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Sample care costs:
Total
Total
Patient pays:
Patient pays:
Total
Total
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.
Amount owed to providers:
$ 7,540
Amount owed to providers:
$ 5,400
Plan pays:
$ 5,300
Plan pays:
$ 3,350
Patient pays:
$ 2,240
Patient pays:
$ 2,050
Sample care costs:
Open Access Aetna Select HSA 80
Summary of Benefits and Coverage
: What this Plan Covers & What it Costs
Coverage Period
: 01/01/2014 - 12/31/2014
Coverage for
: Employee + Family |
Plan Type
: HMO/High Deductible
About these Coverage
Examples:
Having a baby
(normal delivery)
Managing type 2 diabetes
(routine maintenance of a
well-controlled condition)
Anesthesia
900
Education
300
Laboratory tests
500
Laboratory tests
100
Prescriptions
200
Vaccines, other preventive
100
Hospital charges (mother)
$ 2,700
Prescriptions
$ 2,900
Routine obstetric care
2,100 Medical Equipment and Supplies
1,300
Hospital charges (baby)
900 Office Visits and Procedures
700
Deductibles
$ 1,300
Co-insurance
$ 310
Co-pays
$ 20
Limits or exclusions
$ 80
Co-insurance
$ 770
$ 2,050
Radiology
200
$ 5,400
Vaccines, other preventive
40
$ 7,540
Deductibles
$ 1,300
Co-pays
$ 360
Limits or exclusions
$ 150
$ 2,240
Note: These coverage examples are calculated using the deductible for individual coverage. A higher deductible applies to family coverage
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.
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