 01/01/2017 - 12/31/2017 Coverage Examples Coverage for: Employee/Family I Plan Type: POS About these Coverage 9006LT090TCSON6T+E Examples: These examples show how this plan might Amount owed to providers: $7,540 Amount owed to providers: $5,400 cover medical care in given situations. Use these Plan pays $7,320 Plan pays $4,260 examples to see, in general, how much financial protection a sample patient might get if they are Patient pays $220 Patient pays $1,140 covered under different plans. Sample care costs: Sample care costs: This is Hospital charges (mother) $2,700 Prescriptions $2,900 A not a cost Routine obstetric care $2,100 Medical Equipment and $1,300 estimator. Hospital charges (baby) $900 Supplies Anesthesia $900 Office Visits and Procedures $700 Don't use these examples to Education $300 estimate your actual costs Laboratory tests $500 under this plan. The actual Prescriptions $200 Laboratory tests $100 care you receive will be Radiology $200 Vaccines, other preventive $100 different from these Total $5,400 examples, and the cost of Vaccines, other preventive $40 that care will also be Total $7,540 different. Patient pays: Patient pays: Deductibles See the next page for $0 important information Deductibles Copays $1,100 $0 about these examples. Copays $20 Coinsurance $0 Coinsurance SO Limits or exclusions $40 Limits or exclusions $200 Total $1,140 Total $220 7 of 8 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII EFTA00316308  EFTA00316309 /2united-Healthcare Choice Plus V6F /H9 Coverage Period: 01/01/2017 - 12/31/2017 Coverage Examples Coverage for: Employee/Family I Plan Type: POS Questions and answers about the Coverage Examples: What are some of the What does a Coverage Example Can I use Coverage Examples to assumptions behind the show? compare plans? Coverage Examples? For each treatment situation, the coverage Example helps you see how deductibles, /Yes . When you look at the Summary of • Costs don't include premiums. Benefits and Coverage for other plans, you'll cortavments and coinsurance can add up. It • Sample care costs are based on national also helps you see what expenses might be left find the same Coverage Examples. When averages supplied by the U.S. Department you compare plans, check the "Patient Pays" up to you to pay because the service or of Health and Human Services, and aren't treatment isn t covered or payment is limited. box in each example. The smaller that specific to a particular geographic area or number, the more coverage the plan health plan. provides. Does the Coverage Example • The patient's condition was not an exduded or preexisting condition. predict my own care needs? Are there other costs I should • All services and treatments started and consider when comparing plans? ended in the same coverage period. x No . Treatments shown are just examples. • There are no other medical expenses for The care you would receive for this any member covered under this plan. condition could be different based on your 'ries . An important cost is the premium • Out-of-pocket expenses are based only on doctor's advice, your age, how serious your you pay. Generally, the lower your treating the condition in the example. condition is, and many other factors. premium, the more you'll pay in out-of-pocket costs, such as copayments • The patient received all care from deductibles and coinsurance. You should in-network providers. If the patient had Does the Coverage Example also consider contributions to accounts such received care from out-of-network predict my future expenses? as health savings accounts (HSAs), flexible providers, costs would have been higher. spending arrangements (FSAs) or health • If other than individual coverage, the reimbursement accounts (HRAs) that help Patient Pays amount may be more. x No . Coverage Examples are not cost you pay out-of-pocket expenses. estimators. You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Questions: Call 1-800-782-3740 or visit us at www.welcometouhc.com. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cclio.cms.gov or www.dol.goviebsa/healtlueform or call 1-866-487-2365 to request a copy. V6F 8 of 8  349ROSD1060179007 We do not treat members differently because of sex, age, race, color, disability or national origin. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator. Online: [email protected] Mail: Civil Rights Coordinator. UnitedHealthcare Civil Rights Grievance. P.O. Box 30608 Salt Lake City, UTAH 84130 You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free number listed within this Summary of Benefits and Coverage (SBC), 'fly 711, Monday through Friday, 8 a.m. to 8 p.m. You can also file a complaint with the U.S. Dept. of Health and Human Services. Online: https://ocrportal.hhs.goviocaportal/lobby.jsf Complaint forms are available at httplivniwthhs.gov/ocr/office/file/index.html. Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the number contained within this Summary of Benefits and Coverage (SBC), TTY 711. Monday through Friday, 8 a.m. to 8 p.m. EFTA00316310 ATENCION: Si habla espafiol (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposition. Llame al item gratuito que aparece en este Resumen de Beneficios y Cobertura (Summary of Benefits and Coverage, SBC). IRAS : SC (Chinese) , iltag2Migf0111Icial*, (Summary of Benefits and Coverage, SBC)174 PEA flItitittain XIN 1: Neu quY vj noi tieng Viet (Vietnamese), qu9 vj se dtrqc cung cep dich vg trq giap va ng8n ngit man phf. Vui long g9i se dien thooi min phi ghi trong ban Tern lucre ye quyen lqi va dai th9 bao ham (Summary of Benefits and Coverage, SBC) nay. tj*01(Korean)g g satEAPE 2101 XI LIIAS. -t- VALI*. .! 8.114 5J 319-tAi(Summary of Benefits and Coverage, SBC)011 714E IT-R,IIIPLIAM tilEttNAI2. PAUNAWA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng tulong sa wika. Pakitawagan ang toll-free na numerong nakalista sa Buod na ito ng Mga Benepisyo at Sakiaw (Summary of Benefits and Coverage o SBC). BEHMAHHE: 6=7Ra-rime yenyrir nepeaqaa HOCTrIHM HRH nava, %reit pontroil 51:361R RBRUTICSI pyCCHOM (Russian). 1103BORHTe 110 6eCRRaTH0My troarepy TeRe4MHZI, ylat3aHHOMy a ,RaHHOM H063ope nbrox rt noxprznow (Summary of Benefits and Coverage, SBC). cjull pl 4iI 64+11 jay) 'at ); 91 WI, ;Oa iis,,uI eaelaall Si& Oita ,(Arabio daaii Cid 1.11 *Ai (Summary of Benefits and Coverage' SBC) .4-..lialli lsl jdl ual&A &al ATANSYON: Si w pale Kreyol ayisyen (Haitian Creole), ou kapab benefisye sIvis Id gratis you ede w nan lang paw. Tanpri rele nimewo gratis ki nan Rezime avantaj ak pwoteksyon sa a (Summary of Benefits and Coverage, SBC). ATTENTION : Si vous parlez francais (French), des services d'aide linguistique vous sont proposes gratuitement. Veuillez appeler le numero sans frais figurant dans ce Sommaire des prestations et de la couverture (Summary of Benefits and Coverage, SBC). UWAGA: Jettli m6wisz po polsku (Polish), udostcprilliSmy darrnowe uslugi dumacza. Prosimy zadzwonie pod bezplatny numer podany w niniejszym Zestawieniu shviadczen i refundacji (Summary of Benefits and Coverage, SBC). ATENCAO: Se voce fala portugues (Portuguese), contate o servico de assistencia de idiomas gratuito. Ligue para o nfunero gratuito listado neste Resumo de Beneficios e Cobertura (Summary of Benefits and Coverage - SBC). ATrENZIONE: in caso la lingua parlata sitaitaliano (Italian), sono disponibili servizi di assistenza linguistica gratuiti. Chiamate it numero verde indicato allintemo di questo Sommario dei Benefit e della Copertura (Summary of Benefits and Coverage, SEC). EFTA00316311  349ROSD1060 179008 ACI-ITUNG: Falls Sie Deutsch (German) sprechen, stelten Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfiigung. Bite rufen Sie die in dieser Zusammenfassung der Leistungen and Kostentibernahmen (Summary of Benefits and Coverage, SBC) angegebene gebtihrenfreie Rufnummer an. 2tritri : H*i (Japanese) Cffi *1.6tá fitkiSi.oinánt * rontaltniirt0IgtOJ (Summary of Benefits and Coverage, SBC) Kt* á ht 416 7 9 — 1-(tMcrtalitli< ts-I á I, ‘. 1 Clib °it.'"14 tall ...1•14 cf. 641 -M:‘t ../.1Ali Jill 44 csg-1.3 015.:1..) C'1-4-1S g (Farsi) CeUti " -Al :4+91 ..1014 4.$1-45 (Summary of Benefits and Coverage. SBC) (.1.434 .51.0>4.--et> es] t: zit 3TP:r ito (Hindi) aircm. agiv deities' aftiQ, 3croar t] BI1T git chclkd (Summary of Benefits and Coverage, SBC) ataT tkr.fterh Stf CEEB TOOM: Yog koj hals Lus Hrnoob (Etmong), muaj key pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu dawb teev muaj nyob ntawm Tsab Ntawv Nthuav Qhia Coy Txiaj Ntsim Zoo thiab Key Kam Them Nqi (Summary of Benefits and Coverage, SBC) no. darnónatanth: ulttissimgantuamunku (Khmer) tivri4 mininmenweirirlinig AirrisKintitri rvidgirkisiirueirrnicrmtg rettubnemensiabs icuttnittiummusuncuá Atirsuhurbit:3 (Summary of Benefits and Coverage, SBC) ts:9 PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Maidawat nga awagan ti awan bayad na nu tawagan nga numero nga nakalista iti uneg na daytoy nga Dagup dagiti Benipisyo ken Pannakasakup (Summary of Benefits and Coverage, SBC). DÍÍ BAA'AKONINIZIN: Diné (Navajo) bizaad bee yanilti'go, saad bee ilka'anida'awolgii, t'áá jifkeh, bee na'ah66C. T'áá shoodf Naaltsoos Bee 'Aa'éliaythif dóó Bee 'Ak'é'asti' Bee Baa Hanel' (Summary of Benefits and Coverage, SBC) biyi' jfilc'ehgo béésh bee banal bikálgif bee hodiilnih. 000W: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac lambarka bilaashka ah ee ku yaalla Soo-koobitaanka Dheefaha iyo Caymiska (Summary of Benefits and Coverage, SBC). EFTA00316312 EFTA00316313