▪
▪
▪
▪
▪
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Sample care costs:
Total
Total
Patient pays:
Patient pays:
Total
Total
$ 2,480
Note: These coverage examples are calculated using the deductible for individual coverage. A higher deductible applies to family coverage
Limits or exclusions
$ 7,540
$ 1,600
Vaccines, other preventive
200
100
100
$ 2,900
Prescriptions
1,300
700
300
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
$ 2,700
2,100
900
900
Laboratory tests
Sample care costs:
Plan pays:
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.
Aetna HealthFund HSA80
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
: PPO/High Deductible
$ 5,400
Managing type 2 diabetes
(routine maintenance of a
well-controlled condition)
$ 5,060
$ 2,480
$ 7,540
Having a baby
(normal delivery)
$ 3,110
$ 2,290
About these Coverage
Examples:
Patient pays:
Amount owed to providers:
Plan pays:
Amount owed to providers:
Patient pays:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
$ 5,400
Deductibles
Co-pays
$ 1,600
$ 330
$ 280
$ 80
500
Education
Laboratory tests
Radiology
$ 20
$ 710
200
40
Limits or exclusions
Deductibles
Co-pays
Co-insurance
$ 150
Vaccines, other preventive
$ 2,290
Co-insurance
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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