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Page 13
VA
/L/F
/cul
pepr
coua
ndsc
hool
LP-P
PO/N
A/J
Z0U
Q/N
A/1
0-17
auth
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Plan
Cov
ers &
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
over
age
Peri
od: 1
0/01
/201
7 –
09/3
0/20
18
Cul
pepe
r Cou
nty
and
Scho
ols:
Lum
enos
Pla
n C
over
age
for:
Indi
vidu
al +
Fam
ily |
Pla
n T
ype:
HD
HP
The
Sum
mar
y of
Ben
efits
and
Cov
erag
e (S
BC
) doc
umen
t will
hel
p yo
u ch
oose
a h
ealth
pla
n. T
he S
BC
sho
ws
you
how
you
and
the
plan
wou
ld s
hare
the
cost
for c
over
ed h
ealth
car
e se
rvic
es. N
OT
E: I
nfor
mat
ion
abou
t the
cos
t of t
his
plan
(cal
led
the
prem
ium
) will
be
pro
vide
d se
para
tely
. Thi
s is
onl
y a
sum
mar
y. F
or m
ore
info
rmat
ion
abou
t you
r cov
erag
e, o
r to
get a
cop
y of
the
com
plet
e te
rms
of
cov
erag
e, h
ttps:/
/eoc
.ant
hem
.com
/eoc
dps/
aso.
For
gen
eral
def
initi
ons
of c
omm
on te
rms,
such
as
allo
wed
am
ount
, bal
ance
bill
ing,
coi
nsur
ance
, co
paym
ent,
dedu
ctib
le, p
rovi
der,
or o
ther
und
erlin
ed te
rms
see
the
Glo
ssar
y. Y
ou c
an v
iew
the
Glo
ssar
y at
ww
w.h
ealth
care
.gov
/sbc
-glo
ssar
y/ o
r cal
l (80
0)
421-
1880
to re
ques
t a c
opy.
Impo
rtan
t Que
stio
ns
Ans
wer
s W
hy T
his
Mat
ters
: W
hat i
s th
e ov
eral
l de
duct
ible
? $1
,500
/ind
ivid
ual o
r $3
,000
/fam
ily fo
r In-
Net
wor
k Pr
ovid
ers
or O
ut-o
f-N
etw
ork
Prov
ider
s. If
you
cov
er o
nly
your
self,
you
m
ust s
atisf
y th
e in
divi
dual
de
duct
ible
bef
ore
any
cove
red
serv
ices
are
pai
d by
the
heal
th
plan
. If
you
cov
er y
ours
elf a
nd
any
othe
r dep
ende
nts,
the
fam
ily d
educ
tible
mus
t be
satis
fied
befo
re a
ny c
over
ed
serv
ices
are
pai
d by
the
heal
th
plan
.
Gen
eral
ly, y
ou m
ust p
ay a
ll of
the
cost
s fro
m p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
plan
beg
ins
to p
ay. I
f you
hav
e ot
her f
amily
mem
bers
on
the
polic
y, th
e ov
eral
l fam
ily
dedu
ctib
le m
ust b
e m
et b
efor
e th
e pl
an b
egin
s to
pay
.
Are
ther
e se
rvic
es
cove
red
befo
re y
ou
mee
t you
r ded
uctib
le?
Yes
. Pre
vent
ive
care
and
Visi
on
exam
for I
n-N
etw
ork
Prov
ider
s. T
his
plan
cov
ers
som
e ite
ms
and
serv
ices
eve
n if
you
have
n’t y
et m
et th
e de
duct
ible
am
ount
. B
ut a
cop
aym
ent o
r coi
nsur
ance
may
app
ly. F
or e
xam
ple,
this
plan
cov
ers
cert
ain
prev
entiv
e se
rvic
es w
ithou
t cos
t-sha
ring
and
befo
re y
ou m
eet y
our d
educ
tible
. See
a li
st o
f cov
ered
pr
even
tive
serv
ices
at h
ttps:/
/ww
w.h
ealth
care
.gov
/cov
erag
e/pr
even
tive-
care
-ben
efits
/.
Are
ther
e ot
her
dedu
ctib
les
for
spec
ific
serv
ices
?
No.
Y
ou d
on't
have
to m
eet d
educ
tible
s fo
r spe
cific
ser
vice
s.
Wha
t is
the
out-
of-
pock
et li
mit
for t
his
plan
?
$3,0
00/i
ndiv
idua
l or
$5,9
50/f
amily
for I
n-N
etw
ork
Prov
ider
s. $6
,000
/ in
divi
dual
or
$11,
900/
fam
ily fo
r Out
-of-
Net
wor
k Pr
ovid
ers.
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r for
cov
ered
ser
vice
s. If
you
hav
e ot
her f
amily
mem
bers
in th
is pl
an, t
he o
vera
ll fa
mily
out
-of-
pock
et li
mit
mus
t be
met
.
Wha
t is
not i
nclu
ded
in th
e ou
t-of
-poc
ket
limit?
Rou
tine
visio
n ca
re, t
he c
ost o
f ca
re w
hen
the
bene
fit li
mits
ha
ve b
een
reac
hed,
Pre
miu
ms,
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don’
t cou
nt to
war
d th
e ou
t-of-
pock
et li
mit.
