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CITY OF LAKEWOOD: Plan 2—MMOLOPlan AFSCME Coce.agoPertd:January 11'2H„ 3P�th17 <br />SUMMRF•j Of 6OVefatJe:V7hat This Plan Covers BV!lhat it Costs Coveragefcr. Singleor FaWy I Plan Type: PPO <br />Co-paymenfa are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service_ <br />Cc -Insurance is your share of the costs of a covered service, calculated as a pement of the allowed amount for the service. For example, if the Ales <br />allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 10%would be $1C0. This may change if you haven't met your <br />deductible. <br />The amount the plan pays for covered services is based on ffifillkneou amount. If an out-0f�etwork provide r charges more than lh Ig,g LgWA <br />amount you may have to pay the difference. For example, if an outnf-network hosptal charges S1,500 form overnight stay and the, allowed amounlis <br />S190D, you may have to pay the $500 difference. (This is cal!sd balance billing) <br />• This pan may encourage you tome[JePxmk providers by charging yen lower deductibles, co-paymenls and co-insurance amounts. <br />53 <br />