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STATEWIDE No referral needed to see specialists! Nationwide Coverage ! Vision is included |
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| BENEFITS | POS |
Dependent
coverage out of the Area |
HMO |
|
|
ie: away at school |
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| Covered Benefits | |||
| (Benefit Period=Cal. Year) | |||
| Lifetime Maximum | $5,000,000.00 | $5,000,000.00 | $5,000,000.00 |
| Deductible | -0- In Network | 250 | -0- In Network |
| $1,000 Out-of Network | |||
| $ | |||
| Doctor Office Visits | $15,$20,$25 In Network | 80% | $15,$20,$25 In Network |
| Out of Network | 60/40% Out-of-Network | 80% | |
| to
$2500 max paid in year then 100% paid remainder |
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| Preventive & Wellness | $15,$20,$25 In Network | $150/100% | $15,$20,$25 In Network |
|
Prescription Drug |
$10 Gen/$20 Brand $40 Super Brand* |
$10
Gen/$20
Brand $40 Super Brand |
$10 Gen/$20 Brand $40 Super Brand* |
| Rx Deductible option | -$250 ded Rx optional/Save 5% | -$250 ded Rx optionalSave 5% | |
| Pregnancy Care | N/A | N/A | N/A |
|
(available on PPO plans only) |
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| Out-of-Pocket Maximum | $1,000 In Network | $1,000 + ded | $1,000 In Network |
| $2,500 Out-of-Network | |||
| Emergency Room | $100 (waived if admitted) | 80% | $100 (waived if admitted) |
| Ambulatory Surgical Center | $200/250 | 80% | $200/250 |
| Inpatient Hospital | $200,$250 (3 day max) | 80% | $200,$250 (3 day max) |
| 60% Out-of-Network | |||
| 80% | |||
| Ambulance | $50 Per Trip | 80% | $50 Per Trip |
| Vision | $35 per exam | $35 per exam | $35 per exam |
| Dental ($60 a year) | Optional | Optional | |
| GO TO RATES | GO TO RATES | ||
| Send me an application to apply for coverage | Send me an application to apply for coverage | ||