HR Fast Facts: What’s in a Summary of Benefits and Coverage?

The Summary of Benefits and Coverage (SBC) explains different health benefits in a plan.

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The Summary of Benefits and Coverage (SBC) explains different health benefits depending on the different tiers of prescription drugs, benefits regarding surgeries and hospital stays, and coverage for visits to Emergency Rooms and Urgent Care.

Below is an example format for an SBC. Please refer to the SBC in question for details specific to that plan. The layout may differ but the same information will exist.

On this page, we can:

  • Determine costs for prescription drugs according to their assigned benefit tier.
    • Tier 1: Generic drugs
    • Tier 2: Preferred brand name drugs
    • Tier 3: Non-preferred brand name drugs
    • Tier 4: Specialty drugs
  • Learn how the plan will cover outpatient surgical procedures and related services, such as facility fees.
  • Find out what the plan benefits are for emergency room visits, emergency transportation (ambulance, helicopter, etc.), and urgent care visits.
  • Determine coverage for hospital stays.
  • Be aware of important Limitations and Exceptions, like visit limits or preauthorization/precertification requirements.

SBC pg 3.png

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