Page 14
*Fo
r mor
e in
form
atio
n ab
out l
imita
tions
and
exc
eptio
ns, s
ee p
lan
or p
olic
y do
cum
ent a
t http
s://e
oc.a
nthe
m.c
om/e
ocdp
s/as
o.
Bal
ance
-Bill
ing
char
ges,
and
Hea
lth C
are
this
plan
doe
sn't
cove
r. W
ill y
ou p
ay le
ss if
yo
u us
e a
netw
ork
prov
ider
?
Yes
. See
ww
w.a
nthe
m.c
om o
r ca
ll (8
00) 4
21-1
880
for a
list
of
netw
ork
prov
ider
s.
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork.
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the plan’s
netw
ork.
You
will
pay
the
mos
t if y
ou u
se a
n ou
t-of
-net
wor
k pr
ovid
er, a
nd y
ou m
ight
rece
ive
a bi
ll fr
om a
pro
vide
r for
the
diff
eren
ce b
etw
een
the provider’s
char
ge a
nd w
hat y
our p
lan
pays
(bal
ance
bill
ing)
. Be
awar
e yo
ur n
etw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er
for s
ome
serv
ices
(suc
h as
lab
wor
k). C
heck
with
you
r pro
vide
r bef
ore
you
get s
ervi
ces.
Do
you
need
a re
ferr
al
to s
ee a
spe
cial
ist?
N
o.
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
refe
rral
.
All
copa
ymen
t and
coi
nsur
ance
cos
ts s
how
n in
this
char
t are
aft
er y
our d
educ
tible
has
bee
n m
et, i
f a d
educ
tible
app
lies.
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
Wha
t You
Will
Pay
L
imita
tions
, Exc
eptio
ns, &
Oth
er
Impo
rtan
t Inf
orm
atio
n In
-Net
wor
k P
rovi
der
(You
will
pay
the
leas
t)
Out
-of-
Net
wor
k P
rovi
der
(You
will
pay
the
mos
t)
If y
ou v
isit
a he
alth
car
e provider’s
off
ice
or c
linic
Prim
ary
care
visi
t to
trea
t an
inju
ry o
r illn
ess
10%
coi
nsur
ance
30
% c
oins
uran
ce
----
----
none
----
----
Spec
ialis
t visi
t 10
% c
oins
uran
ce
30%
coi
nsur
ance
--
----
--no
ne--
----
--
Prev
entiv
e ca
re/s
cree
ning
/ im
mun
izat
ion
No
char
ge
30%
coi
nsur
ance
You
may
hav
e to
pay
for s
ervi
ces
that
ar
en't
prev
entiv
e. A
sk y
our p
rovi
der i
f th
e se
rvic
es n
eede
d ar
e pr
even
tive.
T
hen
chec
k w
hat y
our p
lan
will
pay
fo
r.
If y
ou h
ave
a te
st
Dia
gnos
tic te
st (x
-ray
, blo
od
wor
k)
10%
coi
nsur
ance
30
% c
oins
uran
ce
----
----
none
----
----
Imag
ing
(CT
/PE
T s
cans
, MR
Is)
10%
coi
nsur
ance
30
% c
oins
uran
ce
----
----
none
----
----
If y
ou n
eed
drug
s to
trea
t you
r ill
ness
or
cond
ition
Tie
r 1 -
Typ
ical
ly G
ener
ic
10%
coi
nsur
ance
(30
day
supp
ly re
tail;
90
day
supp
ly
reta
il m
aint
enan
ce o
r 90
day
supp
ly h
ome
deliv
ery)
10%
coi
nsur
ance
(30
day
supp
ly re
tail;
90
day
supp
ly
reta
il m
aint
enan
ce o
r 90
day
supp
ly h
ome
deliv
ery)
*See
Pre
scrip
tion
Dru
g se
ctio
n. N
ote
that
if y
ou v
isit a
n ou
t-of-
netw
ork
phar
mac
y, y
ou w
ill p
ay th
e fu
ll co
st o
f yo
ur p
resc
riptio
n at
the
phar
mac
y th
en
file
a cl
aim
for r
eim
burs
emen
t. R
eim
burs
emen
t will
be
base
d on
wha
t a
part
icip
atin
g ph
arm
acy
wou
ld re
ceiv
e ha
d th
e pr
escr
iptio
n be
en fi
lled
at a
pa
rtic
ipat
ing
phar
mac
y. M
ost s
peci
alty
dr
ugs
are
limite
d to
a 3
0 da
y su
pply
an
d m
ust b
e ob
tain
ed fr
om th
e sp
ecia
lty p
harm
acy.
