| Carrier | Plan # | Plan Name | Funding | Tier | Network Name | Network Type | Plan Type | Deductible - Individual | Deductible - Family | Coinsurance - Member | Coinsurance - Plan | Out-of-Pocket - Individual | Out-of-Pocket - Family | Virtual Visits | PCP <19 | Primary | Specialist | Prescriptions | EO | ES | EC | EF | Total |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| BCBSTX | B001 | P9M1CHC | FI | P | Blue Choice | PPO | Copay | $0 | $0 | 10% | 90% | $6,300 | $12,600 | $20 | $20 | $20 | $40 | $0-10-50-100-150-250 | |||||
| BCBSTX | B002 | P620CHC | FI | P | Blue Choice | PPO | Copay | $350 | $1,050 | 20% | 80% | $1,600 | $4,800 | $35 | $35 | $35 | $70 | $0-10-35-75-150-250 | |||||
| BCBSTX | B003 | P9K3CHC | FI | P | Blue Choice | PPO | Copay | $600 | $1,200 | 20% | 80% | $1,800 | $3,600 | $35 | $35 | $35 | $70 | $0-10-50-100-150-250 | |||||
| BCBSTX | B004 | P9O3CHC | FI | P | Blue Choice | PPO | Copay | $1,000 | $3,000 | 20% | 80% | $3,000 | $6,000 | $0 | $0 | $0 | $40 | $0-10-50-100-150-250 | |||||
| BCBSTX | B005 | P621CHC | FI | P | Blue Choice | PPO | Copay | $1,350 | $4,050 | 0% | 100% | $1,350 | $4,050 | $30 | $30 | $30 | $55 | $0-10-35-75-150-250 | |||||
| BCBSTX | B006 | G9K8CHC | FI | G | Blue Choice | PPO | Copay | $1,050 | $3,150 | 20% | 80% | $6,300 | $12,600 | $55 | $55 | $55 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B007 | G654CHC | FI | G | Blue Choice | PPO | Copay | $1,300 | $3,900 | 20% | 80% | $5,250 | $10,500 | $55 | $55 | $55 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B008 | G652CHC | FI | G | Blue Choice | PPO | Copay | $1,600 | $4,800 | 20% | 80% | $5,350 | $10,705 | $50 | $50 | $50 | $100 | $5-15-50-100-150-250 | |||||
| BCBSTX | B009 | G653CHC | FI | G | Blue Choice | PPO | Copay | $1,750 | $5,250 | 20% | 80% | $6,750 | $18,400 | $45 | $45 | $45 | $90 | $0-10-50-100-150-250 | |||||
| BCBSTX | B010 | G9K6CHC | FI | G | Blue Choice | PPO | Copay | $2,100 | $6,300 | 10% | 90% | $4,200 | $12,600 | DC | DC | DC | DC | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B011 | G9L1CHC | FI | G | Blue Choice | PPO | Copay | $2,250 | $6,750 | 20% | 80% | $6,750 | $18,400 | $35 | $35 | $35 | $70 | $0-10-50-100-150-250 | |||||
| BCBSTX | B012 | G9L7CHC | FI | G | Blue Choice | PPO | Copay | $3,000 | $9,000 | 10% | 90% | $5,500 | $11,000 | $30 | $30 | $30 | $50 | $0-10-50-100-150-250 | |||||
| BCBSTX | B013 | G9L5CHC | FI | G | Blue Choice | PPO | Copay | $3,100 | $9,300 | 20% | 80% | $8,800 | $17,600 | $0 | $0 | $0 | $80 | $0-10-50-100-150-250 | |||||
| BCBSTX | B014 | G650CHC | FI | G | Blue Choice | PPO | Copay | $3,350 | $10,050 | 0% | 100% | $3,350 | $10,050 | $55 | $55 | $55 | $100 | Ded & Coins | |||||
| BCBSTX | B015 | S663CHC | FI | S | Blue Choice | PPO | Copay | $3,100 | $9,200 | 30% | 70% | $9,200 | $18,400 | $50 | $50 | $50 | $100 | $5-10-50-100-150-250 | |||||
| BCBSTX | B016 | S661CHC | FI | S | Blue Choice | PPO | Copay | $3,650 | $10,950 | 30% | 70% | $9,200 | $18,400 | $55 | $55 | $55 | $100 | $5-10-50-100-150-250 | |||||
| BCBSTX | B017 | S665CHC | FI | S | Blue Choice | PPO | Copay | $3,650 | $10,950 | 40% | 60% | $9,200 | $18,400 | $55 | $55 | $55 | $100 | $5-10-50-100-150-250 | |||||
