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The
Loca
l Cho
ice:
Hig
h D
educ
tible
Hea
lth P
lan
(HD
HP)
Cov
erag
e Pe
riod:
0/01
/201
5 –
0/3
0/20
16Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s Pl
an C
over
s &
Wha
t it C
osts
Cov
erag
e fo
r: In
divi
dual
/Fam
ily|P
lan
Type
: Hig
h D
educ
tible
1 o
f 8
This
is o
nly
a su
mm
ary.
If y
ou w
ant m
ore
deta
il ab
out y
our c
over
age
and
cost
s, yo
u ca
n ge
t the
com
plet
e te
rms i
n th
e po
licy
or p
lan
docu
men
t at w
ww
.thel
ocal
choi
ce.v
irgi
nia.
gov
or b
y ca
lling
1-8
88-6
42-4
414.
Impo
rtan
t Que
stio
ns
Answ
ers
Why
this
Mat
ters
:
Wha
t is
the
over
all
dedu
ctib
le?
Com
bine
d de
duct
ible
for i
n-ne
twor
k pr
ovid
ers $
2,80
0pe
rson
/$5
,600
fam
ilyD
oesn
’t ap
ply
to p
reve
ntiv
e ca
re
You
mus
t pay
all
the
cost
s up
to th
e de
duct
ible
am
ount
bef
ore
this
plan
beg
ins
to p
ay fo
r cov
ered
serv
ices
you
use
. Che
ck y
our p
olic
y or
pla
n do
cum
ent t
o se
e w
hen
the
dedu
ctib
le st
arts
ove
r (us
ually
, but
not
alw
ays,
Janu
ary
1st).
See
the
char
t sta
rting
on
page
2 fo
r how
muc
h yo
u pa
y fo
r cov
ered
serv
ices
afte
r you
m
eet t
he d
educ
tible
. A
re th
ere
othe
r de
duct
ible
s fo
r spe
cific
se
rvic
es?
No.
Y
ou d
on’t
have
to m
eet d
educ
tible
s fo
r spe
cific
serv
ices
, but
see
the
char
t st
artin
g on
pag
e 2
for o
ther
cos
ts fo
r ser
vice
s thi
s pla
n co
vers
.
Is th
ere
an o
ut–o
f–po
cket
lim
it on
my
expe
nses
?
Yes
. For
par
ticip
atin
g pr
ovid
ers $
5,00
0pe
rson
/$1
0,00
0fa
mily
For n
on-p
artic
ipat
ing
prov
ider
s $10
,000
pe
rson
/$2
0,00
0fa
mily
The
out-
of-p
ocke
t lim
it is
the
mos
t you
cou
ld p
ay d
urin
g a
cove
rage
per
iod
(usu
ally
one
yea
r) fo
r you
r sha
re o
f the
cos
t of c
over
ed se
rvic
es. T
his l
imit
help
s yo
u pl
an fo
r hea
lth c
are
expe
nses
. The
re a
re n
o ou
t-of-
netw
ork
bene
fits e
xcep
t in
an
emer
genc
y.
Wha
t is
not i
nclu
ded
in
the
out–
of–p
ocke
t lim
it?
Ded
uctib
le a
nd c
oins
uran
ce fo
r rou
tine
dent
al se
rvic
e an
d ad
ult r
outin
e vi
sion
serv
ices
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don’
t cou
nt to
war
d th
e ou
t-of
-po
cket
lim
it.
Is th
ere
an o
vera
ll an
nual
lim
it on
wha
t th
e pl
an p
ays?
N
o.
The
char
t sta
rting
on
page
2 d
escr
ibes
any
lim
its o
n w
hat t
he p
lan
will
pay
for
specific
cov
ered
serv
ices
, suc
h as
off
ice
visit
s.
Doe
s th
is p
lan
use
a ne
twor
k of
pro
vide
rs?
Yes
. See
ww
w.a
nthe
m.c
om o
r cal
l 1-
800-
552-
2682
for a
list
of i
n-ne
twor
k pr
ovid
ers.
