Page 16 - 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
$3,000 $50 20% 20% $1,900 $500 $400 $200 $60 $1,160 Page 6 of 6 OHPSMP BEN1711538792887-00044

Mia’s Simple Fracture (in-network emergency room visit and follow up care) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Cost Sharing What isn’t covered

n The plan's overall deductible

n Specialist copay n Hospital (facility) coinsurance n Other coinsurance Diagnostic test (x-ray) Total Example Cost In this example, Mia would pay: Deductibles Copayments Coinsurance Limits or exclusions The total Mia would pay is

$3,000 $50 20% 20% $7,400 $0 $1,000 $0 $200 $1,200

Managing Joe’s type 2 Diabetes
(a year of routine in-network care of a

well-controlled condition) This EXAMPLE event includes services like: Primary care physician office visits (including disease Durable medical equipment (glucose meter) Cost Sharing What isn’t covered Note: These numbers assume the patient does not participate in the plan's wellness program. If you participate in the plan's wellness program, you may be able to The plan would be responsible for the other costs of these EXAMPLE covered services.

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