Coverage Examples

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)

■ The plan's overall deductible

$3,500

■ Specialist coinsurance

■ Hospital (facility) coinsurance

■ Other coinsurance

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 $12,700

In this example, Peg would pay:

Cost Sharing
Deductibles	$3,500
Copayments	$10
Coinsurance	$0
What isn’t covered
Limits or exclusions	$60
The total Peg would pay is	$3,570

Managing Joe’s Type 2 Diabetes

(a year of routine in-network care of a well-controlled condition)

■ The plan's overall deductible

$3,500

■ Specialist coinsurance

■ Hospital (facility) coinsurance

■ Other coinsurance

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 $5,600

In this example, Joe would pay:

Cost Sharing
Deductibles	$3,500
Copayments	$200
Coinsurance	$0
What isn’t covered
Limits or exclusions	$20
The total Joe would pay is	$3,720

Mia’s Simple Fracture

(in-network emergency room visit and follow up care)

■ The plan's overall deductible

$3,500

■ Specialist coinsurance

■ Hospital (facility) coinsurance

■ Other coinsurance

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 $2,800

In this example, Mia would pay:

Cost Sharing
Deductibles	$2,800
Copayments	$0
Coinsurance	$0
What isn’t covered
Limits or exclusions	$0
The total Mia would pay is	$2,800

Note: These numbers assume the patient does not participate in the plan's wellness program. If you participate in the plan's wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: 800-332-0741.

The plan would be responsible for the other costs of these EXAMPLE covered services.