If y
ou u
se a
n in
-net
wor
k do
ctor
or o
ther
hea
lth c
are
prov
ider
, thi
s pla
n w
ill p
ay
som
e or
all
of th
e co
sts o
f cov
ered
serv
ices
. Be
awar
e, y
our i
n-ne
twor
k do
ctor
or
hos
pita
l may
use
an
out-o
f-ne
twor
k pr
ovid
er fo
r som
e se
rvic
es. P
lans
use
th
e te
rm in
-net
wor
k, p
refe
rred
, or p
artic
ipat
ing
for p
rovi
ders
in th
eir
netw
ork.
See
the
char
t sta
rting
on
page
2 fo
r how
this
plan
pay
s diff
eren
t kin
ds
of p
rovi
ders
.
Que
stio
ns: C
all 1
-888
-642
-441
4 or
visi
t us a
t ww
w.th
eloc
alch
oice
.vir
gini
a.go
v.
If y
ou a
ren’
t cle
ar a
bout
any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the
Glo
ssar
y. Y
ou c
an v
iew
the
Glo
ssar
y at
ww
w.th
eloc
alch
oice
.vir
gini
a.go
v or
cal
l 1-8
88-6
42-4
414
to re
ques
t a c
opy.
22
2 o
f
Do
I ne
ed a
refe
rral
to
see
a sp
ecia
list?
N
o. Y
ou d
on’t
need
a re
ferr
al to
see
a sp
ecial
ist.
You
can
see
the
spec
ialis
t you
cho
ose
with
out p
erm
issio
n fr
om th
is pl
an.
Are
ther
e se
rvic
es th
is
plan
doe
sn’t
cove
r?
Yes
. So
me
of th
e se
rvice
s thi
s plan
doe
sn’t
cove
r are
liste
d on
pag
e 5.
See
you
r po
licy
or p
lan d
ocum
ent f
or a
dditi
onal
info
rmat
ion
abou
t exc
lude
d se
rvic
es.
Cop
aym
ents
are
fixe
d do
llar a
mou
nts (
for e
xam
ple,
$25)
you
pay
for c
over
ed h
ealth
car
e, us
ually
whe
n yo
u re
ceiv
e th
e se
rvice
.C
oins
uran
ce is
your
shar
e of
the
costs
of a
cov
ered
serv
ice, c
alcul
ated
as a
per
cent
of t
he a
llow
ed a
mou
nt fo
r the
serv
ice. F
or e
xam
ple,
ifth
e pl
an’s
allo
wed
am
ount
for a
n ov
erni
ght h
ospi
tal s
tay
is $1
,000
, you
r coi
nsur
ance
pay
men
t of 2
0% w
ould
be
$200
. Th
is m
ay c
hang
e if
you
have
n’t m
et y
our d
educ
tible
.Th
e am
ount
the
plan
pay
s for
cov
ered
serv
ices i
s bas
ed o
n th
e al
low
ed a
mou
nt. I
f an
out-o
f-net
wor
k pr
ovid
er c
harg
es m
ore
than
the
allo
wed
am
ount
, you
may
hav
e to
pay
the
diffe
renc
e. Fo
r exa
mpl
e, if
an o
ut-o
f-net
wor
k ho
spita
l cha
rges
$1,
500
for a
n ov
erni
ght s
tay
and
the
allo
wed
am
ount
is $
1,00
0, y
ou m
ay h
ave
to p
ay th
e $5
00 d
iffer
ence
. (Th
is is
calle
d ba
lanc
e bi
lling
.)Th
is pl
an m
ay e
ncou
rage
you
to u
se in
-net
wor
k pr
ovid
ers
by c
harg
ing
you
low
er d
educ
tible
s, co
paym
ents
and
coi
nsur
ance
am
ount
s.
