Page 692 - outbind://23/

About these Coverage Examples:

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 on the actual care you receive, the prices your amounts (deductible s, copayments and coinsurance) and
excluded service providerss under the charge, and many other factors. Focus on the plan. Use this information to compare the

portion ofcost sharing
costs you might pay under different health plans. Please note these coverage examples are based on self-
only coverage.
This EXAMPLE event includes services
like:
Total Example Cost $12,800 Specialist office visits (prenatal care) The overall deductible
Childbirth/Delivery Professional Services $0
Childbirth/Delivery Facility Services Specialist copayment $60
Cost Sharing Diagnostic tests (ultrasounds and blood Hospital (facility) copayment
Deductibles $0 work) $1,000/day
Copayments $2,100 Specialist visit (anesthesia) Other coinsurance 0%
Coinsurance $0
This EXAMPLE event includes services
Limits or exclusions $60 like:
The total Peg would pay is $2,160 In this example, Peg would pay: Primary care physician office visits
(including disease education)
(9 months of Pegand a Diagnostic tests (blood work)
hospitalparticipating provider is Having a Prescription drugs

Baby delivery) pre-natal care Durable medical equipment (glucose meter)

Total Example Cost $7,400

The overall deductible
$0
Specialist copayment $60
Hospital (facility) copayment
$1,000/day (a year of routine participating provider
Other coinsurance 0% care of
a well-controlled condition)

9