|
| National Market Place Plan Level Equilavent |
| Medical Coverage |
| Wellness Exams & Preventive Visits |
| Deductible |
| Coinsurance |
| Primary Care Provider(PCP)
Virtual Visit(VV)
Specialists
|
| Inpatient Hospital |
| Outpatient Hospital |
| Emergency Room |
| Urgent Care/Convenience Care |
| Annual Out-Of-Pocket
Maximum |
| Lifetime Maximum |
| Prescription Drugs |
| Retail Network (31 days) |
| Mail Order (90 days) |
| Specialty Drugs |
|
| Choice Plus 80/60 |
| No Deductible |
| In-Network |
Out-of-Network |
| 100% with #br#
No Copay |
Mammogram &
Pap Smear Only #br#
60% |
| None |
$1000/Ind. #br#
$2000/Fam. |
| 80% |
60% |
| 100% after Copays
#br# #br#
PCP & VV: $25
Specialist: $40 |
60% |
| 80% |
60% |
| 80% |
60% |
| 100% after $250 Copay #br#
(waived if admitted) |
| 100% after #br#
$50 Copay |
60% |
| $3,500/Ind. #br#
$7,000/Fam. |
$13,000/Ind. #br#
$26,000/Fam. |
| UNLIMITED |
| Tier 1 |
Tier 2 |
Tier 3 |
| $10 |
$35 |
$60 |
| $25 |
$85 |
$150 |
| $60 |
|
| Network 1000 |
| Moderate Deductible |
| In-Network |
Out-of-Network |
| 100% with #br#
No Copay |
Mammogram &
Pap Smear Only #br#
60% |
| $1,000/Ind. #br#
$2,000/Fam. |
$3,000/Ind. #br#
$6,000/Fam. |
| 80% |
60% |
| 100% after Copays #br# #br#
PCP & VV: $30
Specialist: $45 |
60% |
| 80% |
60% |
| 80% |
60% |
| 100% after $250 Copay #br#
(waived if admitted) |
| 100% after #br#
$50 Copay |
60% |
| $5,000/Ind. #br#
$10,000/Fam. |
$15,000/Ind. #br#
$30,000/Fam. |
| UNLIMITED |
| Tier 1 |
Tier 2 |
Tier 3 |
| $10 |
$45 |
$70 |
| $25 |
$110 |
$175 |
| $70 |
|
