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<br /> <br /> <br /> <br />6 of 6 <br /> <br /> About these Coverage Examples: <br /> <br />This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be <br />different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing <br />amounts (deductibles , copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion <br />of costs you might pay under different health plans . Please note these coverage examples are based on self -only coverage. <br /> <br />Peg is Having a Baby <br />(9 months of in-network pre-natal care and a <br />hospital delivery) <br /> Managing Joe’s type 2 Diabetes <br />(a year of routine in-network care of a well- <br />controlled condition) <br /> Mia’s Simple Fracture <br />(in-network emergency room visit and follow up <br />care) <br /> <br />◼ The plan’s overall deductible <br /> <br />$2,400 <br /> <br />◼ The plan’s overall deductible <br /> <br />$2,400 <br /> <br />◼ The plan’s overall deductible <br /> <br />$2,400 <br />◼ Specialist coinsurance 0% ◼ Specialist coinsurance 0% ◼ Specialist coinsurance 0% <br />◼ Hospital (facility) <br />coinsurance <br />0% ◼ Hospital (facility) <br />coinsurance <br />0% ◼ Hospital (facility) <br />coinsurance <br />0% <br />◼ Other coinsurance 0% ◼ Other coinsurance 0% ◼ Other coinsurance 0% <br /> <br />This EXAMPLE event includes services like: <br />Specialist office visits (prenatal care) <br />Childbirth/Delivery Professional Services <br />Childbirth/Delivery Facility Services <br />Diagnostic tests (ultrasounds and blood work) <br />Specialist visit (anesthesia) <br /> <br /> <br />This EXAMPLE event includes services like: <br />Primary care physician office visits (including <br />disease education) <br />Diagnostic tests (blood work) <br />Prescription drugs <br />Durable medical equipment (glucose meter) <br /> <br /> <br />This EXAMPLE event includes services like: <br />Emergency room care (including medical supplies) <br />Diagnostic test (x-ray) <br />Durable medical equipment (crutches) <br />Rehabilitation services (physical therapy) <br /> <br />Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800 <br /> <br />In this example, Peg would pay: <br /> <br />In this example, Joe would pay: <br /> <br />In this example, Mia would pay: <br />Cost Sharing Cost Sharing Cost Sharing <br />Deductibles $2,400 Deductibles $2,400 Deductibles $2,400 <br />Copayments $0 Copayments $0 Copayments $0 <br />Coinsurance $0 Coinsurance $0 Coinsurance $0 <br />What isn’t covered What isn’t covered What isn’t covered <br />Limits or exclusions $70 Limits or exclusions $20 Limits or exclusions $0 <br />The total Peg would pay is $2,470 The total Joe would pay is $2,420 The total Mia would pay is $2,400 <br /> <br />