Com
mon
Med
ical
Eve
nt
Serv
ices
You
May
Ne
ed
Your
Cos
t If Y
ou
Use
an
In-N
etw
ork
Prov
ider
Your
Cos
t If Y
ou
Use
a
Non-
Netw
ork
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou v
isit
a he
alth
ca
re p
rovi
der’s
offi
ce
or c
linic
Prim
ary
care
visi
t to
treat
an
inju
ry o
r illn
ess
20%
coi
nsur
ance
afte
r de
duct
ible
40%
coi
nsur
ance
afte
r de
duct
ible
––––
––––
–––n
one–
––––
––––
––
Spec
ialist
visi
t 20
% c
oins
uran
ce a
fter
dedu
ctib
le 40
% c
oins
uran
ce a
fter
dedu
ctib
le ––
––––
––––
–non
e–––
––––
––––
Oth
er p
ract
ition
er o
ffice
vi
sit
20%
coi
nsur
ance
afte
r de
duct
ible
40%
coi
nsur
ance
afte
r de
duct
ible
Cove
rage
is li
mite
d to
30
visit
s ann
ual m
ax fo
r ch
iropr
actic
. Pr
even
tive c
are/
sc
reen
ing/
imm
uniza
tion
No
char
ge
40%
coi
nsur
ance
afte
r de
duct
ible
––––
––––
–––n
one–
––––
––––
––
If y
ou h
ave
a te
st
Diag
nost
ic te
st (x
-ray,
bloo
d w
ork)
20
% c
oins
uran
ce a
fter
dedu
ctib
le 40
% c
oins
uran
ce a
fter
dedu
ctib
le ––
––––
––––
–non
e–––
––––
––––
Imag
ing
(CT/
PET
scan
s, M
RIs)
20
% c
oins
uran
ce a
fter
dedu
ctib
le 40
% c
oins
uran
ce a
fter
dedu
ctib
le Pr
e-au
thor
izat
ion
may
be
requ
ired.
23
3 o
f
Com
mon
Med
ical
Eve
nt
Serv
ices
You
May
Ne
ed
Your
Cos
t If Y
ou
Use
an
In-N
etw
ork
Prov
ider
Your
Cos
t If Y
ou
Use
a
Non-
Netw
ork
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou n
eed
drug
s to
tr
eat y
our i
llnes
s or
co
nditi
on
Mor
e in
form
atio
n ab
out p
resc
riptio
n dr
ug c
over
age
is av
ailab
le at
w
ww
.ant
hem
.com
.
Gen
eric
drug
s 20
% c
oins
uran
ce a
fter
dedu
ctib
le 40
% c
oins
uran
ce a
fter
dedu
ctib
le
Cove
rs u
p to
a 3
4-da
y su
pply
(reta
il pr
escr
iptio
n); 9
0 da
y su
pply
(hom
e de
liver
y pr
escr
iptio
n). I
f you
use
a n
on-n
etw
ork
phar
mac
y, yo
u pa
y th
e di
ffere
nce
betw
een
the
phar
mac
y ch
arge
and
the
plan
allo
wab
le ch
arge
.
Pref
erre
d br
and
drug
s 20
% c
oins
uran
ce a
fter
dedu
ctib
le 40
% c
oins
uran
ce a
fter
dedu
ctib
le Pl
ease
see
limita
tions
in G
ener
ic dr
ugs.
Non
-pre
ferr
ed b
rand
dr
ugs
20%
coi
nsur
ance
afte
r de
duct
ible
40%
coi
nsur
ance
afte
r de
duct
ible
Plea
se se
e lim
itatio
ns in
Gen
eric
drug
s.
Spec
ialty
dru
gs
20%
coi
nsur
ance
afte
r de
duct
ible
40%
coi
nsur
ance
afte
r de
duct
ible
Plea
se se
e lim
itatio
ns in
Gen
eric
drug
s.
