Common use of Your Grievance and Appeals Rights Clause in Contracts

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you file your appeal. Contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx. Does this plan provide Minimum Essential Coverage? Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Para obtener asistencia en Español, llame al 0-000-000-0000. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––––– This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. (a year of routine in-network care of a well- controlled condition)  The plan’s overall deductible $0  Specialist copayment $20  Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $20  Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $20  Hospital (facility) coinsurance 0%  Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $0 Copayments $30 Coinsurance $10 Limits or exclusions $60 Deductibles $0 Copayments $160 Coinsurance $1200 Limits or exclusions $60 Deductibles $0 Copayments $210 Coinsurance $50 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you file your appeal. Contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx. Does this plan provide Minimum Essential Coverage? Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Para obtener asistencia en Español, llame al 0-000-000-0000. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––––– This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. (a year of routine in-network care of a well- controlled condition)  ◼ The plan’s overall deductible $0  ◼ Specialist copayment $20  ◼ Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $20  Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $20  Hospital (facility) coinsurance 0%  No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $0 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $0 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $0 Copayments $30 20 Coinsurance $10 0 Limits or exclusions $100 Deductibles $0 Copayments $160 Coinsurance $1,200 Limits or exclusions $60 Deductibles $0 Copayments $160 200 Coinsurance $1200 Limits or exclusions $60 Deductibles $0 Copayments $210 Coinsurance $50 80 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services. The information listed here is not a guarantee of payment. Payment is based on the Delta Dental allowance for each procedure. To be covered, services must be dentally necessary and in accordance with Delta Dental's treatment guidelines. All services must be performed in a dental office. These benefits are listed according to the level of coverage (i.e. 100%,80%) . Your group number is 5885‐0608. Coverage for benefits with time limitations (i.e. 6,12,24,36 or 60 months) is calculated to the exact day.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you file your appeal. Contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx. Does this plan provide Minimum Essential Coverage? Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Para obtener asistencia en Español, llame al 0-000-000-0000. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––––– This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. (a year of routine in-network care of a well- controlled condition)  ◼ The plan’s overall deductible $0  ◼ Specialist copayment $20  ◼ Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $20  Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $20  Hospital (facility) coinsurance 0%  No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) ◼ The plan’s overall deductible $0 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) ◼ The plan’s overall deductible $0 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance No Charge ◼ Other coinsurance 20% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $0 Copayments $30 20 Coinsurance $10 0 Limits or exclusions $100 Deductibles $0 Copayments $160 Coinsurance $1,200 Limits or exclusions $60 Deductibles $0 Copayments $160 200 Coinsurance $1200 Limits or exclusions $60 Deductibles $0 Copayments $210 Coinsurance $50 80 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services. The information listed here is not a guarantee of payment. Payment is based on the Delta Dental allowance for each procedure. To be covered, services must be dentally necessary and in accordance with Delta Dental's treatment guidelines. All services must be performed in a dental office. These benefits are listed according to the level of coverage (i.e. 100%,80%) . Your group number is 5885-0605. Coverage for benefits with time limitations (i.e. The annual maximum is: $2,000.00 per member per calendar year (Periodontal services limited to $400.00) The annual deductible is: $0.00 The maximum lifetime cap: Unlimited • Oral exam - once per calendar year performed by a general dentist • Cleaning - twice per calendar year • Fluoride treatment - for children under age 19 once per calendar year • Bitewing x-rays - one set per calendar year • Complete x-ray series or panoramic film once every 36 months • Single x-rays as required • Palliative treatment (minor procedures necessary to relieve acute pain) twice per calendar year • Amalgam (silver) fillings. Composite (white) fillings on front teeth only. For composite fillings on back teeth, the plan pays up to what would’ve been paid for an amalgam filling. Patient responsible for balance up to the dentist's charge. • Space maintainers once every 60 months for lost deciduous (baby) teeth • Extractions and other routine oral surgery when not covered by a patient's medical plan • General anesthesia or intravenous (I.V.) sedation for certain complex surgical procedures • Root canal therapy on permanent teeth - one procedure per tooth per lifetime. Vital pulpotomy and apicoectomies also covered once per tooth per lifetime. • Repairs to existing partial or complete dentures once per calendar year • Recementing crowns or bridges once every 60 months • Rebasing or relining of partial or complete dentures once every 60 months • Crowns over natural teeth, build ups, posts and cores - replacement limited to once every 60 months • Periodontal maintenance following active therapy - two per year • Root planing and scaling once per quadrant every 24 months. • Osseous (bone) surgery once per quadrant every 36 months (bone grafts are not covered). • Gingivectomies once per site every 36 months. • Soft tissue grafts once per site every 60 months • Crown lengthening once per site every 60 months Delta Dental of Rhode Island ◼ P. O. Xxx 0000 ◼ Xxxxxxxxxx, XX 00000-0000 ◼ 0.000.000.0000 ◼ xxxxxxxxxxxxx.xxx Exclusions & Limitations Unless specifically covered by your dental plan, the following are not covered: ◼ Services that are not dentally necessary and appropriate according to our review guidelines. Services subject to these guidelines include, but are not limited to, root canals; crowns and related services; bridges; periodontal services; orthodontics; and oral surgery. We will make a decision whether a service is dentally necessary based on these guidelines. A service may not be covered under these guidelines even if it was recommended by a dentist. Our guidelines can be found on our website at xxx.xxxxxxxxxxxxx.xxx. You can have your dentist send us a request for a pre-treatment estimate in advance of the service to see if the service meets our guidelines. ◼ Services greater than the annual maximum. ◼ Services received from a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trustee or similar person or group. ◼ An illness or injury that Delta Dental decides is employment-related. ◼ Services you would not have to pay for if you did not have this Delta Dental coverage. ◼ Services or supplies that are experimental in terms of generally accepted dental standards. ◼ Services done by a dentist who is a member of your immediate family. ◼ An illness, injury or dental condition for which benefits are, or would have been available, through a government program if you did not have this Delta Dental coverage. ◼ Services done by someone who is not a licensed dentist or a licensed hygienist working as authorized by applicable law. ◼ Exams by specialists, except for periodic oral exams. ◼ Consultations. ◼ Disorders related to the temporomandibular joints (TMJ), including night guards and surgery. ◼ Services to increase the height of teeth or restore occlusion. ◼ Restorations needed because of teeth grinding or due to erosion, abrasion or attrition. ◼ Services done mainly to change or to improve your appearance. ◼ Occlusal guards. ◼ Implants. ◼ Bone grafts. ◼ Splinting and other services to stabilize teeth. ◼ Laboratory or bacteriological tests or reports. ◼ Temporary, complete dentures or temporary, fixed bridges or crowns. ◼ Prescription drugs. ◼ Guided tissue regeneration. ◼ General anesthesia or intravenous sedation for non-surgical extractions, diagnostic, preventive, or minor restorative services. ◼ General anesthesia or intravenous sedation given by anyone other than a dentist. Delta Dental can adopt; and, apply, policies that we deem reasonable when we approve the eligibility of subscribers; and, the appropriateness of treatment plans and related charges.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you file your appeal. Contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx. Does this plan provide Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage? Yes. If , you don’t have Minimum Essential Coverage may not be eligible for a month, you’ll have to make a payment when you file your the premium tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? Yescredit. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Para obtener asistencia en Español, llame al 0-000-000-0000. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––––– Other Covered Services (Limitations may apply to these services. This is not isn’t a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health planscomplete list. Please note these coverage examples are based on self-only coverage. (a year of routine in-network care of a well- controlled condition)  The plan’s overall deductible $0  Specialist copayment $20  Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $20  Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $20  Hospital (facility) coinsurance 0%  Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $0 Copayments $30 Coinsurance $10 Limits or exclusions $60 Deductibles $0 Copayments $160 Coinsurance $1200 Limits or exclusions $60 Deductibles $0 Copayments $210 Coinsurance $50 Limits or exclusions $0 The see your plan would be responsible for the other costs of these EXAMPLE covered servicesdocument.)

