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City of Lakewood: Plan 1 Coverage Period: 01101/2017. 1213112017 <br />Summary of Benefits and Coverage: What This Plan Covers& What it Costs Coverage for: Single or Family i Plan Type: PPO <br />!Cooavments, are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you Morava the service_ <br />• Coinsurance is your share of the costs of a covered service, calculated as a percent oflhe allowed amount for the service. For example, if the plads <br />--_--- allowed amount for an overnight hospital slay is$1,000, your coinsurance payment of20%would be$200- This may change if you haven't met your <br />deductible. <br />The amount the plan pays for covered services is based on the allowed amount. if an out oi-nehvork Provide r charges more than the allowed <br />amount, you may have to pay the difference. For example, if an ouFrif-nehvork 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 deductibles copayments and coinsurance amounts. <br />City of Lakewood : Plan 1 Coverage Period: 0110112017 .12131/2017 <br />Summary of Benefits and Coverage: What This Plan Covers &What It Costs Coverage for: Single or Family I Plan Type: PPO <br />on corresponding medical benefits —cone <br />--none— <br />---none - <br />none--- <br />- --- <br />ennpahent Benefits paid based on corresponding medical benefits _none <br />- <br />care <br />care <br />Habilitation services (Speech <br />Therapy) <br />SUM nursing taro <br />Durable medical equipment <br />-none — <br />_:.-- <br />I No charge after deductible 304o coinsurance <br />nonee <br />'. No charge aflerdeducM1ble 30%coinsurance <br />', none <br />No charge afterdeduciible <br />_ <br />--none-- <br />No charge after deduc6bie ', 30%coinsurance <br />— _-. <br />- none------ <br />-after deductible <br />No charge after 30%coinsurance <br />none- <br />_-__. - __ <br />No charge after deductible ', 30%coinsurance <br />20%camsurance <br />'-none <br />20%coinsurance <br />-.. _.. <br />No charge after deductible <br />—none <br />'. No charge '30%coinsurance <br />_.. __. <br />Not Covered <br />'. Excluded Service <br />Cuesuons: Call 800,540.2683 or visit us at Medldutual.comlSBC. <br />If you aren't dear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary <br />at MedMnWoLcomISBC or call 800,540 2583 to request a copy. <br />50 <br />P 4of8 <br />Sa193559e <br />ar-u+e11a. narnwia <br />