The plan would be responsible for the other costs of these EXAMPLE covered services. Page 7 of 7 Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) The plan’s overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance Managing Joe’s type 2 Diabetes (a year of routine in-network care of a well- controlled condition) The plan’s overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance Mia’s Simple Fracture (in-network emergency room visit and follow up care) The plan’s overall deductible Specialist coinsurance Hospital (facility) coinsurance Other coinsurance Cost Sharing Deductibles $5,000 Copayments $0 Coinsurance $0 What isn’t covered Limits or exclusions $60 The total Peg would pay is $5,060 Cost Sharing Deductibles $1,100 Copayments $0 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Joe would pay is $1,100 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 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. About these Coverage Examples: $5,000 0% 0% 0% This EXAMPLE event includes services like: $5,000 0% 0% 0% This EXAMPLE event includes services like: This EXAMPLE event includes services like: $5,000 0% 0% 0% Specialist office visits (pre-natal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Total Example Cost $12,700 Total Example Cost $5,600 $2,800 Total Example Cost