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About these Coverage

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 you r providers charge, and
many other factors. Focus on the cost sharing

amounts (deductibles, copayments and coinsurance) and excluded service s under the plan. Use this information
to compare the portion of costs you might pay under different healt h plans. Please note these coverage examples
are based on self-only coverage.

Examples:

This EXAMPLE event includes services
(9 months of Pegand a hospital
delivery)participating provider is Having like:
Cost Sharing Specialist office visits (prenatal care)
a Baby pre-natal care Childbirth/Delivery Professional Services
Deductibles $0 Childbirth/Delivery Facility Services
Copayments $100 Diagnostic tests (ultrasounds and blood
Coinsurance $1,800 work)
The overall deductible Specialist visit (anesthesia)
$0
Limits or exclusions $60 Specialist copayment $40
The total Peg would pay is $1,960
Hospital (facility) coinsurance
20% In this example, Peg would pay:
Other coinsurance 20%
Total Example Cost $12,800

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