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Total Example Cost $7,400 Hospital (facility) coinsurance
20%
In this example, Joe would pay: Other coinsurance
Cost Sharing 20%
(a year of routine This EXAMPLE event includes services
Deductibles $0 like:
Copayments $1,500 Emergency room care (including medical
Coinsurance $0 supplies)
Diabetesparticipating provider care of
Diagnostic test (x-ray)
a well-controlled condition) Limits or exclusions $30 Durable medical equipment (crutches)

The total Joe would pay is $1,530 Rehabilitation services (physical therapy)

The overall deductible
$0 Total Example Cost $1,900
Specialist copayment $40
Hospital (facility) coinsurance (participating provider and follow In this example, Mia would pay:
20% Cost Sharing
Other coinsurance 20% up care) Simple Fracture emergency
room visit Deductibles $0
This EXAMPLE event includes services Copayments $200
like: Coinsurance $200
Primary care physician office visits
(including disease education) The overall deductible
Diagnostic tests (blood work) $0 Limits or exclusions $0
Prescription drugs Specialist copayment The total Mia would pay is $400
Durable medical equipment (glucose meter) $40

Note: These numbers assume the patient does not participate in the wellness program. If you participate in the
wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: 1-

800-624-8822.