Tie
r 2 -
Typ
ical
ly P
refe
rred
/
Bra
nd
10%
coi
nsur
ance
(30
day
supp
ly re
tail;
90
day
supp
ly
reta
il m
aint
enan
ce o
r 90
day
supp
ly h
ome
deliv
ery)
10%
coi
nsur
ance
(30
day
supp
ly re
tail;
90
day
supp
ly
reta
il m
aint
enan
ce o
r 90
day
supp
ly h
ome
deliv
ery)
Tie
r 3 -
Typ
ical
ly N
on-P
refe
rred
/
Spec
ialty
Dru
gs
10%
coi
nsur
ance
(30
day
supp
ly re
tail;
90
day
supp
ly
10%
coi
nsur
ance
(30
day
supp
ly re
tail;
90
day
supp
ly
Page 15
*Fo
r mor
e in
form
atio
n ab
out l
imita
tions
and
exc
eptio
ns, s
ee p
lan
or p
olic
y do
cum
ent a
t http
s://e
oc.a
nthe
m.c
om/e
ocdp
s/as
o.
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
Wha
t You
Will
Pay
L
imita
tions
, Exc
eptio
ns, &
Oth
er
Impo
rtan
t Inf
orm
atio
n In
-Net
wor
k P
rovi
der
(You
will
pay
the
leas
t)
Out
-of-
Net
wor
k P
rovi
der
(You
will
pay
the
mos
t)
Mor
e in
form
atio
n ab
out p
resc
ript
ion
drug
cov
erag
e is
avai
labl
e at
ht
tp:/
/ww
w.a
nthe
m.c
om/p
harm
acyi
nfo
rmat
ion/
Nat
iona
l
reta
il m
aint
enan
ce o
r 90
day
supp
ly h
ome
deliv
ery)
re
tail
mai
nten
ance
or 9
0 da
y su
pply
hom
e de
liver
y)
If y
ou h
ave
outp
atie
nt s
urge
ry
Faci
lity
fee
(e.g
., am
bula
tory
su
rger
y ce
nter
) 10
% c
oins
uran
ce
30%
coi
nsur
ance
--
----
--no
ne--
----
--
Phys
icia
n/su
rgeo
n fe
es
10%
coi
nsur
ance
30
% c
oins
uran
ce
----
----
none
----
----
If y
ou n
eed
imm
edia
te
med
ical
att
entio
n
Em
erge
ncy
room
car
e 10
% c
oins
uran
ce
30%
coi
nsur
ance
--
----
--no
ne--
----
--
Em
erge
ncy
med
ical
tr
ansp
orta
tion
10%
coi
nsur
ance
C
over
ed a
s In
-Net
wor
k --
----
--no
ne--
----
--
Urg
ent c
are
10%
coi
nsur
ance
30
% c
oins
uran
ce
----
----
none
----
----
If
you
hav
e a
hosp
ital s
tay
Faci
lity
fee
(e.g
., ho
spita
l roo
m)
10%
coi
nsur
ance
30
% c
oins
uran
ce
----
----
none
----
----
Ph
ysic
ian/
surg
eon
fees
10
% c
oins
uran
ce
30%
coi
nsur
ance
--
----
--no
ne--
----
--
If y
ou n
eed
men
tal h
ealth
, be
havi
oral
hea
lth,
or s
ubst
ance
ab
use
serv
ices
Out
patie
nt s
ervi
ces
Off
ice
Visi
t 10
% c
oins
uran
ce
Oth
er O
utpa
tient
10
% c
oins
uran
ce
Off
ice
Visi
t 30
% c
oins
uran
ce
Oth
er O
utpa
tient
30
% c
oins
uran
ce
Off
ice
Visi
t --
----
--no
ne--
----
--
Oth
er O
utpa
tient
--
----
--no
ne--
----
--
Inpa
tient
ser
vice
s 10
% c
oins
uran
ce
30%
coi
nsur
ance
--
----
--no
ne--
----
--
If y
ou a
re
preg
nant
Off
ice
visit
s 10
% c
oins
uran
ce
30%
coi
nsur
ance
M
ater
nity
car
e m
ay in
clud
e te
sts
and
serv
ices
des
crib
ed e
lsew
here
in th
e SB
C (i
.e. u
ltras
ound
.)
Chi
ldbi
rth/
deliv
ery
prof
essio
nal
serv
ices
10
% c
oins
uran
ce
30%
coi
nsur
ance
Chi
ldbi
rth/
deliv
ery
faci
lity
serv
ices
10
% c
oins
uran
ce
30%
coi
nsur
ance
If y
ou n
eed
help
re
cove
ring
or h
ave
othe
r spe
cial
he
alth
nee
ds
Hom
e he
alth
car
e 10
% c
oins
uran
ce
30%
coi
nsur
ance
10
0 vi
sits/
bene
fit p
erio
d.
Reh
abili
tatio
n se
rvic
es
10%
coi
nsur
ance
30
% c
oins
uran
ce
*See
The
rapy
Ser
vice
s se
ctio
nH
abili
tatio
n se
rvic
es
10%
coi
nsur
ance
30
% c
oins
uran
ce
Skill
ed n
ursin
g ca
re
10%
coi
nsur
ance
30
% c
oins
uran
ce
100
days
lim
it/st
ay.
Dur
able
med
ical
equ
ipm
ent
10%
coi
nsur
ance
30
% c
oins
uran
ce
----
----
none
----
----
H
ospi
ce s
ervi
ces
10%
coi
nsur
ance
30
% c
oins
uran
ce
----
----
none
----
----
Page 16
*Fo
r mor
e in
form
atio
n ab
out l
imita
tions
and
exc
eptio
ns, s
ee p
lan
or p
olic
y do
cum
ent a
t http
s://e
oc.a
nthe
m.c
om/e
ocdp
s/as
o.