| BCBSTX | B018 | S9M2CHC | FI | S | Blue Choice | PPO | Copay | $3,850 | $11,550 | 20% | 80% | $9,100 | $18,200 | $50 | $50 | $50 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B019 | S9L9CHC | FI | S | Blue Choice | PPO | Copay | $3,850 | $11,550 | 30% | 70% | $9,100 | $18,200 | $55 | $55 | $55 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B020 | S9N3CHC | FI | S | Blue Choice | PPO | Copay | $4,100 | $12,300 | 20% | 80% | $8,200 | $16,400 | $0 | $0 | $0 | $110 | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B021 | S9N1CHC | FI | S | Blue Choice | PPO | Copay | $4,100 | $12,300 | 40% | 60% | $9,200 | $18,400 | $0 | $0 | $0 | $90 | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B022 | S666CHC | FI | S | Blue Choice | PPO | Copay | $4,350 | $13,050 | 30% | 70% | $9,100 | $18,200 | $55 | $55 | $55 | $100 | $5-15-50-100-250-350 | |||||
| BCBSTX | B023 | S9K1CHC | FI | S | Blue Choice | PPO | Copay | $5,100 | $15,300 | 30% | 70% | $9,100 | $18,200 | $45 | $45 | $45 | $90 | $0-10-50-100-150-250 | |||||
| BCBSTX | B024 | S667CHC | FI | S | Blue Choice | PPO | Copay | $6,100 | $12,200 | 20% | 80% | $8,350 | $16,700 | $55 | $55 | $55 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B025 | S660CHC | FI | S | Blue Choice | PPO | Copay | $6,500 | $13,000 | 10% | 90% | $9,200 | $18,400 | $50 | $50 | $50 | $100 | $5-10-50-100-150-250 | |||||
| BCBSTX | B026 | S9L7CHC | FI | S | Blue Choice | PPO | Copay | $8,200 | $16,400 | 0% | 100% | $8,200 | $16,400 | $55 | $55 | $55 | $110 | $0-10-50-100-150-250 | |||||
| BCBSTX | B027 | B662CHC | FI | B | Blue Choice | PPO | Copay | $8,650 | $17,300 | 0% | 100% | $8,650 | $17,300 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B028 | G651CHC | FI | G | Blue Choice | PPO | HSA | $3,500 | $10,500 | 0% | 100% | $3,500 | $10,500 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B029 | G656CHC | FI | G | Blue Choice | PPO | HSA | $4,100 | $12,300 | 0% | 100% | $4,100 | $12,300 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B030 | S9L5CHC | FI | S | Blue Choice | PPO | HSA | $3,600 | $7,200 | 20% | 80% | $7,200 | $14,400 | $40 | $40 | $40 | $80 | Ded, $5-15-50-100-250-350 | |||||
| BCBSTX | B031 | S9L3CHC | FI | S | Blue Choice | PPO | HSA | $4,100 | $12,300 | 20% | 80% | $7,000 | $14,000 | D&C | D&C | D&C | D&C | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B032 | S662CHC | FI | S | Blue Choice | PPO | HSA | $5,500 | $11,000 | 0% | 100% | $5,500 | $11,000 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B033 | S9M4CHC | FI | S | Blue Choice | PPO | HSA | $6,100 | $12,200 | 0% | 100% | $6,100 | $12,200 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B034 | B660CHC | FI | B | Blue Choice | PPO | HSA | $6,750 | $13,500 | 30% | 70% | $7,750 | $15,500 | D&C | D&C | D&C | D&C | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B035 | B661CHC | FI | B | Blue Choice | PPO | HSA | $7,500 | $15,000 | 0% | 100% | $7,500 | $15,000 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B036 | P9M1ADT | FI | P | Blue Advantage | HMO | Copay | $0 | $0 | 10% | 90% | $6,300 | $12,600 | $20 | $20 | $20 | $40 | $0-10-50-100-150-250 | |||||
| BCBSTX | B037 | P610ADT | FI | P | Blue Advantage | HMO | Copay | $350 | $1,050 | 20% | 80% | $1,600 | $4,800 | $35 | $35 | $35 | $70 | $0-10-35-75-150-250 | |||||
| BCBSTX | B038 | P9K3ADT | FI | P | Blue Advantage | HMO | Copay | $600 | $1,200 | 20% | 80% | $1,800 | $3,600 | $35 | $35 | $35 | $70 | $0-10-50-100-150-250 | |||||
| BCBSTX | B039 | P9O5ADT | FI | P | Blue Advantage | HMO | Copay | $1,000 | $3,000 | 20% | 80% | $3,000 | $6,000 | $0 | $0 | $0 | $40 | $0-10-50-100-150-250 | |||||
| BCBSTX | B040 | P611ADT | FI | P | Blue Advantage | HMO | Copay | $1,350 | $4,050 | 0% | 100% | $1,350 | $4,050 | $30 | $30 | $30 | $55 | $0-10-35-75-150-250 | |||||
| BCBSTX | B041 | G665ADT | FI | G | Blue Advantage | HMO | Copay | $0 | $0 | 0% | 100% | $9,200 | $18,400 | $50 | $50 | $50 | $90 | $5-15-50-100-150-250 | |||||
