Page 7 of 7 P_250018_L The plan would be responsible for the other costs of these EXAMPLE covered services. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Mia’s Simple Fracture (in-network emergency room visit and follow up care) Managing Joe’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) ◼ The plan’s overall deductible $2000 ◼ Specialist 20% ◼ Hospital (facility) 20% ◼ Other 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/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 $2000 Copayments $10 Coinsurance $2100 What isn’t covered Limits or exclusions $60 The total Peg would pay is $4170 ◼ The plan’s overall deductible $2000 ◼ Specialist 20% ◼ Hospital (facility) 20% ◼ Other 20% 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 $1200 Copayments $1000 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Joe would pay is $2200 ◼ The plan’s overall deductible $2000 ◼ Specialist 20% ◼ Hospital (facility) 20% ◼ Other 20% 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 $2000 Copayments $10 Coinsurance $200 What isn’t covered Limits or exclusions $0 The total Mia would pay is $2210 Note: These numbers assume the patient is not participating in an employer-sponsored Health Reimbursement Arrangement (HRA). Your employer may or may not sponsor an HRA. If you participate in an HRA, your costs may be lower than the costs in these coverage examples. For information, including whether your employer sponsors an HRA, please contact your plan administrator. 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.