2020 SBC HRA Plan_Mid-America Apartments_3332254_01.01.2020

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe's type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia's Simple Fracture (in-network emergency room visit and follow up care)

■ The plan's overall deductible ■ Specialist copayment ■ Hospital (facility) coinsurance

$1,500

■ The plan's overall deductible ■ Specialist copayment ■ Hospital (facility) coinsurance

$1,500

■ The plan's overall deductible ■ Specialist copayment ■ Hospital (facility) coinsurance

$1,500

$40 20% 20%

$40 20% 20%

$40 20% 20%

■ Other coinsurance

■ Other coinsurance

■ Other coinsurance

This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost

$12,800

Total Example Cost

$7,400

Total Example Cost

$1,900

In this example, Peg would pay: Cost Sharing Deductibles

In this example, Joe would pay: Cost Sharing Deductibles

In this example, Mia would pay: Cost Sharing Deductibles

$1,500

$130

$1,350

Copayments Coinsurance

$50

Copayments Coinsurance

$1,200

Copayments Coinsurance

$200

$2,200

$0

$0

What isn't covered

What isn't covered

What isn't covered

Limits or exclusions

$10

Limits or exclusions

$200 $1,530

Limits or exclusions

$0

The total Peg would pay is

$3,760

The total Joe would pay is

The total Mia would pay is

$1,550

The plan would be responsible for the other costs of these EXAMPLE covered services.

Plan Name: HRA Plan Ben Ver: 16 Plan ID: 8533559

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