My Health Coverage at-a-Glance

Plan Information

Plan name Group number

Website Phone number 

Member ID number 

Other 

Know what you pay for care

Coinsurance 

A portion you pay as your share of the cost for 

services after you pay any deductibles. 

Copayment (Copay) 

A set amount you pay for a medical service or 

supply. There may be different costs for a doctor’s 

visit, hospital outpatient visit, or prescription. 

Primary care copay 

Primary coinsurance 

Specialist copay 

Specialist coinsurance 

Hospital coinsurance 

Prescription Hospital copay 

Prescription coinsurance 

Preventive services 

Routine health care screenings, check-ups, and 

vaccines. For example, flu shots, depression 

screenings, and blood pressure tests.

Deductible

The amount you pay for health care services before

your health plan begins to pay.

Cost 

Out-of-pocket maximum

Cost 

Out-of-pocket maximum 

The most you pay before your plan starts to pay 

100% for covered services in a plan year.

Premium 

The payment you make to a health insurance 

company or plan for your coverage. This is usually 

paid each month to keep your coverage. 

Cost 

$ or n/a per month/year/etc.

$ or n/a

$ or n/a

$ or n/a

$ or n/a

$ or n/a

$ or n/a

$ or n/a

$ or n/a

$ or n/a $ or n/a

$ or n/a

Services I can get before I meet my deductible. This 

includes preventive services, like flu shot, pap test, and 

colorectal cancer test, etc. 

Enter current maximum and note if it includes 

deductible and other costs.

$0 (for most plans, adjust if needed) 
Dates to remember and other notes

Additional information

Review your plan each year before Open Enrollment and contact your plan with any life changes (like getting 

married, or having a baby) or any changes in contact information. For more information on how to get started go to 

http://bit.ly/C2C5Ways and read the 5 Ways to Make the Most of Your Health Coverage.

For more information and a glossary of terms, go to http://bit.ly/C2CRoadmapBetterCare

to read the Roadmap to Better Care and a Healthier You.

Paid for by the US Department of Health and Human Services

Cost tip: Services usually cost less if you use in-network providers. These are facilities, providers, and 

suppliers your plan has agreed to use to offer services. To find out who is in-network, check the plan 

directory and ask your provider’s office.

Premium due date Renewal date/other 

Other information 

Pay premium on 10/15/2018 Renew plan on 08/19/2019

Contact information, allergies, prescription lists, link to summary of benefits and coverage, password hint, 

local contact information, etc.

Know where to go for care

Emergency Department (ED or ER) 

The ED in your local hospital is where you would receive service 

for an illness, injury, symptom, or condition so serious that a 

reasonable person would seek care and treatment right away to 

keep the condition from getting worse.

Pharmacy 

A store where prescriptions are given and sold. To fill 

prescriptions, find a pharmacy that’s in-network. This way you 

won’t pay as much. See the plan directory or check with your 

local pharmacy. 

Specialists

A physician who focuses on a specific area of medicine or a 

group of patients to diagnose, manage, prevent, or treat certain 

types of symptoms and conditions. A non-physician specialist is 

a provider who has more training in a specific area.

Primary Care Provider

The main provider (often a doctor) you see first for most health 

problems. This could be a private practice, community clinic, or other 

place. Go to this provider for preventive services, prescriptions or 

other health questions.

My provider’s name 

My provider’s phone number 

My pharmacy’s address 

My pharmacy’s phone number 

My specialist’s name 

My specialist’s phone number 

My local hospital’s address 

My local hospital’s phone number 

go.cms.gov/c2c

CMS Product No. 909505

September 2018