The plan would be responsible for the other costs of these EXAMPLE covered services. 5 of " 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 visit and follow up care) ◼ The plan’s overall deductible $1,300 ◼ The plan’s overall deductible $1,300 ◼ The plan’s overall deductible $1,300 ◼ Specialist coinsurance 20% ◼ Specialist coinsurance 20% ◼ Specialist coinsurance 20% ◼ Hospital (facility) coinsurance 20% ◼ Hospital (facility) coinsurance 20% ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 0% ◼ Other coinsurance 0% ◼ Other coinsurance 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) 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 would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $1,300 Deductibles $959 Deductibles $1,300 Copayments $0 Copayments $0 Copayments $0 Coinsurance $2,520 Coinsurance $240 Coinsurance $385 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 $3,916 The total Joe would pay is $7,239 The total Mia would pay is $1,685