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xamples of how this plan might cover medical care. Your actual costs will be
es your providers charge, and many other factors. Focus on the cost sharing
excluded services under the plan. Use this information to compare the portion of
ote these coverage examples are based on self-only coverage.
s type 2 Diabetes Mia’s Simple Fracture
-network care of a well- (in-network emergency room visit and follow
d condition) up care)
eductible $2,500 ? The plan’s overall deductible $2,500
nt ? Specialist copayment $60
insurance $60 ? Hospital (facility) coinsurance 0%
0% ? Other coinsurance
0%
0%
ncludes services like: This EXAMPLE event includes services like:
ffice visits (including Emergency room care (including medical
supplies)
work)
Diagnostic test (x-ray)
ent (glucose meter) Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
$7,400 Total Example Cost $1,900
ould pay: $0 In this example, Mia would pay: $1,400
t Sharing $1,500 Cost Sharing $400
$0
sn’t covered $0 Deductibles
ay is $0
$20 Copayments $1,800
$1,520 Coinsurance
What isn’t covered
Limits or exclusions
The total Mia would pay is
r costs of these EXAMPLE covered services. 6 of 6
