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 Managing Joe’s type 2 Diabetes Mia’s Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow hospital delivery) controlled condition) up care) $900 $900 $900 The overall The overall The overall 10% 10% coinsurance coinsurance coinsurance 10% 10% 10% 10% Hospital (facility) coinsurance Hospital (facility) coinsurance Hospital (facility) coinsurance 10% 10% 10% Other coinsurance Other coinsurance Other coinsurance This EXAMPLE event includes services This EXAMPLE event includes services This EXAMPLE event includes services like: like: like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies) Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment (glucose meter) Total Example Cost $12,840 Total Example Cost $7,460 Total Example Cost $2,010 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $900 Deductibles $900 Deductibles $900 Copayments $0 Copayments $792 Copayments $0 Coinsurance $900 Coinsurance $108 Coinsurance $193 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $60 Limits or exclusions $55 Limits or exclusions $0 The total Peg would pay is $1,860 The total Joe would pay is $1,855 The total Mia would pay is $1,093
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 overall $900 The overall $900 The overall $900 coinsurance 10% coinsurance 10% coinsurance 10% Hospital (facility) coinsurance 10% Hospital (facility) coinsurance 10% Hospital (facility) coinsurance 10% Other coinsurance 10% Other coinsurance 10% Other coinsurance 10% 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 $12,840 Total Example Cost $7,460 Total Example Cost $2,010 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $900 Deductibles $900 Deductibles $900 Copayments $0 Copayments $792 Copayments $0 Coinsurance $900 Coinsurance $108 Coinsurance $193 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $60 Limits or exclusions $55 Limits or exclusions $0 The total Peg would pay is $1,860 The total Joe would pay is $1,855 The total Mia would pay is $1,093
FINAL_Standard_Motor_Products_-_Medical_Plan_PPO_2018_(003).docx