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you file your appeal. Contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx. Does this plan provide Minimum Essential Coverage? Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Para obtener asistencia en Español, llame al 0-000-000-0000. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 0-000-000-0000. 如果需要中文的帮助，请拨打这个号码 0-000-000-0000. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 0-000-000-0000. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––––– This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. (a year of routine in-network care of a well- controlled condition)  The plan’s overall deductible $0  Specialist copayment $20 15  Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $20 15  Hospital (facility) coinsurance 0%  Other coinsurance 20%  The plan’s overall deductible $0  Specialist copayment $20 15  Hospital (facility) coinsurance 0%  Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $0 Copayments $30 20 Coinsurance $10 Limits or exclusions $60 Deductibles $0 Copayments $160 110 Coinsurance $1200 Limits or exclusions $60 Deductibles $0 Copayments $210 200 Coinsurance $50 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services.

Your Grievance and Appeals Rights. There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: contact the plan at 0-000-000-0000 or (000) 000-0000 or TDD 711. You may also contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or xxx.xxx.xxx/xxxx/xxxxxxxxxxxx. Additionally, a consumer assistance program can help you file your appeal. Contact your state insurance department at (000) 000-0000 or by email at XxxxxxXxxXxxxxxx@xxxx.xx.xxx. Does this plan provide Minimum Essential Coverage? Yes. If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Para obtener asistencia en Español, llame al 01-000800-000639-00002227. Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 01-000800-000639-00002227. 如果需要中文的帮助，请拨打这个号码 01-000800-000639-00002227. Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 01-000800-000639-00002227. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.–––––––––––––––––––––– This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. (a year of routine in-network care of a well- controlled condition)  ◼ The plan’s overall deductible $0  ◼ Specialist copayment $20  10 ◼ Hospital (facility) coinsurance 0%  ◼ Other coinsurance 20%  ◼ The plan’s overall deductible $0  ◼ Specialist copayment $20  10 ◼ Hospital (facility) coinsurance 0%  ◼ Other coinsurance 20%  ◼ The plan’s overall deductible $0  ◼ Specialist copayment $20  10 ◼ Hospital (facility) coinsurance 0%  ◼ Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Deductibles $0 Copayments $30 20 Coinsurance $10 Limits or exclusions $60 Deductibles $0 Copayments $160 100 Coinsurance $1200 Limits or exclusions $60 Deductibles $0 Copayments $210 180 Coinsurance $50 Limits or exclusions $0 The plan would be responsible for the other costs of these EXAMPLE covered services.