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. This EXAMPLE event includes services like: Rehabilitation services (physical therapy) Primary care physician office visits (including The overall $150 $30 disease education) Total Example Cost $1,900 Diagnostic tests (blood work) Hospital (facility) $100 In this example, Mia would pay: Other 0% Prescription drugs Cost Sharing Durable medical equipment (glucose meter) Deductibles* $0 This EXAMPLE event includes services like: Copayments $200 Specialist office visits (prenatal care) Total Example Cost $7,400 Coinsurance $0 Childbirth/Delivery Professional Services In this example, Joe would pay: What isn't covered Childbirth/Delivery Facility Services Cost Sharing Limits or exclusions $0 Diagnostic tests (ultrasounds and blood work) Deductibles* $200 The total Mia would pay is $200 Specialist visit (anesthesia) Copayments $800 Coinsurance $0 Total Example Cost $12,800 What isn't covered In this example, Peg would pay: Limits or exclusions $20 Cost Sharing The total Joe would pay is $1,020 Deductibles* $200 Copayments $200 Coinsurance $0 The overall $150 What isn't covered $30 Limits or exclusions $60 Hospital (facility) $100 Other 0% The total Peg would pay is $460 This EXAMPLE event includes services like: The overall $150 Emergency room care (including medical $30 supplies) Hospital (facility) $100 Diagnostic test (x-ray) Other 0% Durable medical equipment (crutches)
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. The overall $150 $30 Hospital (facility) $100 Other 0% 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) Total Example Cost $12,800 In this example, Peg would pay: Cost Sharing Deductibles* $200 Copayments $200 Coinsurance $0 What isn't covered Limits or exclusions $60 The total Peg would pay is $460 The overall $150 $30 Hospital (facility) $100 Other 0% 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) Total Example Cost $7,400 In this example, Joe would pay: Cost Sharing Deductibles* $200 Copayments $800 Coinsurance $0 What isn't covered Limits or exclusions $20 The total Joe would pay is $1,020 The overall $150 $30 Hospital (facility) $100 Other 0% 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 $1,900 In this example, Mia would pay: Cost Sharing Deductibles* $0 Copayments $200 Coinsurance $0 What isn't covered Limits or exclusions $0 The total Mia would pay is $200
summary%20of%20benefits%20and%20coverages.docx