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 care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) an 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 are based on self-only coverage.
eg is Having a Baby
Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well-
Mia’s Simple Fracture
P
of in-network pre-natal care and a
(in-network emergency room visit and follow up hospital
(9 months
controlled condition)
care)
◼ The plan’s overall deductible
◼ The plan’s overall deductible
s overall deductible
$500
$500
$500
i ◼ The plan’ ◼ Specialis ◼ Hospital ( ◼ Other coi This EXAMPL Specialist off Childbirth/Del Childbirth/De Diagnostic tes Specialist vis
◼ Specialist copayment
◼ Specialist copayment
t copayment coinsurance
$50
$50
$50
◼ Hospital (facility) coinsurance
◼ Hospital (facility) coinsurance
20% 20%
20% 20%
20% nsuran
◼ Other coinsurance
◼ Other coinsurance
20%
E event includes services like:
This EXAMPLE event includes services like: Primary care physician office visits (including
This EXAMPLE event includes services like: Emergency room care (including medical
ce visits (prenatal care) ivery Professional Services
disease education)
supplies)
livery Facility Services
Diagnostic tests (blood work)
Diagnostic test ( x-ray )
ts (ultrasounds and blood work)
Prescription drugs
Durable medical equipment (crutches) Rehabilitation services (physical therapy)
it (anesthesia)
Durable medical equipment (glucose meter)
Total Example Cost
$12,700
Total Example Cost
$5,600
Total Example Cost
In this example, Joe would pay:
In this example, Peg would pay:
In this example, Mia would pay:
Cost Sharing
Cost Sharing
Cost Sharing
Deductibles
$500
Deductibles*
$700
Deductibles*
Copayments
$0
Copayments
$800
Copayments
Coinsurance
$2,100
Coinsurance
$60
Coinsurance
What isn’t covered
What isn’t covered
What isn’t covered
Limits or exclusions
$60
Limits or exclusions
Limits or exclusions
$20
The total Joe would pay is
$1,580
The total Peg would pay is
$2,660
The total Mia would pay is
*Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?”.
The plan would be responsible for the other costs of these EXAMPLE covered services.
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