About these Coverage Examples: Treatments shown are just examples of how this plan might cover medical care. Your actual costs will This is not a cost estimator. 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 and follow hospital delivery) controlled condition) up care) $200 $200 $200 The overall The overall The overall    $20 $20 $20 copayment copayment copayment    10% 10% 10% Hospital (facility) coinsurance Hospital (facility) coinsurance Hospital (facility) coinsurance    Other coinsurance 10% coinsurance 10% coinsurance 10%    This EXAMPLE includes services like: This EXAMPLE event includes services This EXAMPLE event includes services Specialist office visits (prenatal care) like: like: Childbirth/Delivery Professional Services Primary care physician office visits (including Emergency room care (including medical supplies) Childbirth/Delivery Facility Services disease education) Diagnostic test (x-ray) Diagnostic tests (ultrasounds and blood work) Diagnostic tests (blood work) Durable medical equipment (crutches) Specialist (anesthesia) Prescription drugs Rehabilitation services (physical therapy) Durable medical equipment (glucose meter) Total Example Cost $12,840 Total Example Cost $7,460 Total Example Cost $2,010 In this example, Peg pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $200 Deductibles $120 Deductibles $80 Copayments $0 Copayments $250 Copayments $475 Coinsurance $800 Coinsurance $13 Coinsurance $18 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $96 Limits or exclusions $6,041 Limits or exclusions $0 The total Peg would pay is $1,096 The total Joe would pay is $6,424 The total Mia would pay is $564
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 and follow up care)  The overall $200  The overall $200  The overall $200  copayment $20  copayment $20  copayment $20  Hospital (facility) coinsurance 10%  Hospital (facility) coinsurance 10%  Hospital (facility) coinsurance 10%  Other coinsurance 10%  coinsurance 10%  coinsurance 10% This EXAMPLE includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist (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 pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $200 Deductibles $120 Deductibles $80 Copayments $0 Copayments $250 Copayments $475 Coinsurance $800 Coinsurance $13 Coinsurance $18 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $96 Limits or exclusions $6,041 Limits or exclusions $0 The total Peg would pay is $1,096 The total Joe would pay is $6,424 The total Mia would pay is $564
SBCNortheastern-PPO-1-2019.docx