Page 17 - RTF.20 Employee Benefits
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$0      $0
                                             $2,000                          $1,900       $1,400         $1,800
                                                  $60       0%     0%                        $400                      7of 7
                   amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
                different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
             This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
                                Mia’s Simple Fracture (in-network emergency room visit and follow   up care)  „ The plan’s overall deductible    „ Specialist copayment „ Hospital (facility) coinsurance  This EXAMPLE event includes services like:  Emergency room care (including medical   Durable medical equipment (crutches)  Rehabilitation services (physical therapy)  In this example, Mia would pay:  Cost Sharing   What isn’t covered   The total Mia would pay is

                      costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.















                                                     „ Other coinsurance  supplies)   Diagnostic test (x-ray)   Total Example Cost      Deductibles   Copayments   Coinsurance   Limits or exclusions

                                            $2,000        $60       0%  0%     $7,400       $0      $1,400      $0      $20   $1,420


                                Managing Joe’s type 2 Diabetes


                                     controlled condition)   (a year of routine in-network care of a well-  Cost Sharing   What isn’t covered





                                            „ The plan’s overall deductible    „ Specialist copayment „ Hospital (facility) coinsurance  This EXAMPLE event includes services like:  Primary care physician office visits (including   Diagnostic tests (blood work)  Durable medical equipment (glucose meter)   In this example, Joe would pay:  The total Joe would pay is  The plan would be responsible for the other costs of these EXAMPLE covered services.












                                                     „ Other coinsurance  disease education)   Prescription drugs    Total Example Cost      Deductibles   Copayments   Coinsurance   Limits or exclusions
                                            $2,000                           $12,800      $2,000         $2,110
                                                  $60       0%     0%                          $100      $0      $10





       About these Coverage Examples:                  Peg is Having a Baby    (9 months of in-network pre-natal care and a      hospital delivery)     „ The plan’s overall deductible    „ Specialist copayment „ Hospital (facility) coinsurance  „ Other coinsurance This EXAMPLE event includes services like:  Specialist office visits (prenatal care)  Childbirth/Delivery Professional Services  Childbirth/Delivery Facility Services  Diagnostic tests (ultrasounds and blood work)  Speciali
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