Open Enrollment 2018

About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

Managing type 2 diabetes (routine maintenance of a well-controlled condition)

Having a baby (normal delivery)

 Amount owed to providers: $7,540  Plan pays: $8,250  Patient pays: $4,550 Sample care costs: Hospital charges (mother)

 Amount owed to providers: $5,400  Plan pays: $2,787  Patient pays: $4,613 Sample care costs: Prescriptions Medical Equipment and Supplies

$2,700 $2,100

$2,900 $1,300

Routine obstetric care Hospital charges (baby)

$900 $900 $500 $200 $200

Office Visits and Procedures

$700 $300 $100 $100

This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples.

Anesthesia

Education

Laboratory tests

Laboratory tests

Prescriptions

Vaccines, other preventive

Total

$5,400

Radiology

Vaccines, other preventive

$40

Patient pays: Deductibles

Total

$7,540

$4,000

Co-pays

$435 $178

Patient pays: Deductibles

$4,000

Coinsurance

Co-pays

$540

Limits or exclusions

$0

Total

$4,613

Coinsurance

$0

Limits or exclusions

$10

Total

$4,550

Note: These coverage examples calculations are based on Individual Coverage Tier numbers for this plan.

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CareFirst SBC ID: SBC20170403MANBTHMMX98RXCMMX90N012017