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SBC - Coverage Examples

The SBC gives two common examples of how the plan would pay for coverage: having a baby, and managing Type 2 Diabetes.

This is the standard format for all SBCs up until April 1, 2017. Please refer to the SBC in question for details specific to that plan. The layout may differ but the same information will exist.


On this page, we can:


  • View an example potential costs and coverage for two different situations: having a baby and managing type 2 diabetes.
    • How much would potentially go to satisfying the deductible
    • How much to pay in copays after deductible has been met
    • How much to pay in coinsurance after deductible has been met
    • Benefit limits due to plan restrictions, limits, and exclusions
    • Total cost owed to the provider, how much the plan would potentially pay, and how much the patient would potentially pay for these situations

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