If y
ou h
ave
outp
atie
nt s
urge
ry
Facil
ity fe
e (e
.g.,
ambu
lator
y su
rger
y ce
nter
) 20
% c
oins
uran
ce a
fter
dedu
ctib
le 40
% c
oins
uran
ce a
fter
dedu
ctib
le ––
––––
––––
–non
e–––
––––
––––
Phys
ician
/sur
geon
fees
20
% c
oins
uran
ce a
fter
dedu
ctib
le 40
% c
oins
uran
ce a
fter
dedu
ctib
le ––
––––
––––
–non
e–––
––––
––––
If y
ou n
eed
imm
edia
te m
edic
al
atte
ntio
n
Em
erge
ncy
room
serv
ices
20%
coi
nsur
ance
afte
r de
duct
ible
40%
coi
nsur
ance
afte
r de
ducib
le.
Em
erge
ncy
serv
ices
will
be
cons
ider
ed at
th
e In
-Net
wor
k be
nefit
lev
el; h
owev
er, b
alanc
e bi
lling
may
still
occ
ur.
––––
––––
–––n
one–
––––
––––
––
Em
erge
ncy
med
ical
trans
porta
tion
20%
coi
nsur
ance
afte
r de
duct
ible
40%
coi
nsur
ance
afte
r de
ducib
le.
Em
erge
ncy
serv
ices
will
be
cons
ider
ed at
th
e In
-Net
wor
k be
nefit
lev
el; h
owev
er, b
alanc
e bi
lling
may
still
occ
ur.
––––
––––
–––n
one–
––––
––––
––
Urg
ent c
are
20%
coi
nsur
ance
afte
r de
duct
ible
40%
coi
nsur
ance
afte
r de
duct
ible
––––
––––
–––n
one–
––––
––––
––
24
4 o
f
Com
mon
Med
ical
Eve
nt
Serv
ices
You
May
Ne
ed
Your
Cos
t If Y
ou
Use
an
In-N
etw
ork
Prov
ider
Your
Cos
t If Y
ou
Use
a
Non-
Netw
ork
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou h
ave
a ho
spita
l sta
y
Facil
ity fe
e (e
.g.,
hosp
ital
room
) 20
% c
oins
uran
ce a
fter
dedu
ctib
le 40
% c
oins
uran
ce a
fter
dedu
ctib
le ––
––––
––––
–non
e–––
––––
––––
Phys
ician
/sur
geon
fee
20%
coi
nsur
ance
afte
r de
duct
ible
40%
coi
nsur
ance
afte
r de
duct
ible
––––
––––
–––n
one–
––––
––––
––
If y
ou h
ave
men
tal
heal
th, b
ehav
iora
l he
alth
, or s
ubst
ance
ab
use
need
s
Men
tal/
Beha
vior
al he
alth
outp
atien
t ser
vice
s 20
% c
oins
uran
ce a
fter
dedu
ctib
le 40
% c
oins
uran
ce a
fter
dedu
ctib
le ––
––––
––––
–non
e–––
––––
––––
Men
tal/
Beha
vior
al he
alth
inpa
tient
serv
ices
20%
coi
nsur
ance
afte
r de
duct
ible
40%
coi
nsur
ance
afte
r de
duct
ible
––––
––––
–––n
one–
––––
––––
––
Subs
tanc
e us
e di
sord
er
outp
atien
t ser
vice
s 20
% c
oins
uran
ce a
fter
dedu
ctib
le 40
% c
oins
uran
ce a
fter
dedu
ctib
le ––
––––
––––
–non
e–––
––––
––––
Subs
tanc
e us
e di
sord
er
inpa
tient
serv
ices
20%
coi
nsur
ance
afte
r de
duct
ible
40%
coi
nsur
ance
afte
r de
duct
ible
––––
––––
–––n
one–
––––
––––
––
Em
ploy
ee A
ssist
ance
Pr
ogra
m (E
AP)
N
o Ch
arge
40
% c
oins
uran
ce a
fter
dedu
ctib
le Co
vers
up
to 4
visi
ts p
er in
ciden
t with
in a
12
mon
th p
erio
d.