Com
mon
M
edic
al E
vent
Se
rvic
es Y
ou M
ay N
eed
Wha
t You
Will
Pay
L
imita
tions
, Exc
eptio
ns, &
Oth
er
Impo
rtan
t Inf
orm
atio
n In
-Net
wor
k P
rovi
der
(You
will
pay
the
leas
t)
Out
-of-
Net
wor
k P
rovi
der
(You
will
pay
the
mos
t)
If y
our c
hild
ne
eds
dent
al o
r ey
e ca
re
Chi
ldre
n’s
eye
exam
$1
5/vi
sit d
educ
tible
doe
s no
t app
ly
$30
allo
wan
ce/v
isit
dedu
ctib
le d
oes
not a
pply
*S
ee V
ision
Ser
vice
s se
ctio
nC
hild
ren’
s gl
asse
s N
ot c
over
ed
Not
cov
ered
C
hild
ren’
s de
ntal
che
ck-u
p N
ot c
over
ed
Not
cov
ered
Page 17
*Fo
r mor
e in
form
atio
n ab
out l
imita
tions
and
exc
eptio
ns, s
ee p
lan
or p
olic
y do
cum
ent a
t http
s://e
oc.a
nthe
m.c
om/e
ocdp
s/as
o.
Exc
lude
d Se
rvic
es &
Oth
er C
over
ed S
ervi
ces:
Se
rvic
es Y
our P
lan
Gen
eral
ly D
oes
NO
T C
over
(Che
ck y
our p
olic
y or
pla
n do
cum
ent f
or m
ore
info
rmat
ion
and
a lis
t of a
ny o
ther
exc
lude
d se
rvic
es.)
xA
cupu
nctu
rex
Baria
tric
surg
ery
xC
osm
etic
surg
ery
xD
enta
l car
ex
Hea
ring
aids
xIn
fert
ility
trea
tmen
tx
Long
- ter
m c
are
xR
outin
e fo
ot c
are
unle
ss y
ou h
ave
been
diag
nose
d w
ith d
iabe
tes.
xW
eigh
t los
s pro
gram
s
Oth
er C
over
ed S
ervi
ces
(Lim
itatio
ns m
ay a
pply
to th
ese
serv
ices
. Thi
s is
n’t a
com
plet
e lis
t. Pl
ease
see
you
r pla
n do
cum
ent.)
x
Chi
ropr
actic
car
e 30
visi
ts/b
enef
it pe
riod.
xC
over
age
prov
ided
out
side
the
Uni
ted
Stat
esw
ww
.bcb
s.com
/blu
ecar
dwor
ldw
ide
xPr
ivat
e-du
ty n
ursin
g 16
hour
/mem
ber/
bene
fit p
erio
dx
Rou
tine
eye
care
-one
eye
exa
m/m
embe
r/be
nefit
per
iod.
You
r Rig
hts
to C
ontin
ue C
over
age:
The
re a
re a
genc
ies t
hat c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our c
over
age
afte
r it e
nds.
The
cont
act i
nfor
mat
ion
for t
hose
ag
enci
es is
: Dep
artm
ent o
f Hea
lth a
nd H
uman
Ser
vice
s, C
ente
r for
Con
sum
er In
form
atio
n an
d In
sura
nce
Ove
rsig
ht, a
t 1-8
77-2
67-2
323
x615
65 o
r w
ww
.cci
io.c
ms.g
ov. O
ther
cov
erag
e op
tions
may
be
avai
labl
e to
you
too,
incl
udin
g bu
ying
indi
vidu
al in
sura
nce
cove
rage
thro
ugh
the
Hea
lth In
sura
nce
Mar
ketp
lace
. For
mor
e in
form
atio
n ab
out t
he M
arke
tpla
ce, v
isit w
ww
.Hea
lthC
are.
gov
or c
all 1
-800
-318
-259
6.
You
r Gri
evan
ce a
nd A
ppea
ls R
ight
s: T
here
are
age
ncie
s th
at c
an h
elp
if yo
u ha
ve a
com
plai
nt a
gain
st y
our p
lan
for a
den
ial o
f a c
laim
. Thi
s com
plai
nt is
ca
lled
a gr
ieva
nce
or a
ppea
l. Fo
r mor
e in
form
atio
n ab
out y
our r
ight
s, lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill re
ceiv
e fo
r tha
t med
ical
cla
im. Y
our p
lan
docu
men
ts a
lso p
rovi
de c
ompl
ete
info
rmat
ion
to su
bmit
a cl
aim
, app
eal,
or a
grie
vanc
e fo
r any
reas
on to
you
r pla
n. F
or m
ore
info
rmat
ion
abou
t you
r rig
hts,
this
notic
e, o
r ass
istan
ce, c
onta
ct:
ATT
N: G
rieva
nces
and
App
eals,
P.O
. Box
274
01, R
ichm
ond,
VA
232
79
Doe
s th
is p
lan
prov
ide
Min
imum
Ess
entia
l Cov
erag
e? Y
es
If y
ou d
on’t
have
Min
imum
Ess
entia
l Cov
erag
e fo
r a m
onth
, you
’ll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess y
ou q
ualif
y fo
r an
exem
ptio
n fr
om th
e re
quire
men
t tha
t you
hav
e he
alth
cov
erag
e fo
r tha
t mon
th.
