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2. $700 deductable, 30% Co-insurance, $40 co pay Paid by Insurance Paid by you Total Expense $3400 $350 $140 $220 Car Accident - ER X-Rays

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2. $700 deductable, 30% Co-insurance, $40 co pay Paid by Insurance Paid by you Total Expense $3400 $350 $140 $220 Car Accident - ER X-Rays Lab Tests Prescription Drugs 1. Total Medical Expense 2. Deductible 3. Net Expense after deductible 4. 30% Co-insurance 70% of Net Expense Doctor Visits - 8 @ $120 each $40 Copay each visit Remaining Expenses Out-of-pocket Maximum - $2000 Total Owed by you Total Paid by Insurance Company

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