If y
ou a
re p
regn
ant
Pren
atal
and
postn
atal
care
20
% c
oins
uran
ce a
fter
dedu
ctib
le 40
% c
oins
uran
ce a
fter
dedu
ctib
le ––
––––
––––
–non
e–––
––––
––––
Deli
very
and
all i
npat
ient
serv
ices
20%
coi
nsur
ance
afte
r de
duct
ible
40%
coi
nsur
ance
afte
r de
duct
ible
––––
––––
–––n
one–
––––
––––
––
If y
ou n
eed
help
re
cove
ring
or h
ave
othe
r spe
cial
hea
lth
need
s
Hom
e he
alth
care
20
% c
oins
uran
ce a
fter
dedu
ctib
le 40
% c
oins
uran
ce a
fter
dedu
ctib
le Co
vera
ge is
lim
ited
to 9
0 vi
sits m
ax. p
er
cove
rage
per
iod.
Reha
bilit
atio
n se
rvice
s 20
% c
oins
uran
ce a
fter
dedu
ctib
le 40
% c
oins
uran
ce a
fter
dedu
ctib
le ––
––––
––––
–non
e–––
––––
––––
Hab
ilita
tion
serv
ices
20%
coi
nsur
ance
afte
r de
duct
ible
40%
coi
nsur
ance
afte
r de
duct
ible
––––
––––
–––n
one–
––––
––––
––
Skill
ed n
ursin
g ca
re
20%
coi
nsur
ance
afte
r de
duct
ible
40%
coi
nsur
ance
afte
r de
duct
ible
Cove
rage
is li
mite
d to
180
day
s max
. per
co
vera
ge p
erio
d.
Dur
able
med
ical
equi
pmen
t 20
% c
oins
uran
ce a
fter
dedu
ctib
le 40
% c
oins
uran
ce a
fter
dedu
ctib
le ––
––––
––––
–non
e–––
––––
––––
Hos
pice
serv
ice
20%
coi
nsur
ance
afte
r de
duct
ible
40%
coi
nsur
ance
afte
r de
duct
ible
––––
––––
–––n
one–
––––
––––
––
25
5 o
f
If y
our c
hild
nee
ds
dent
al o
r eye
car
e
Eye
exa
m
$15
copa
y N
ot C
over
ed
Lim
it on
e ex
am p
er p
lan y
ear
Glas
ses
$20
copa
y fo
r len
ses,
balan
ce o
ver $
100
for
fram
es
Not
Cov
ered
Se
e yo
ur fo
rmal
cont
ract
for c
ompl
ete
deta
ils
Den
tal c
heck
-up
No
Char
ge
Prov
ider
Cha
rge
in
exce
ss o
f plan
’s co
ntra
ctua
l rat
e
Den
tal c
over
age
adm
inist
ered
by
Delt
a D
enta
l of
Virg
inia,
ww
w.d
elta
dent
alva
.com
or c
all
1-88
8-33
5-82
96.
Excl
uded
Ser
vice
s &
Oth
er C
over
ed S
ervi
ces:
Serv
ices
You
r Pla
n Do
es N
OT
Cove
r (T
his
isn’
t a c
ompl
ete
list.
Che
ck y
our p
olic
y or
pla
n do
cum
ent f
or o
ther
exc
lude
d se
rvic
es.)
Acu
punc
ture
Cosm
etic
surg
ery
Hea
ring
aids
Infe
rtilit
y tre
atm
ent
Long
-term
car
e
Rout
ine
eye
care
Rout
ine
foot
car
e (e
xcep
t for
som
e di
abet
ictre
atm
ent –
plea
se se
e yo
ur m
embe
rha
ndbo
ok fo
r com
plet
e de
tails
)
Weig
ht lo
ss p
rogr
ams
Oth
er C
over
ed S
ervi
ces
(Thi
s is
n’t a
com
plet
e lis
t. C
heck
you
r pol
icy
or p
lan
docu
men
t for
oth
er c
over
ed s
ervi
ces
and
your
cos
ts fo
r the
se
serv
ices
.)
Baria
tric
surg
ery
Chiro
prac
tic c
are
Den
tal c
are
Mos
t cov
erag
e pr
ovid
ed o
utsid
e th
e U
nite
dSt
ates
. See
ww
w.a
nthe
m.c
om/t
lc
Non
-em
erge
ncy
care
whe
n tra
velin
g ou
tside
the
U.S
.
