Understanding your Explanation of Benefits (EOB)

1 A 000345 J280 EVGA *0003456*Statement date: October 15, 2016 JANE H DOE 111 AETNA STREET HARTFORD CT 06156 Jane H DoeW1234567890987654-10-001 A P1 (*TOTest INCC ontact us at ID:Member:Group#:Group name:QUESTIONS?Track your health care costs1-800-XXX-XXXXOr write to the address shown above.$ you owe or already paidAmount billed $ Plan payments and discounts- $ You owe$ $ $ $ $ you saved$1, (In-network)Amount you have left to meet deductibleGoing to a doctor or hospital in the networksaves you s because we have arranged discountedrates with these online provider directory can help you find adoctor or other health care professional. Just goto deductible$1, used- $ remaining$1, $ $ $1, guide to key termsTermThis meansYour totalsAmount billed :The amount your doctor or health care provider billed for services.)

2 $ rate:The agreed upon amount the in-network doctor or health care provider accepts as their fee.$ $ $ difference between the amount billed and the in-network arranged claim that needs more review by us or an amount we did not pay. You may or may not have topay this. Read your Claim Remarks to learn amount you pay before your health plan will pay you pay part of the bill and we pay part of the bill. Some plans do not have fixed dollar amount you pay when you visit a doctor or other health care provider.$ $ $ you saved:Pending or not payable:Deductible:Coinsurance:Copay:Sta y healthyWhen you visit your doctor, be prepared with the questions you want to ask. Write them down and bring them with you.

3 Ask about tests, medicationsPage 1 of 3 EL PASO TX 79998-1106 Aetna Life Insurance BOX 981106 Explanation of Benefits (EOB) - This is not a billThis statement is called your EOB. It shows how much you may owe, the amount that was billed , and your member rate. It also shows theamount you saved and what your plan paid. Look at this statement carefully and make sure it is correct. If you do owe anything, you willreceive a bill from your doctor or health care provider(s).$1, next steps you need to take over the next 000345 J280 EVGA *0003456*Statement date: October 15, 2016 JANE H DOE 111 AETNA STREET HARTFORD CT 06156 Jane H DoeW1234567890987654-10-001 A P1 (*TOTest INCC ontact us at ID:Member:Group#:Group name:QUESTIONS?)

4 Track your health care costs1-800-XXX-XXXXOr write to the address shown above.$ you owe or already paidAmount billed $ Plan payments and discounts- $ You owe$ $ $ $ $ you saved$1, (In-network)Amount you have left to meet deductibleGoing to a doctor or hospital in the networksaves you s because we have arranged discountedrates with these online provider directory can help you find adoctor or other health care professional. Just goto deductible$1, used- $ remaining$1, $ $ $1, guide to key termsTermThis meansYour totalsAmount billed :The amount your doctor or health care provider billed for services.$ rate:The agreed upon amount the in-network doctor or health care provider accepts as their fee.

5 $ $ $ difference between the amount billed and the in-network arranged claim that needs more review by us or an amount we did not pay. You may or may not have topay this. Read your Claim Remarks to learn amount you pay before your health plan will pay you pay part of the bill and we pay part of the bill. Some plans do not have fixed dollar amount you pay when you visit a doctor or other health care provider.$ $ $ you saved:Pending or not payable:Deductible:Coinsurance:Copay:Sta y healthyWhen you visit your doctor, be prepared with the questions you want to ask. Write them down and bring them with you. Ask about tests, medicationsPage 1 of 3 EL PASO TX 79998-1106 Aetna Life Insurance BOX 981106 Explanation of Benefits (EOB) - This is not a billThis statement is called your EOB.

6 It shows how much you may owe, the amount that was billed , and your member rate. It also shows theamount you saved and what your plan paid. Look at this statement carefully and make sure it is correct. If you do owe anything, you willreceive a bill from your doctor or health care provider(s).$1, next steps you need to take over the next 000345 J280 EVGA *0003456*Statement date: October 15, 2016 JANE H DOE 111 AETNA STREET HARTFORD CT 06156 Jane H DoeW1234567890987654-10-001 A P1 (*TOTest INCC ontact us at ID:Member:Group#:Group name:QUESTIONS?Track your health care costs1-800-XXX-XXXXOr write to the address shown above.$ you owe or already paidAmount billed $ Plan payments and discounts- $ You owe$ $ $ $ $ you saved$1, (In-network)Amount you have left to meet deductibleGoing to a doctor or hospital in the networksaves you s because we have arranged discountedrates with these online provider directory can help you find adoctor or other health care professional.)

7 Just goto deductible$1, used- $ remaining$1, $ $ $1, guide to key termsTermThis meansYour totalsAmount billed :The amount your doctor or health care provider billed for services.$ rate:The agreed upon amount the in-network doctor or health care provider accepts as their fee.$ $ $ difference between the amount billed and the in-network arranged claim that needs more review by us or an amount we did not pay. You may or may not have topay this. Read your Claim Remarks to learn amount you pay before your health plan will pay you pay part of the bill and we pay part of the bill. Some plans do not have fixed dollar amount you pay when you visit a doctor or other health care provider.$ $ $ you saved:Pending or not payable:Deductible:Coinsurance:Copay:Sta y healthyWhen you visit your doctor, be prepared with the questions you want to ask.

8 Write them down and bring them with you. Ask about tests, medicationsPage 1 of 3 EL PASO TX 79998-1106 Aetna Life Insurance BOX 981106 Explanation of Benefits (EOB) - This is not a billThis statement is called your EOB. It shows how much you may owe, the amount that was billed , and your member rate. It also shows theamount you saved and what your plan paid. Look at this statement carefully and make sure it is correct. If you do owe anything, you willreceive a bill from your doctor or health care provider(s).$1, next steps you need to take over the next 000345 J280 EVGA *0003456*Statement date: October 15, 2016 JANE H DOE 111 AETNA STREET HARTFORD CT 06156 Jane H DoeW1234567890987654-10-001 A P1 (*TOTest INCC ontact us at ID:Member:Group#:Group name:QUESTIONS?)

9 Track your health care costs1-800-XXX-XXXXOr write to the address shown above.$ you owe or already paidAmount billed $ Plan payments and discounts- $ You owe$ $ $ $ $ you saved$1, (In-network)Amount you have left to meet deductibleGoing to a doctor or hospital in the networksaves you s because we have arranged discountedrates with these online provider directory can help you find adoctor or other health care professional. Just goto deductible$1, used- $ remaining$1, $ $ $1, guide to key termsTermThis meansYour totalsAmount billed :The amount your doctor or health care provider billed for services.$ rate:The agreed upon amount the in-network doctor or health care provider accepts as their fee.

10 $ $ $ difference between the amount billed and the in-network arranged claim that needs more review by us or an amount we did not pay. You may or may not have topay this. Read your Claim Remarks to learn amount you pay before your health plan will pay you pay part of the bill and we pay part of the bill. Some plans do not have fixed dollar amount you pay when you visit a doctor or other health care provider.$ $ $ you saved:Pending or not payable:Deductible:Coinsurance:Copay:Sta y healthyWhen you visit your doctor, be prepared with the questions you want to ask. Write them down and bring them with you. Ask about tests, medicationsPage 1 of 3 EL PASO TX 79998-1106 Aetna Life Insurance BOX 981106 Explanation of Benefits (EOB) - This is not a billThis statement is called your EOB.