Doe
s th
is p
lan
mee
t the
Min
imum
Val
ue S
tand
ards
? Y
es
If y
our p
lan
does
n’t m
eet t
he M
inim
um V
alue
Sta
ndar
ds, y
ou m
ay b
e el
igib
le fo
r a p
rem
ium
tax
cred
it to
hel
p yo
u pa
y fo
r a p
lan
thro
ugh
the
Mar
ketp
lace
.
––––
––––
––––
––––
––––
––To
see e
xam
ples
of ho
w th
is pl
an m
ight c
over
costs
for a
sam
ple m
edica
l situ
ation
, see
the n
ext s
ection
.––
––––
––––
–
Page 18
The
pla
n w
ould
be
resp
onsib
le fo
r the
oth
er c
osts
of t
hese
EX
AM
PLE
cov
ered
ser
vice
s.
Abo
ut th
ese
Cov
erag
e E
xam
ples
:
Thi
s is
not
a c
ost e
stim
ator
. Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
plan
mig
ht c
over
med
ical
car
e. Y
our a
ctua
l cos
ts w
ill
be d
iffer
ent d
epen
ding
on
the
actu
al c
are
you
rece
ive,
the
pric
es y
our p
rovi
ders
cha
rge,
and
man
y ot
her f
acto
rs. F
ocus
on
the
cost
sh
arin
g am
ount
s (d
educ
tible
s, co
paym
ents
and
coi
nsur
ance
) and
exc
lude
d se
rvic
es u
nder
the
plan
. Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
cos
ts y
ou m
ight
pay
und
er d
iffer
ent h
ealth
pla
ns. P
leas
e no
te th
ese
cove
rage
exa
mpl
es a
re b
ased
on
self-
only
cov
erag
e.
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Man
agin
g Jo
e’s
type
2 D
iabe
tes
(a y
ear o
f rou
tine
in-n
etw
ork
care
of a
wel
l- co
ntro
lled
cond
ition
)
Mia
’s S
impl
e Fr
actu
re
(in-n
etw
ork
emer
genc
y ro
om v
isit a
nd fo
llow
up
car
e)
� T
he p
lan’
s ov
eral
l ded
uctib
le
$1,5
00
� T
he p
lan’
s ov
eral
l ded
uctib
le
$1,5
00
� T
he p
lan’
s ov
eral
l ded
uctib
le
$1,5
00
� S
peci
alis
t coi
nsur
ance
10
%
� S
peci
alis
t coi
nsur
ance
10
%
� S
peci
alis
t coi
nsur
ance
10
%
� H
ospi
tal (
faci
lity)
coi
nsur
ance
10
%
� H
ospi
tal (
faci
lity)
coi
nsur
ance
10
%
� H
ospi
tal (
faci
lity)
coi
nsur
ance
10
%
� O
ther
coi
nsur
ance
10
%
� O
ther
coi
nsur
ance
10
%
� O
ther
coi
nsur
ance
10
%
Thi
s E
XA
MP
LE
eve
nt in
clud
es s
ervi
ces
like:
Sp
ecia
list o
ffic
e vi
sits
(pren
atal
care
C
hild
birt
h/D
eliv
ery
Prof
essio
nal S
ervi
ces
Chi
ldbi
rth/
Del
iver
y Fa
cilit
y Se
rvic
es
Dia
gnos
tic te
sts
(ultr
asou
nds a
nd
lood
wor
Sp
ecia
list v
isit
anest
hesia
Thi
s E
XA
MP
LE
eve
nt in
clud
es s
ervi
ces
like:
P
rim
ary
care
phy
sici
an o
ffic
e vi
sits
(inclu
ding
di
sease
educ
ation
D
iagn
ostic
test
s loo
d wo
r
Pre
scri
ptio
n dr
ugs
D
urab
le m
edic
al e
quip
men
t glu
cose
mete
r
Thi
s E
XA
MP
LE
eve
nt in
clud
es s
ervi
ces
like:
E
mer
genc
y ro
om c
are
inclu
ding
med
ical s
uppl
ies
Dia
gnos
tic te
st x
ra
Dur
able
med
ical
equ
ipm
ent
crutch
es
Reh
abili
tatio
n se
rvic
es p
hsic
al th
erap
Tot
al E
xam
ple
Cos
t $1
2,84
0 T
otal
Exa
mpl
e C
ost
$7,4
60
Tot
al E
xam
ple
Cos
t $2
,010
In th
is e
xam
ple,
Peg
wou
ld p
ay:
In th
is e