Priv
ate-
duty
nur
sing
26
6 o
f
Your
Rig
hts
to C
ontin
ue C
over
age:
If y
ou lo
se c
over
age
unde
r the
plan
, the
n, d
epen
ding
upo
n th
e cir
cum
stan
ces,
Fede
ral a
nd S
tate
law
s may
pro
vide
pro
tect
ions
that
allo
w y
ou to
kee
p he
alth
cove
rage
. Any
such
righ
ts m
ay b
e lim
ited
in d
urat
ion
and
will
requ
ire y
ou to
pay
a p
rem
ium
, whi
ch m
ay b
e sig
nific
antly
hig
her t
han
the
prem
ium
you
pay
w
hile
cove
red
unde
r the
plan
. Oth
er li
mita
tions
on
your
righ
ts to
con
tinue
cov
erag
e m
ay a
lso a
pply.
For m
ore
info
rmat
ion
on y
our r
ight
s to
cont
inue
cov
erag
e, co
ntac
t the
plan
at 1
-888
-642
-441
4. Y
ou m
ay a
lso c
onta
ct y
our s
tate
insu
ranc
e de
partm
ent,
the
U.S
. Dep
artm
ent o
f Lab
or, E
mpl
oyee
Ben
efits
Sec
urity
Adm
inist
ratio
n at
1-8
66-4
44-3
272
or w
ww
.dol
.gov
/ebs
a, o
r the
U.S
. Dep
artm
ent o
f Hea
lth a
nd
Hum
an S
ervi
ces a
t 1-8
77-2
67-2
323
x615
65 o
r ww
w.c
ciio
.cm
s.go
v.
Your
Grie
vanc
e an
d Ap
peal
s Ri
ghts
:If
you
hav
e a
com
plain
t or a
re d
issat
isfied
with
a d
enial
of c
over
age
for c
laim
s und
er y
our p
lan, y
ou m
ay b
e ab
le to
app
eal o
r file
a gr
ieva
nce.
For
qu
estio
ns a
bout
you
r rig
hts,
this
notic
e, or
ass
istan
ce, y
ou c
an c
onta
ct:
Dire
ctor
, Dep
artm
ent o
f Hum
an R
esou
rce
Man
agem
ent,
101
Nor
th 1
4th S
treet
–
12th F
loor
, Rich
mon
d, V
irgin
ia 23
219-
3657
. Mar
k en
velo
pe C
onfid
entia
l-App
eal E
nclo
sed.
Tel
epho
ne: 1
-888
-642
-441
4.
Does
this
Cov
erag
e Pr
ovid
e M
inim
um E
ssen
tial C
over
age?
Th
e A
fford
able
Care
Act
requ
ires m
ost p
eopl
e to
hav
e he
alth
care
cov
erag
e th
at q
ualif
ies a
s “m
inim
um e
ssen
tial c
over
age.”
Thi
s pl
an o
r pol
icy
does
pr
ovid
e m
inim
um e
ssen
tial c
over
age.
Does
this
Cov
erag
e M
eet t
he M
inim
um V
alue
Sta
ndar
d?Th
e A
fford
able
Care
Act
est
ablis
hes a
min
imum
valu
e st
anda
rd o
f ben
efits
of a
hea
lth p
lan.
The
min
imum
valu
e st
anda
rd is
60%
(act
uaria
l valu
e). T
his
heal
th c
over
age
does
mee
t the
min
imum
val
ue s
tand
ard
for t
he b
enef
its it
pro
vide
s.
