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Company |
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Plan Name |
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Plan A 100%2,3 |
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Plan A 80%2,3 |
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Plan B 70%2,3 |
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Plan C 50%2,3 |
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Our Newest Plan A |
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Our Most Popular Plan |
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Budget-Minded Premiums 15%-35% Less |
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Save Even More Premiums 28%-40% Less |
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Plan Type |
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PPO |
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PPO |
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PPO |
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PPO |
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Summary of Benefits |
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Network |
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Non-Network |
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Network |
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Non-Network |
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Network |
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Non-Network |
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Network |
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Non-Network |
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Office Visit/Copay Primary doctors and specialists
(including surgery, lab work, therapy and radiology performed by the same doctor on the same day in the office) |
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100% after a $15 copay with no deductible for primary physicians4 or a $30 copay for specialists1 |
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70% after calendar year deductible |
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100% after a $15 copay with no deductible for primary physicians or a $30 copay for specialists1 |
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70% after calendar year deductible |
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100% after a $25 copay with no deductible for primary physicians or a $50 copay for specialists1 |
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70% after calendar year deductible |
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100% after a $30 copay with no deductible for primary physicians or a $60 copay for specialists1 |
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70% after calendar year deductible |
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Benefit period deductible |
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Deductible options: $250, $500, $1,000 |
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Same as In-Network |
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Deductible options: $250, $500, $1,000, $2,500 |
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Same as In-Network |
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Deductible options: $500, $1,000, $2,500, $3,500, $5,000 |
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Same as In-Network |
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Deductible options: $1,000, $2,500, $3,500, $5,000 |
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Same as In-Network |
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Coinsurance (% Paid by Company) Includes Home Health Care, Skilled Nursing, and Inpatient Hospital Care. |
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100% after calendar year deductible. You pay nothing after deductible of covered charges. |
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70% after calendar year deductible |
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80% after calendar year deductible |
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70% after calendar year deductible |
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70% after calendar year deductible |
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60% after calendar year deductible |
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50% after calendar year deductible |
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40% after calendar year deductible |
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Annual Out-of-Pocket Coinsurance Limit (% Paid by You) |
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After calendar year deductible you pay nothing. |
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You pay 20% after calendar year deductible until you have paid maximum $2000 per individual, $4000 per family |
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You pay 30% after calendar year deductible until you have paid maximum $3000 per individual, $6000 per family |
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You pay 50% after calendar year deductible until you have paid maximum $3000 per individual, $6000 per family |
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Lifetime Maximum |
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unlimited |
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unlimited |
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$5 million |
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$5 million |
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Prescription Drugs |
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Unlimited coverage for generic drugs (max for brand drugs is $2000 benefit per person per calendar year)
Includes family planning
100% after copayment with no deductible $10 copay for generic $35 or $50 copay for brand.6 Tier 4/25% coinsurance |
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Unlimited coverage for generic drugs (max for brand drugs is $2000 benefit per person per calendar year)
Includes family planning
100% after copayment with no deductible $10 copay for generic $35 or $50 copay for brand.6 Tier 4/25% coinsurance |
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Unlimited coverage for generic drugs
(max for brand drugs is $2000 benefit per person per calendar year)
Includes family planning
100% after $200 annual deductible per member $10 copay for generic
$35 or $50 for brand.6 Tier 4/25% coinsurance |
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Unlimited coverage for generic drugs
(max for brand drugs is $2000 benefit per person per calendar year)
Includes family planning
100% after $500 annual deductible per member $10 copay for generic
$35 or $50 for brand.6 Tier 4/25% coinsurance |
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Urgent Care Centers |
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100% after $30 copay with no deductible |
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100% after $30 copay with no deductible |
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100% after $30 copay with no deductible |
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100% after $30 copay with no deductible |
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100% after $50 copay with no deductible |
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100% after $50 copay with no deductible |
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100% after $60 copay with no deductible |
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100% after $60 copay with no deductible |
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Emergency Room |
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100% after $150 copay7 (copay waived if admitted) |
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100% after $150 copay7 (copay waived if admitted) |
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100% after $150 copay7 (copay waived if admitted) |
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100% after $150 copay7 (copay waived if admitted) |
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100% after $150 copay7 (copay waived if admitted) |
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100% after $150 copay7 (copay waived if admitted) |
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100% after $150 copay7 (copay waived if admitted) |
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100% after $150 copay7 (copay waived if admitted) |
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Preventive Care |
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Routine physical exam, including gynecological exam |
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100% after a $15 copay with no deductible for primary physicians4 or a $30 copay for specialists1 |
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Not available |
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100% after a $15 copay with no deductible for primary physicians4 or a $30 copay for specialists1 |
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Not available |
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100% after a $25 copay with no deductible for primary physicians4 or a $50 copay for specialists1 |
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Not available |
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100% after a $30 copay with no deductible for primary physicians4 or a $60 copay for specialists1 |
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Not available |
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Well-child and baby care (including periodic assessments and immunizations) |
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100% after a $15 copay with no deductible for primary physicians4 or a $30 copay for specialists1 |
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Not available |
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100% after a $15 copay with no deductible for primary physicians4 or a $30 copay for specialists1 |
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Not available |
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100% after a $25 copay with no deductible for primary physicians4 or a $50 copay for specialists1 |
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Not available |
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100% after a $30 copay with no deductible for primary physicians4 or a $60 copay for specialists1 |
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Not available |
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Immunizations |
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100% |
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Not available |
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100% |
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Not available |
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100% |
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Not available |
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100% |
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Not available |
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MRI PET & CT Scans |
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Subject to the deductible and coinsurance regardless of where performed. |
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Physical Therapy |
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$15/$30 copay maximum combined therapy 30 visits |
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70% after calendar year deductible |
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$15/$30 copay maximum combined therapy 30 visits |
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70% after calendar year deductible |
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$25/$50 copay maximum combined therapy 30 visits |
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60% after calendar year deductible |
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$30/$60 copay maximum combined therapy 30 visits |
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40% after calendar year deductible |
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Routine Eye Exam |
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100% after $15 copay |
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Not Available |
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100% after $15 copay |
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Not Available |
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Covered In-Network w/copay of $25 |
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Not Available |
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Covered In-Network w/copay of $30 |
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Not Available |
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Mental Health |
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$2,000 benefit max per person per calendar year; $10,000 lifetime max per
person Inpatient facility, Inpatient professional. Outpatient professional
50% after calendar year deductible |
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$2,000 benefit max per person per calendar year; $10,000 lifetime max per
person Inpatient facility, Inpatient professional. Outpatient professional
50% after calendar year deductible |
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$2,000 benefit max per person per calendar year; $10,000 lifetime max per
person Inpatient facility, Inpatient professional. Outpatient professional
50% after calendar year deductible |
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$2,000 benefit max per person per calendar year; $10,000 lifetime max per
person Inpatient facility, Inpatient professional. Outpatient professional
50% after calendar year deductible |
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Maternity Benefits |
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Optional -- please call for rates. |
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Optional -- please call for rates. |
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Optional -- please call for rates. |
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Optional -- please call for rates. |
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Note |
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COVERAGE MAY BEGIN ON THE 1ST OR 15TH OF EACH MONTH BUT APPLICATION MUST BE SUBMITTED AT LEAST 7 DAYS PRIOR TO REQUESTED EFFECTIVE DATE.
IF YOU NEED ASSISTANCE, PLEASE CALL 888-765-5400 OR 252-726-5400. |
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