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City of Lakewood : Plan 1 Coverage Period: 0110112014.1213112014 <br />Summary of Benefits and Coverage: What This Plan Covers a What It Coats Coverage for: Single or Family Plan Type: PPO <br />• Copavments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. <br />At• Coinsurance is your share of the costs of covered service, calculated as a percent of the allowed amount for the service. For example, if the plan's <br />allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $ 200. This may change if you haven't met your <br />deductible <br />ible <br />• The amount the plan pays for covered services is based on the allowed amount, It an out-of network provider charges more than the allowed <br />amount you may have to pay the difference. For example, if an ouloRnetwork hospital charges $1,500 for an overnight stay and the allowed amount is <br />$1,000, you may have to pay the $500 difference. (This is called balance billing ) <br />This plan may encourage you to use Network providers by charging you lower dedueNhlee. apaymanta and coinsurance amounts. <br />Questions: Call 800.540.2583 or visit us at MedMulual com/SBC. P,ge 2 of S <br />If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary se4936a,3 <br />at MedMutual.comlSBC or call 800.540.2583 to request a copy. 2eN1331e5vs59e4o 323 <br />31 <br />