Lang
uage
Acc
ess
Serv
ices
:
––––
––––
––––
––––
––––
––To
see e
xamp
les of
how
this
plan
migh
t cov
er cos
ts for
a sa
mple
medi
cal s
ituat
ion, s
ee th
e nex
t pag
e.–––
––––
––––
––––
––––
–––
27
7 o
f
Havi
ng a
bab
y (n
orm
al de
liver
y)
Man
agin
g ty
pe 2
dia
bete
s (ro
utin
e main
tena
nce o
f a w
ell-c
ontro
lled
cond
ition
)
Abou
t the
se C
over
age
Exam
ples
: Th
ese e
xam
ples
show
how
this
plan
mig
ht co
ver
med
ical c
are i
n gi
ven
situa
tions
. Use
thes
e ex
ampl
es to
see,
in g
ener
al, h
ow m
uch
finan
cial
prot
ectio
n a s
ampl
e pat
ient m
ight
get
if th
ey ar
e co
vere
d un
der d
iffer
ent p
lans.
Amou
nt o
wed
to p
rovi
ders
: $7,
540
Plan
pay
s $3
,790
Patie
nt p
ays
$3,7
50
Sam
ple
care
cos
ts:
Hos
pita
l cha
rges
(mot
her)
$2,7
00
Rout
ine o
bste
tric c
are
$2,1
00
Hos
pita
l cha
rges
(bab
y)
$900
A
nesth
esia
$900
La
bora
tory
tests
$5
00
Pres
crip
tions
$2
00
Radi
olog
y $2
00
Vac
cines
, oth
er p
reve
ntiv
e $4
0 T
otal
$7
,540
Patie
nt p
ays:
D
educ
tibles
$2
,800
Co
pays
$0
Co
insu
ranc
e $9
50
Lim
its o
r exc
lusio
ns
$0
Tot
al
$3,7
50
Amou
nt o
wed
to p
rovi
ders
: $5,
400
Plan
pay
s $2
,100
Patie
nt p
ays
$3,3
00
Sam
ple
care
cos
ts:
Pres
crip
tions
$2
,900
M
edica
l Equ
ipm
ent a
nd S
uppl
ies
$1,3
00
Offi
ce V
isits
and
Proc
edur
es
$700
Ed
ucat
ion
$300
La
bora
tory
tests
$1
00
Vac
cines
, oth
er p
reve
ntiv
e $1
00
Tot
al
$5,4
00
Patie
nt p
ays:
D
educ
tibles
$2
,800
Co
pays
$0
Co
insu
ranc
e $5
00
Lim
its o
r exc
lusio
ns
$0
Tot
al
$3,3
00
This
is
not a
cos
t es
timat
or.
Don
’t us
e the
se ex
ampl
es to
es
timat
e you
r act
ual c
osts
unde
r thi
s plan
. The
actu
al ca
re yo
u re
ceiv
e will
be
diffe
rent
from
thes
e ex
ampl
es, a
nd th
e cos
t of
that
care
will
also
be
diffe
rent
.
See t
he n
ext p
age f
or
impo
rtant
info
rmat
ion
abou
t th
ese e
xam
ples
.
28
8 o
f
Que
stio
ns a
nd a
nsw
ers
abou
t the
Cov
erag
e Ex
ampl
es:
Wha
t are
som
e of
the
assu
mpt
ions
beh
ind
the
Cove
rage
Exa
mpl
es?
Costs
don
’t in
clude
pre
miu
ms.
Sam
ple
care
costs
are
base
d on
nat
iona
lav
erag
es su
pplie
d by
the U
.S.
Dep
artm
ent o
f Hea
lth an
d H
uman
Serv
ices,
and
aren
’t sp
ecifi
c to
apa
rticu
lar g
eogr
aphi
c ar
ea o
r hea
lth p
lan.
The
patie
nt’s
cond
ition
was
not
anex
clude
d or
pre
exist
ing
cond
ition
.A
ll se
rvice
s and
trea
tmen
ts sta
rted
and
ende
d in
the
sam
e co
vera
ge p
erio
d.Th
ere
are
no o
ther
med
ical e
xpen
ses f
oran
y m
embe
r cov
ered
und
er th
is pl
an.
Out
-of-p
ocke
t exp
ense
s are
bas
ed o
nly
on tr
eatin
g th
e co
nditi
on in
the
exam
ple.
The
patie
nt re
ceiv
ed al
l car
e fro
m in
-ne
twor
k pr
ovid
ers.
