|
| | | | | | | | | | In Network and Out of Network |
| | $500/$1,000
(in and out of network combined) | | | | | | | $15/$50/$65 Select or $10 Generic Select | |
| | $750/$1,500
(in and out of network combined) | | | | | | | $15/$50/$65 Select or $10 Generic Select | |
| | $1,000/$2,000
(in and out of network combined) | | | | | | | $15/$50/$65 Select or $10 Generic Select | |
| | $1,500/$3,000
(in and out of network combined) | | | | | | | $15/$60/$75 Select or $15 Generic Select | |
| | $2,000/$4,000
(in and out of network combined) | | | | | | | $15/$60/$75 Select or $15 Generic Select | |
| | $3,000/$6,000
(in and out of network combined) | | | | | | | $15/$60/$75 Select or $15 Generic Select | |
| | $5,000/$10,000
(in and out of network combined) | | | | | | | $15/$60/$75 Select or $15 Generic Select | |
| PPO 3000/100 Summary of Benefits Plan Description Form Brand RX Summary Generic Rx Summary | $3,000/$9,000 | $6,000/$18,000 | $35/$60 | 50% coinsurance | 100% covered | 50% coinsurance | $3,000/$9,000 (includes deductible) | $10,000/$30,000 (includes deductible) |
$15/$40/$55 Select or $15 Generic Select | Not available |
|
PPO 4000/100 Summary of Benefits Plan Description Form Brand Rx Summary Generic Rx Summary | $4,000/$12,000 | $6,000/$18,000 | $40/$65 | 50% coinsurance | 100% covered | 50% coinsurance | $4,000/$12,000 (includes deductible) | $10,000/$30,000 (includes deductible) |
$15/$50/$65 Select or $15 Generic Select | Not available |
|
PPO 5000/100 Summary of Benefits Plan Description Form Brand Rx Summary Generic Rx Summary | $5,000/$15,000 | $7,000/$21,000 | $45/$65 | 50% coinsurance | 100% covered | 50% coinsurance | $5,000/$15,000 (includes deductible) | $10,000/$30,000 (includes deductible) |
$15/$50/$65 Select or $15 Generic Select | Not available |
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