s Use the following information to determine the costs to you and/or to the insurance company for the following occurrences: 1) You have $500 per person Wellness Benefit to cover tests things like annual physicals and blood 2) You have a $1000 Individual Deductible and your family (spouse and children) has a $1000 Family Deductible. 3) You have a $20,000 annual Maximum Family Out-of- Pocket expense provision. 4) Once you have met your Individual or Family Deductible, your insurance will pay 80% of the expenses and you will pay 20% as your co-pay. Unless the occurrence is a Wellness expense, you and/or your family have to meet their deductibles first before insurance will pay anything. Example: Assume that you have met your deductible, and you go to the Emergency Room for a large cut on your shin which required cleaning, 20 stitches, a tetanus shot, and antibiotics. (80/20 plan) Total Charges = $2,500 total Your Responsibility = $2,500*.20 = $500 (the co-pay goes toward your MOOP) Insurance Responsibility = $2,500*.80 = $2,000 Visit and Cost You go to your doctor for a Routine Physical $300 for the extended office visit and $400 for the blood work Chiropractic visit for you and your spouse- $100 each Emergency Room visit for your acute bronchitis $2500 Emergency Room visit for your spouse for a severe migraine with head CT and MRI- $5500 Doctors visit for your 2 children for bronchitis - $200 each for the office visit Doctor's referral for your other child for severe double pneumonia- admitted for 3 days of treatment- $12,000 Chiropractic Therapy visit for you and your spouse $100 each Physical Therapy for your back 10 visits at $100 each Total Costs Your Cost Insurance Cost Wellness and Deductible Worksheet Wellness Benefit = $500 $500