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City of Lakewood : Plan 2 Coverage Period: 0110V2014- 1213112014 <br />Summary of Benefits and Coverage: What This Plan Covers &What it Costa Coverage for: Single or Family I Plan Type: PPO <br />Cooavmente are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. <br />jft Coinsurance is your share of the costs of a 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 />• <br />The amoount the plan pays for covered services is based on the allowed amount. If an outof- network orovider charges more than the allowed <br />amount you may have to pay the di0erence. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is <br />51,000, you may have to pay the $500 difference. (This is celled balance billing.) <br />This plan may encourage you to use Network providers by charging you lower deductibles. conayments and coinsurance amounts. <br />Questions: Cali 800.5401583 or visit us at MedMutual.wmlSBC. pnge 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 5e493590 <br />at MedMutual.comlSBC or oil 800.640.2583 to request a copy. BEN133190993012,00025 <br />35 <br />