If th
e pa
tient
had
rece
ived
care
from
out
-of-n
etw
ork
prov
ider
s, co
sts w
ould
hav
e be
en h
ighe
r.
Wha
t doe
s a
Cove
rage
Exa
mpl
e sh
ow?
For e
ach
treat
men
t situ
atio
n, th
e Co
vera
ge
Exam
ple
help
s you
see
how
ded
uctib
les,
copa
ymen
ts, a
nd c
oins
uran
ce c
an ad
d up
. It
also
help
s you
see
wha
t exp
ense
s mig
ht b
e lef
t up
to y
ou to
pay
bec
ause
the
serv
ice o
r tre
atm
ent i
sn’t
cove
red
or p
aym
ent i
s lim
ited.
Does
the
Cove
rage
Exa
mpl
e pr
edic
t my
own
care
nee
ds?
No.
Tre
atm
ents
show
n ar
e ju
st ex
ampl
es.
The
care
you
wou
ld re
ceiv
e fo
r thi
s co
nditi
on c
ould
be
diffe
rent
bas
ed o
n yo
ur
doct
or’s
advi
ce, y
our a
ge, h
ow se
rious
you
r co
nditi
on is
, and
man
y ot
her f
acto
rs.
Does
the
Cove
rage
Exa
mpl
e pr
edic
t my
futu
re e
xpen
ses?
No.
Cov
erag
e Exa
mpl
es ar
e no
t cos
tes
timat
ors.
You
can’
t use
the
exam
ples
to
estim
ate
costs
for a
n ac
tual
cond
ition
. The
y ar
e fo
r com
para
tive
purp
oses
onl
y. Yo
ur
own
costs
will
be
diffe
rent
dep
endi
ng o
n th
e ca
re y
ou re
ceiv
e, th
e pr
ices y
our
prov
ider
s ch
arge
, and
the
reim
burs
emen
t yo
ur h
ealth
plan
allo
ws.
Can
I use
Cov
erag
e Ex
ampl
es
to c
ompa
re p
lans
?
Yes
. Whe
n yo
u lo
ok at
the
Sum
mar
y of
Bene
fits a
nd C
over
age
for o
ther
plan
s,yo
u’ll
find
the
sam
e Co
vera
ge E
xam
ples
.W
hen
you
com
pare
plan
s, ch
eck
the
“Pat
ient P
ays”
box
in e
ach
exam
ple.
The
small
er th
at n
umbe
r, th
e m
ore
cove
rage
the
plan
pro
vide
s.
Are
ther
e ot
her c
osts
I sh
ould
co
nsid
er w
hen
com
parin
g pl
ans?
Yes
. An
impo
rtant
cos
t is t
he p
rem
ium
you
pay.
Gen
erall
y, th
e lo
wer
you
rpr
emiu
m, t
he m
ore
you’
ll pa
y in
out
-of-
pock
et c
osts,
such
as c
opay
men
ts,
dedu
ctib
les,
and
coin
sura
nce.
You
shou
ld al
so c
onsid
er c
ontri
butio
ns to
acco
unts
such
as h
ealth
savi
ngs a
ccou
nts
(HSA
s), fl
exib
le sp
endi
ng ar
rang
emen
ts(F
SAs)
or h
ealth
reim
burs
emen
t acc
ount
s(H
RAs)
that
help
you
pay
out
-of-p
ocke
tex
pens
es.
29
Hig
h D
educ
tible
Hea
lth P
lan
Empl
oyee
Mon
thly
Rat
es
Hig
h D
educ
tible
Hea
lth P
lan
with
Pre
vent
ativ
e D
enta
l
Empl
oyee
Onl
y$0
.00
Empl
oyee
+ O
ne$1
34.0
0
Fam
ily$2
68.0
0
Hig
h D
educ
tible
Hea
lth P
lan
with
Com
preh
ensi
ve D
enta
l
Empl
oyee
Onl
y$0
.00
Empl
oyee
+ O
ne$1
58.0
0
Fam
ily$3
03.0
0
30
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