xam
ple,
Joe
wou
ld p
ay:
In th
is e
xam
ple,
Mia
wou
ld p
ay:
Cos
t Sha
ring
Cos
t Sha
ring
Cos
t Sha
ring
Ded
uctib
les
$1,5
00
Ded
uctib
les
$1,1
98
Ded
uctib
les
$1,5
00
Cop
aym
ents
$1
20
Cop
aym
ents
$7
,170
C
opay
men
ts
$0
Coi
nsur
ance
$0
C
oins
uran
ce
$0
Coi
nsur
ance
$0
ha
t isn
t cov
ered
hat i
snt c
overe
d ha
t isn
t cov
ered
Lim
its o
r exc
lusio
ns
$60
Lim
its o
r exc
lusio
ns
$21
Lim
its o
r exc
lusio
ns
$0
The
tota
l Peg
wou
ld p
ay is
$1
,680
T
he to
tal J
oe w
ould
pay
is
$8,3
89
The
tota
l Mia
wou
ld p
ay is
$1
,500
Page 19
Lan
guag
e A
cces
s Se
rvic
es:
(TT
Y/T
DD
: 711
)
Alb
ania
n (S
hqip
): N
ëse
keni
pye
tje n
ë lid
hje
me
këtë
dok
umen
t, ke
ni të
dre
jtë të
mer
rni f
alas
ndi
hmë
dhe
info
rmac
ion
në g
juhë
n tu
aj. P
ër të
kon
takt
uar m
e nj
ë pë
rkth
yes,
tele
fono
ni (8
00) 4
21-1
880
Am
haric
(አአአአ
)አ ስ
ስስስ
ስስስ
ስስስስስ
ስስስ
ስስስስ
ስስስስ
ስስስ
ስስስስ
ስስ
ስስስ
ስስስ
ስስስ
ስስስስስ
ስስስ
ስስስስስ
ስስስስስስ
ስስስስስ
(800
) 421
-188
0ስስስስስ
.(800
) 421
-188
0
Arm
enia
n (հայերեն)
. Եթե
այս
փաստ
աթղ
թի հետ
կապվա
ծ հա
րցեր
ունեք
, դուք իր
ավո
ւնք ունեք անվճա
ր ստ
անա
լ օգնություն և
տեղեկատվո
ւթյուն
ձեր
լեզվով
: Թարգմա
նչի հետ
խոս
ելու
համա
ր զա
նգահա
րեք հետևյալ հ
եռախոս
ահա
մարո
վ՝ (8
00) 4
21-1
880:
(800
) 421
-188
0.
(800
) 421
-188
0
(800
) 421
-188
0
Chi
nese
(中文
)：如果您對本文件有任何疑問，您有權使用您的語言免費獲得協助和資訊。如需與譯員通話，請致電
(800
) 421
-188
0。
(800
) 421
-188
0.
Dut
ch (N
eder
land
s): B
ij vr
agen
ove
r dit
docu
men
t heb
t u re
cht o
p hu
lp e
n in
form
atie
in u
w ta
al z
onde
r bijk
omen
de k
oste
n. A
ls u
een
tolk
wilt
spre
ken,
be
lt u
(800
) 421
-188
0.
(800
) 421
-188
0
Fren
ch (F
ranç
ais)
: Si
vou
s ave
z de
s que
stio
ns su
r ce
docu
men
t, vo
us a
vez
la p
ossib
ilité
d’a
ccéd
er g
ratu
item
ent à
ces
info
rmat
ions
et à
une
aid
e da
ns v
otre
la
ngue
. Pou
r par
ler à
un
inte
rprè
te, a
ppel
ez le
(800
) 421
-188
0.
Page 20
Lan
guag
e A
cces
s Se
rvic
es:
8 of
11
Ger
man
(Deu
tsch
): W
enn
Sie
Frag
en z
u di
esem
Dok
umen
t hab
en, h
aben
Sie
Ans
pruc
h au
f kos
tenf
reie
Hilf
e un
d In
form
atio
n in
Ihre
r Spr
ache
. Um
mit
eine
m D
olm
etsc
her z
u sp
rech
en, b
itte
wäh
len
Sie
(800
) 421
-188
0.
Gre
ek (Ε
λλην
ικά)
Αν
έχετ
ε τυ
χόν
απορ
ίες σ
χετικ
ά με
το
παρό
ν έγ
γραφ
ο, έ
χετε
το
δικα
ίωμα
να
λάβε
τε β
οήθε
ια κ
αι π
ληρο
φορί
ες σ
τη γ
λώσσ
α σα
ς δωρ
εάν.
Για
να
μιλή
σετε
με
κάπο
ιον
διερ
μηνέ
α, τ
ηλεφ
ωνήσ
τε σ
το (8
00) 4
21-1
880.
G
ujar
ati (ગજુ
રાતી
): જો આ
દસ્તાવેજ
અંગે આપને
કોઈપ
ણ પ્રશ્નો હોય
તો, કોઈપ
ણ ખર્ચ વગ
ર આપન
ી ભાષામા ંમદદ
અને માહહતી
મેળવ
વાનો
તમન
ે અહિકાર છે
. દુભાહષયા
સાથે
વાત
કરવા
માટે
, કોલ
કરો (
800)
421
-188
0.
Hai
tian
Cre
ole
(Kre
yòl A
yisy
en):
Si o
u ge
n ne
npòt
kes
yon
sou
doki
man
sa
a, o
u ge
n dw
a po
u jw
enn
èd a
k en
fòm
asyo
n na
n la
ng o
u gr
atis.
