Page 22 - PWH.19 Employee Benefits
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About these Coverage Examples:
This is not a cost estimator. Treatments shown are just exam
be different depending on the actual care you receive, the prices
sharing amounts (deductibles, copayments and coinsurance) and
the portion of costs you might pay under different health plans.
Peg is Having a Baby Managing Joe’s
(9 months of in-network pre-natal care and a (a year of routine in-n
hospital delivery) controlled
The plan’s overall deductible $5,000 The plan’s overall de
Specialist coinsurance 0% Specialist coinsuranc
Hospital (facility) coinsurance 0% Hospital (facility) co
Other coinsurance 0% Other coinsurance
This EXAMPLE event includes services This EXAMPLE event
like: like:
Specialist office visits (prenatal care) Primary care physician
Childbirth/Delivery Professional Services disease education)
Childbirth/Delivery Facility Services Diagnostic tests (blood w
Diagnostic tests (ultrasounds and blood work) Prescription drugs
Specialist visit (anesthesia) Durable medical equip
Total Example Cost $12,840 Total Example Cost
In this example, Peg would pay: $5,000 In this example, Joe wo
Cost Sharing $40 Cost S
$0
Deductibles Deductibles
Copayments $60 Copayments
Coinsurance $5,100 Coinsurance
What isn’t covered What isn
Limits or exclusions Limits or exclusions
The total Peg would pay is The total Joe would p
The plan would be responsible for the othe
