Page 6 - QCS.19 Employee Benefits
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About these Coverage Examples:
This is not a cost estimator. Treatments shown are just e
different depending on the actual care you receive, the pric
amounts (deductibles, copayments and coinsurance) and e
costs you might pay under different health plans. Please no
Peg is Having a Baby Managing Joe’s
(9 months of in-network pre-natal care and a (a year of routine in-
hospital delivery) controlled
? The plan’s overall deductible $2,500 ? The plan’s overall de
? Specialist copayment $60 ? Specialist copaymen
? Hospital (facility) coinsurance 0% ? Hospital (facility) coi
? Other coinsurance ? Other coinsurance
0%
This EXAMPLE event in
This EXAMPLE event includes services like: Primary care physician o
Specialist office visits (prenatal care) disease education)
Childbirth/Delivery Professional Services Diagnostic tests (blood w
Prescription drugs
Childbirth/Delivery Facility Services Durable medical equipm
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
Total Example Cost $12,800 Total Example Cost
In this example, Peg would pay: $2,500 In this example, Joe wo
Cost Sharing $100 Cost
$0
Deductibles Deductibles
$10 Copayments
Copayments $2,610 Coinsurance
Coinsurance
What is
What isn’t covered Limits or exclusions
The total Joe would pa
Limits or exclusions
The total Peg would pay is
The plan would be responsible for the other
