Page 20 - Public Citizen 2021-2022
P. 20
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 providers charge, and many other factors. Focus on the cost sharing amounts (deductibles,
copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different
health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby Managing Joe's type 2 Diabetes Mia's Simple Fracture
(9 months of in-network pre-natal care and a (a year of a routine in-network care of a (in-network emergency room visit and follow
hospital delivery) well-controlled condition) up care)
The plan’s overall deductible $0 The plan’s overall deductible $0 The plan’s overall deductible $0
Specialist Copayment $10 Specialist Copayment $10 Specialist Copayment $10
Hospital (facility) Copayment $0 Hospital (facility) Copayment $0 Hospital (facility) Copayment $50
Other Copayment $0 Other Copayment $0 Other Copayment $0
This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies)
Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy)
Specialist visit (anesthesia) Durable medical equipment (glucose meter)
Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $0 Deductibles $0 Deductibles $0
Copayments $0 Copayments $315 Copayments $118
Coinsurance $0 Coinsurance $0 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $10 Limits or exclusions $0 Limits or exclusions $0
The total Peg would pay is $10 The total Joe would pay is $315 The total Mia would pay is $118
The plan would be responsible for the other costs of these EXAMPLE covered services.
SBC ID: SBC20210607MANBPPDBL01RXXDB755N072021 Page 7 of 7