Pou
pal
e ak
yon
en
tèpr
èt, r
ele
(800
) 421
-188
0.
(8
00) 4
21-1
880
H
mon
g (W
hite
Hm
ong)
: Yog
tias
koj
mua
j lus
nug
dab
tsi n
tsig
txog
dai
m n
taw
v no
, koj
mua
j cai
tau
txai
s ke
v pa
b th
iab
lus
qhia
hai
s ua
koj
hom
lus
yam
ts
im x
am tu
s nq
i. T
xhaw
m ra
u th
am n
rog
tus
neeg
txha
is lu
s, hu
xov
tooj
rau
(800
) 421
-188
0.
Igbo
(Igb
o):
br
na
nw
ere
ajj
b
la g
basa
ra a
kwkw
a,
nw
ere
ikik
e nw
eta
enye
mak
a na
ozi
n'as
s g
na
akw
gh
gw
bla
. Ka
g n
a k
wa
okw
u kw
uo o
kwu,
kp
(800
) 421
-188
0.
Ilok
ano
(Ilo
kano
): N
u ad
daan
ka
iti a
niam
an a
sal
udso
d pa
ngge
p iti
day
toy
a do
kum
ento
, add
a ka
rben
gam
a m
akaa
la ti
tulo
ng k
en im
porm
asyo
n ba
baen
ti
leng
uahe
m n
ga a
wan
ti b
ayad
na.
Tap
no m
akat
ungt
ong
ti m
aysa
nga
tagi
pata
rus,
awag
an ti
(800
) 421
-188
0.
Indo
nesi
an (B
ahas
a In
done
sia)
: Jik
a A
nda
mem
iliki
per
tany
aan
men
gena
i dok
umen
ini,
And
a m
emili
ki h
ak u
ntuk
men
dapa
tkan
ban
tuan
dan
info
rmas
i da
lam
bah
asa
And
a ta
npa
biay
a. U
ntuk
ber
bica
ra d
enga
n in
terp
rete
r kam
i, hu
bung
i (80
0) 4
21-1
880.
It
alia
n (I
talia
no):
In c
aso
di e
vent
uali
dom
ande
sul
pre
sent
e do
cum
ento
, ha
il di
ritto
di r
icev
ere
assis
tenz
a e
info
rmaz
ioni
nel
la s
ua li
ngua
sen
za a
lcun
cos
to
aggi
untiv
o. P
er p
arla
re c
on u
n in
terp
rete
, chi
ami i
l num
ero
(800
) 421
-188
0
(8
00) 4
21-1
880
Page 21
Lan
guag
e A
cces
s Se
rvic
es:
9 of
11
(800
) 421
-188
0
Kir
undi
(Kir
undi
): U
gize
ikib
azo
ico
aric
o co
se k
uri i
yi n
yand
iko,
ufis
e ub
uren
ganz
ira b
wo
kuro
nka
ubuf
asha
mu
rurim
i rw
awe
ata
gici
ro. K
ugira
uvu
gish
e um
usem
uzi,
akur
a (8
00) 4
21-1
880.
K
orea
n (한국어
): 본
문서에
대해
어떠한
문의사항이라도
있을
경우
, 귀하에게는
귀하가
사용하는
언어로
무료
도움
및 정보를
얻을
권리가
있습니다
. 통역사와
이야기하려면
(800
) 421
-188
0 로
문의하십시오
.
(800
) 421
-188
0.
(
800)
421
-188
0.
(800
) 421
-188
0
Oro
mo
(Oro
mifa
a): S
anad
i kan
aa w
ajiin
wal
qaba
ate
gaff
i kam
iyuu
yoo
qab
duu
tana
an, G
arga
arsa
arg
achu
u fi
odee
ffan
oo a
faan
ket
iin k
affa
ltii a
lla a
rgac
huuf
m
irgaa
qab
daa.
Tur
jum
aana
dub
aach
uuf,
(800
) 421
-188
0 bi
lbill
a.
Pen
nsyl
vani
a D
utch
(Dei
tsch
): W
ann
du F
roog
e iw
wer
sel
le D
ocum
ent h
osch
t, du
hos
cht d
ie R
echt
um
Hel
fe u
n In
form
atio
n zu
grie
ge in
dei
Sch
proo
ch
mita
us K
osch
t. U
m m
it en
Iww
erse
tze
zu s
chw
etze
, ruf
f (80
0) 4
21-1
880
aa.
Pol
ish
(pol
ski)
:
.
,
(800
) 421
-188
0.
Por
tugu
ese
(Por
tugu
ês):
Se
tiver
qua
isque
r dúv
idas
ace
rca
dest
e do
cum
ento
, tem
o d
ireito
de
solic
itar a
juda
e in
form
açõe
s no
seu
idio
ma,
sem
qua
lque
r cu
sto.
Par
a fa
lar c
om u
m in
térp
rete
, lig
ue p
ara
(800
) 421
-188
0.
(800
) 421
-188
0
Page 22
Lan
guag
e A
cces
s Se
rvic
es:
10 o
f 11
(8
00) 4
21-1
880.
(800
) 421
-188
0.
