Insurance Company 1: Plan Option 1 Coverage Period: 1/1/2011 – 12/31/2011 Coverage Examples Coverage for: Individual + Spouse | Plan Type: PPO About these Coverage Having a baby Managing type 2 diabetes Examples: (normal delivery) (routine maintenance of a well-controlled condition) These examples show how this plan might cover  Amount owed to providers: $7,540  Amount owed to providers: $5,400 medical care in given situations. Use these  Plan pays $5,490  Plan pays $3,520 examples to see, in general, how much financial  Patient pays $2,050  Patient pays $1,880 protection a sample patient might get if they are covered under different plans. Sample care costs: Sample care costs: Hospital charges (mother) $2,700 Prescriptions $2,900 Routine obstetric care $2,100 Medical Equipment and Supplies $1,300 This is Hospital charges (baby) $900 Office Visits and Procedures $700 not a cost Anesthesia $900 Education $300 Laboratory tests $500 Laboratory tests $100 estimator. Prescriptions $200 Vaccines, other preventive $100 Radiology $200 Total $5,400 Don’t use these examples to Vaccines, other preventive $40 estimate your actual costs Patient pays: under this plan. The actual Total $7,540 Deductibles $800 care you receive will be different from these Patient pays: Copays $500 examples, and the cost of Deductibles $700 Coinsurance $500 that care will also be Copays $30 Limits or exclusions $80 different. Coinsurance $1320 Total $1,880 See the next page for Limits or exclusions $0 important information about Total $2,050 Note: These numbers assume the patient is these examples. participating in our diabetes wellness program. If you have diabetes and do not participate in the wellness program, your costs may be higher. For more information about the diabetes wellness program, please contact: [insert]. Questions: Call 1-800-[insert] or visit us at www.[insert]. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 7 of 8 at www.[insert] or call 1-800-[insert] to request a copy.