Documentation

Documentation:

• If COINSURANCE & DEDUCTIBLE

DEDUCTIBLE is NOT YET MET

(For ANTHEM only $85 will be collected)

Will collect $70 towards deductible per visit. Once deductible is met will collect ___ coinsurance until OOP max met

DEDUCTIBLE IS MET

Deductible is met, will collect __ coinsurance per visit until OOP max met. OOP MAX MET (regardless if deductible is met or not met)

Individual deductible is met, will collect __ coinsurance per visit until OOP max met.

Family deductible is met, will collect __ coinsurance per visit until OOP max met.

OOP MAX MET (regardless if deductible is met or not met)

OOP max is met, insurance will cover 100%

Individual OOP max is met, insurance will cover 100%

Family OOP max is met, insurance will cover 100%

• COPAY only

OOP MAX is NOT MET

Will collect $__ copay until OOP max met.

OOP MAX MET

OOP max is met, insurance will cover 100%

Individual OOP max is met, insurance will cover 100%

Family OOP max is met, insurance will cover 100%