About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your charge, and many other factors. Focus on the amounts (, and ) and under the . Use this information to compare the portion of costs you might pay under different health . 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 (in-network emergency room visit and follow hospital delivery) condition) up care) The overall $2,600 The overall $2,600 The overall $2,600 coinsurance 20% coinsurance 20% coinsurance 20% Hospital (facility) Hospital (facility) Hospital (facility) 20% 20% 20% coinsurance coinsurance coinsurance Other coinsurance 20% Other coinsurance 20% Other coinsurance 20% This EXAMPLE event includes services This EXAMPLE event includes services This EXAMPLE event includes services like: like: like: Specialist office visits (prenatal Primary care physician office visits (including Emergency room care 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 Total Example Cost Total Example Cost $12,800 $7,400 $1,900 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing $2,600 $2,600 $1,305 Deductibles Deductibles Deductibles $0 $325 $0 Copayments Copayments Copayments $1,500 $240 $385 Coinsurance Coinsurance Coinsurance 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 $4,160 The total Joe would pay is $3,220 The total Mia would pay is $1,690
About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your charge, and many other factors. Focus on the amounts (, and ) and under the . Use this information to compare the portion of costs you might pay under different health . 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 condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) The overall $2,600 The overall $2,600 The overall $2,600 coinsurance 20% coinsurance 20% coinsurance 20% Hospital (facility) coinsurance 20% Hospital (facility) coinsurance 20% Hospital (facility) coinsurance 20% Other coinsurance 20% Other coinsurance 20% Other coinsurance 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) 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 $12,800 Total Example Cost $7,400 Total Example Cost $1,900 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 $2,600 Deductibles $2,600 Deductibles $1,305 Copayments $0 Copayments $325 Copayments $0 Coinsurance $1,500 Coinsurance $240 Coinsurance $385 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 $4,160 The total Joe would pay is $3,220 The total Mia would pay is $1,690
HSA2018SBC.docx