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) $4,000 ◼ Primary care physician coinsurance 20% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20% ◼ The plan’s overall deductible This EXAMPLE event includes services like: Primary care physician visits ( prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests ( ultrasounds and blood work) Specialist visit (anesthesia)
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
◼ The plan’s overall deductible
$4,000
$4,000
◼ Specialist coinsurance
◼ Specialist coinsurance
20% 20% 20%
20% 20% 20%
◼ Hospital (facility) coinsurance
◼ Hospital (facility) coinsurance
◼ Other coinsurance
◼ Other coinsurance
This EXAMPLE event includes services like: Specialist 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
$12,700
Total Example Cost
$5,600
Total Example Cost
$2,800
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
$4,000
$4,000
$2,800
Copayments Coinsurance
$0
Copayments Coinsurance
$0
Copayments Coinsurance
$0 $0
$1,700
$300
What isn’t covered
What isn’t covered
What isn’t covered
Limits or exclusions
$60
Limits or exclusions
$20
Limits or exclusions
$0
The total Peg would pay is
$5,760
The total Mia would pay is
$2,800
The total Joe would pay is
$4,320
The plan would be responsible for the other costs of these EXAMPLE covered services.
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