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.
Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition)
◼ The plan’s overall deductible ◼ Specialist coinsurance ◼ Hospital (facility) coinsurance ◼ Other coinsurance $1,600 20% 20% 20% 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) Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery)
◼ The plan’s overall deductible ◼ Specialist coinsurance ◼ Hospital (facility) coinsurance ◼ Other coinsurance $1,600 20% 20% 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test ( x-ray ) Mia’s Simple Fracture (in-network emergency room visit and follow up care)
◼ The plan’s overall deductible ◼ Specialist coinsurance ◼ Hospital (facility) coinsurance ◼ Other coinsurance
$1,600 20% 20% 20%
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)
Durable medical equipment (crutches) Rehabilitation services (physical therapy)
Total Example Cost
$12,700
Total Example Cost
$5,600
Total Example Cost
$2,800
In this example, Joe would pay:
In this example, Peg would pay: Cost Sharing Deductibles
In this example, Mia would pay:
Cost Sharing
Cost Sharing
Deductibles*
$1,600 Deductibles*
$1,600
$1,600
Copayments
$400 Copayments
$10
Copayments
$10
Coinsurance
$200
$200 Coinsurance
Coinsurance
$1,900
What isn’t covered
What isn’t covered
What isn’t covered
$0
Limits or exclusions
$60
Limits or exclusions
$20 Limits or exclusions
The total Mia would pay is
$1,810
The total Peg would pay is
$3,570
The total Joe would pay is
$2,220
*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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