UT-Battelle, LLC Employee Assistance Program - Benefits

Coverage ExampleAbout these CoverageExamples:These examples show how this plan might covermedical care in given situations. Use theseexamples to see, in general, how much financialprotection a sample patient might get if they arecovered under different plans.This isnot a costestimator.Don’t use these examples toestimate your actual costsunder this plan. The actualcare you receive will bedifferent from theseexamples, and the cost ofthat care will also bedifferent.See the next page forimportant information aboutthese examples.Having a baby(normal delivery) Amount owed to providers: $7,540 Plan pays $0Patient pays This condition is not covered bythis plan, so the patient pays 100%.Sample care costs:Hospital charges (mother) $2,700Routine obstetric care $2,100Hospital charges (baby) $900Anesthesia $900Laboratory tests $500Prescriptions $200Radiology $200Vaccines, other preventive $40Total $7,540Patient pays: This condition is not covered, sothe patient pays 100%.Deductibles $Copays $Coinsurance $Limits or exclusions $Total $Managing type 2 diabetes(routine maintenance of awell-controlled condition) Amount owed to providers: $5,400 Plan pays $0Patient pays This condition is not covered bythis plan, so the patient pays 100%.Sample care costs:Prescriptions $2,900Medical Equipment and Supplies $1,300Office Visits and Procedures $700Education $300Laboratory tests $100Vaccines, other preventive $100Total $5,400Patient pays: This condition is not covered, sothe patient pays 100%.Deductibles $Copays $Coinsurance $Limits or exclusions $Total $Questions: Call 1-800-888-2273 or visit us at www. magellanhealth.com/member.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 5 of 6at www.magellanhealth.com/member or call 1-800-888-2273 to request a copy.OMB Control Numbers 1545-2229,1210-0147, and 0938-1146