Sam
oan
(Sam
oa):
Afa
i e ia
i ni o
u fe
sili e
uig
a i l
enei
tusi,
e ia
i lou
‘aia
e m
aua
se fe
soas
oani
ma
faam
atal
aga
i lou
lava
gag
ana
e au
noa
ma
se to
togi
. Ina
ia
tala
noa
i se
taga
ta fa
alili
u, v
ili (8
00) 4
21-1
880.
Se
rbia
n (S
rpsk
i): U
kolik
o im
ate
bilo
kak
vih
pita
nja
u ve
zi
,
.
, (8
00) 4
21-1
880.
Sp
anis
h (E
spañ
ol):
Si t
iene
pre
gunt
as a
cerc
a de
est
e do
cum
ento
, tie
ne d
erec
ho a
reci
bir a
yuda
e in
form
ació
n en
su
idio
ma,
sin
cos
tos.
Para
hab
lar c
on u
n in
térp
rete
, lla
me
al (8
00) 4
21-1
880.
T
agal
og (T
agal
og):
Kun
g m
ayro
on k
ang
anum
ang
kata
nung
an tu
ngko
l sa
doku
men
tong
ito,
may
kar
apat
an k
ang
hum
ingi
ng
tulo
ng a
t im
porm
asyo
n sa
iy
ong
wik
a na
ng w
alan
g ba
yad.
Mak
ipag
-usa
p sa
isan
g ta
gapa
gpal
iwan
ag, t
awag
an a
ng (8
00) 4
21-1
880.
T
hai (ไทย)
: หากทา่นมคี
าถามใดๆ เกีย่วกับ
เอกส
ารฉบั
บนี ้ทา่นมสี
ทิธิท์
ีจ่ะไดร้ับความชว่ยเหล
อืและขอ้
มลูในภาษาของทา่นโดยไมม่
คีา่ใชจ้า่ย โดยโทร
(8
00) 4
21-1
880 เพือ่พ
ดูคยุก
ับลา่ม
(8
00) 4
21-1
880.
(
800)
421
-188
0
Vie
tnam
ese
(Ti
ng V
it)
: Nu
quý
v c
ó b
t k th
c m
c nà
o v
tài l
iu
này,
quý
v c
ó qu
yn
nhn
s tr
giú
p và
thôn
g tin
bng
ngô
n ng
ca
quý
v h
oàn
toàn
mi
.
i vi m
t thô
ng d
ch v
iên,
hãy
gi (
800)
421
-188
0.
.(8
00) 4
21-1
880
(80
0) 4
21-1
880.
Page 23
Lan
guag
e A
cces
s Se
rvic
es:
11 o
f 11
It’s
impo
rtan
t we
trea
t you
fair
ly
Tha
t’s w
hy w
e fo
llow
fede
ral c
ivil
right
s la
ws
in o
ur h
ealth
pro
gram
s an
d ac
tiviti
es. W
e do
n’t d
iscrim
inat
e, e
xclu
de p
eopl
e, o
r tre
at th
em d
iffer
ently
on
the
basis
of r
ace,
col
or, n
atio
nal o
rigin
, sex
, age
or d
isabi
lity.
For
peo
ple
with
disa
bilit
ies,
we
offe
r fre
e ai
ds a
nd s
ervi
ces.
For p
eopl
e w
hose
prim
ary
lang
uage
isn’
t E
nglis
h, w
e of
fer f
ree
lang
uage
ass
istan
ce s
ervi
ces
thro
ugh
inte
rpre
ters
and
oth
er w
ritte
n la
ngua
ges.
Inte
rest
ed in
thes
e se
rvic
es?
Cal
l the
Mem
ber S
ervi
ces
num
ber o
n yo
ur I
D c
ard
for h
elp
(TT
Y/T
DD
: 711
). If
you
thin
k w
e fa
iled
to o
ffer
thes
e se
rvic
es o
r disc
rimin
ated
bas
ed o
n ra
ce, c
olor
, nat
iona
l orig
in, a
ge,
disa
bilit
y, o
r sex
, you
can
file
a c
ompl
aint
, also
kno
wn
as a
grie
vanc
e. Y
ou c
an fi
le a
com
plai
nt w
ith o
ur C
ompl
ianc
e C
oord
inat
or in
writ
ing
to C
ompl
ianc
e C
oord
inat
or, P
.O. B
ox 2
7401
, Mai
l Dro
p V
A20
02-N
160,
Ric
hmon
d, V
A 2
3279
. Or y
ou c
an fi
le a
com
plai
nt w
ith th
e U
.S. D
epar
tmen
t of H
ealth
and
H
uman
Ser
vice
s, O
ffic
e fo
r Civ
il R
ight
s at
200
Ind
epen
denc
e A
venu
e, S
W; R
oom
509
F, H
HH
Bui
ldin
g; W
ashi
ngto
n, D
.C. 2
0201
or b
y ca
lling
1-8
00-3
68-
1019
(TD
D: 1
- 800
-537
-769
7) o
r onl
ine
at h
ttps:/
/ocr
port
al.h
hs.g
ov/o
cr/p
orta
l/lo
bby.
jsf. C
ompl
aint
form
s ar
e av
aila
ble
at
http
://w
ww
.hhs
.gov
/ocr
/off
ice/
file/
inde
x.ht
ml.
