VitalCare MEC
The federally required SBC for VitalCare Minimum Essential Coverage — cost-sharing, exclusions, and coverage examples.
Coverage period 1/1/2026–12/31/2026 · Staff Benefits Management & Administrators (SBMA): VitalCare Minimum Essential Coverage (MEC) · Coverage for eligible members & eligible dependents · Plan type: PPO.
This SBC shows how you and the plan would share the cost for covered health care services. It's only a summary — call 1-888-505-7724 for the complete terms of coverage, or see the Glossary at dol.gov/ebsa/healthreform.
Coverage is limited to the formulary drug list. Preventive medications are covered at no cost as required by law. No coverage for non-preferred or specialty drugs, and no out-of-network drug coverage.
All copayment and coinsurance costs shown are after your deductible has been met, if a deductible applies. Network providers are what you'll pay least; this plan has no out-of-network coverage.
| Service | Network Provider | Out-of-Network |
|---|---|---|
| Primary care visit to treat an injury or illness | $25 copayment | Not covered |
| Specialist visit | $25 copayment | Not covered |
| Preventive care / screening / immunization | No charge | Not covered |
You may have to pay for services that aren't preventive — ask your provider whether what's needed is preventive care.
| Service | Network Provider | Out-of-Network |
|---|---|---|
| Diagnostic test (x-ray, blood work) | $50 copayment | Not covered |
| Imaging (CT/PET scans, MRIs) | Not covered | Not covered |
No coverage for outpatient services provided at a hospital, drug testing, allergy testing, genetic testing, or pathology.
| Service | Network Provider | Out-of-Network |
|---|---|---|
| Facility fee (e.g. ambulatory surgery center) | Not covered | Not covered |
| Physician/surgeon fees | Not covered | Not covered |
| Service | Network Provider | Out-of-Network |
|---|---|---|
| Emergency room care | Not covered | Not covered |
| Emergency medical transportation | Not covered | Not covered |
| Urgent care | $50 copayment | Not covered |
| Service | Network Provider | Out-of-Network |
|---|---|---|
| Facility fee (e.g. hospital room) | Not covered | Not covered |
| Physician/surgeon fees | Not covered | Not covered |
| Service | Network Provider | Out-of-Network |
|---|---|---|
| Outpatient services | Not covered | Not covered |
| Inpatient services | Not covered | Not covered |
| Service | Network Provider | Out-of-Network |
|---|---|---|
| Office visits | $25 copayment | Not covered |
| Childbirth/delivery professional services | Not covered | Not covered |
| Childbirth/delivery facility services | Not covered | Not covered |
| Service | Network Provider | Out-of-Network |
|---|---|---|
| Home health care | Not covered | Not covered |
| Rehabilitation services | Not covered | Not covered |
| Habilitation services | Not covered | Not covered |
| Skilled nursing care | Not covered | Not covered |
| Durable medical equipment | Not covered | Not covered |
| Hospice services | Not covered | Not covered |
| Service | Network Provider | Out-of-Network |
|---|---|---|
| Children's eye exam | Not covered | Not covered |
| Children's glasses | Not covered | Not covered |
| Children's dental check-up | Not covered | Not covered |
For more information about limitations and exceptions, call 1-888-505-7724.
Services your plan generally does NOT cover. Check your policy or plan document for a complete list of excluded services.
Other covered services (limitations may apply; not a complete list): None.
Not a cost estimator — these are examples of how the plan might cover care, based on self-only coverage. Focus on the cost-sharing amounts and excluded services to compare plans.
9 months of in-network pre-natal care and a hospital delivery
A year of routine in-network care of a well-controlled condition
In-network emergency room visit and follow-up care
The plan would be responsible for the other costs of these example covered services.
The Department of Labor's Employee Benefits Security Administration can help if you want to continue coverage after it ends — dol.gov/ebsa/healthreform or 1-866-444-3272. Other options, including Marketplace coverage, are at healthcare.gov or 1-800-318-2596.
If you have a complaint about a denied claim (a grievance or appeal), your explanation of benefits and plan documents explain how to submit it. For help, call 1-888-505-7724.
This plan provides Minimum Essential Coverage but does not meet the Minimum Value Standards — you may be eligible for a premium tax credit toward a Marketplace plan.
Spanish, Tagalog, Chinese, and Navajo language assistance is available at 1-888-505-7724. Additional language services are available upon request.
Questions about this plan? An Indie Healthcare benefits specialist can walk you through it — no phone tree.