Page 23 - PWH.19 Employee Benefits

mples of how this plan might cover medical care. Your actual costs will
s your providers charge, and many other factors. Focus on the cost
d excluded services under the plan. Use this information to compare
. Please note 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 $5,000 The plan’s overall deductible $5,000
ce 0% Specialist coinsurance
oinsurance 0% Hospital (facility) coinsurance 0%
0% Other coinsurance 0%
0%

t includes services This EXAMPLE event includes services
n office visits (including like:
work) Emergency room care (including medical supplies)
pment (glucose meter) Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)

$7,460 Total Example Cost $2,010

ould pay: $1,198 In this example, Mia would pay: $1,925
Sharing $4,446 Cost Sharing $0
$0
n’t covered $0 Deductibles
pay is Copayments $0
$55 Coinsurance $1,925
$5,699
What isn’t covered
Limits or exclusions

The total Mia would pay is

er costs of these EXAMPLE covered services.

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