Page 15 - QCHC.19 Employee Benefits

on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and
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
coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please
(in-network emergency room visit and follow up
Mia’s Simple Fracture
Managing Joe’s type 2 Diabetes
(a year of routine in-network care of a
well-controlled condition) care) $3,000 n The plan's overall deductible $3,000 $50 n Specialist copay $50 20% 20% n Hospital (facility) coinsurance 20% 20% n Other coinsurance This EXAMPLE event includes services like: This EXAMPLE event includes services like: Emergency room care (including medical supplies) Primary care physician office visits (including disease Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Durable medical equipment (glucose meter) $1,900 Total Example Cost $7,400 In this example, Mia would pay:
n The plan's overall deductible
note these coverage examples are based on self-only coverage.
n Specialist copay n Hospital (facility) coinsurance n Other coinsurance education) Diagnostic tests (blood work) Prescription drugs Total Example Cost In this example, Joe would pay: Deductibles Copayments Coinsurance Limits or exclusions The total Joe would pay is

$3,000 $50 20% 20% $12,800 $3,000 $30 $1,700 $1,100 $5,830 reduce your costs. For more information about the wellness program, please contact: 800-540-2583.

Peg is having a baby (9 months of in-network pre-natal care and a hospital delivery) This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Diagnostic tests (ultrasounds and blood work) In this example, Peg would pay: Cost Sharing What isn’t covered
About these Coverage Examples:
n The plan's overall deductible

n Specialist copay n Hospital (facility) coinsurance n Other coinsurance Childbirth/Delivery Facility Services Specialist visit (anesthesia) Total Example Cost Deductibles Copayments Coinsurance Limits or exclusions The total Peg would pay is