| BCBSTX | B042 | G662ADT | FI | G | Blue Advantage | HMO | Copay | $1,050 | $3,150 | 20% | 80% | $6,300 | $12,600 | $55 | $55 | $55 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B043 | G9E5ADT | FI | G | Blue Advantage | HMO | Copay | $1,300 | $3,900 | 20% | 80% | $5,250 | $10,500 | $55 | $55 | $55 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B044 | G663ADT | FI | G | Blue Advantage | HMO | Copay | $1,600 | $4,800 | 20% | 80% | $5,350 | $10,705 | $50 | $50 | $50 | $100 | $5-15-50-100-150-250 | |||||
| BCBSTX | B045 | G9E3ADT | FI | G | Blue Advantage | HMO | Copay | $1,750 | $5,250 | 20% | 80% | $6,750 | $18,400 | $45 | $45 | $45 | $90 | $0-10-50-100-150-250 | |||||
| BCBSTX | B046 | G661ADT | FI | G | Blue Advantage | HMO | Copay | $2,100 | $6,300 | 10% | 90% | $4,200 | $12,600 | DC | DC | DC | DC | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B047 | G664ADT | FI | G | Blue Advantage | HMO | Copay | $2,250 | $6,750 | 20% | 80% | $6,750 | $18,400 | $35 | $35 | $35 | $70 | $0-10-50-100-150-250 | |||||
| BCBSTX | B048 | G9K7ADT | FI | G | Blue Advantage | HMO | Copay | $3,000 | $9,000 | 10% | 90% | $5,500 | $11,000 | $30 | $30 | $30 | $50 | $0-10-50-100-150-250 | |||||
| BCBSTX | B049 | G9K5ADT | FI | G | Blue Advantage | HMO | Copay | $3,100 | $9,300 | 20% | 80% | $8,800 | $17,600 | $0 | $0 | $0 | $80 | $0-10-50-100-150-250 | |||||
| BCBSTX | B050 | G660ADT | FI | G | Blue Advantage | HMO | Copay | $3,350 | $10,050 | 0% | 100% | $3,350 | $10,050 | $55 | $55 | $55 | $100 | Ded & Coins | |||||
| BCBSTX | B051 | S9J7ADT | FI | S | Blue Advantage | HMO | Copay | $3,100 | $9,200 | 30% | 70% | $9,200 | $18,400 | $50 | $50 | $50 | $100 | $5-10-50-100-150-250 | |||||
| BCBSTX | B052 | S643ADT | FI | S | Blue Advantage | HMO | Copay | $3,650 | $10,950 | 30% | 70% | $9,200 | $18,400 | $55 | $55 | $55 | $100 | $5-10-50-100-150-250 | |||||
| BCBSTX | B053 | S9J9ADT | FI | S | Blue Advantage | HMO | Copay | $3,650 | $10,950 | 40% | 60% | $9,200 | $18,400 | $55 | $55 | $55 | $100 | $5-10-50-100-150-250 | |||||
| BCBSTX | B054 | S9E3ADT | FI | S | Blue Advantage | HMO | Copay | $3,850 | $11,550 | 20% | 80% | $9,100 | $18,200 | $50 | $50 | $50 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B055 | S642ADT | FI | S | Blue Advantage | HMO | Copay | $3,850 | $11,550 | 30% | 70% | $9,100 | $18,200 | $55 | $55 | $55 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B056 | S9N3ADT | FI | S | Blue Advantage | HMO | Copay | $4,100 | $12,300 | 20% | 80% | $8,200 | $16,400 | $0 | $0 | $0 | $110 | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B057 | S9N1ADT | FI | S | Blue Advantage | HMO | Copay | $4,100 | $12,300 | 40% | 60% | $9,200 | $18,400 | $0 | $0 | $0 | $90 | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B058 | S641ADT | FI | S | Blue Advantage | HMO | Copay | $4,350 | $13,050 | 30% | 70% | $9,100 | $18,200 | $55 | $55 | $55 | $100 | $5-15-50-100-250-350 | |||||
| BCBSTX | B059 | S9L1ADT | FI | S | Blue Advantage | HMO | Copay | $5,100 | $15,300 | 30% | 70% | $9,100 | $18,200 | $45 | $45 | $45 | $90 | $0-10-50-100-150-250 | |||||
| BCBSTX | B060 | S9E5ADT | FI | S | Blue Advantage | HMO | Copay | $6,100 | $12,200 | 20% | 80% | $8,350 | $16,700 | $55 | $55 | $55 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B061 | S640ADT | FI | S | Blue Advantage | HMO | Copay | $6,500 | $13,000 | 10% | 90% | $9,200 | $18,400 | $50 | $50 | $50 | $100 | $5-10-50-100-150-250 | |||||
| BCBSTX | B062 | S644ADT | FI | S | Blue Advantage | HMO | Copay | $8,200 | $16,400 | 0% | 100% | $8,200 | $16,400 | $55 | $55 | $55 | $110 | $0-10-50-100-150-250 | |||||
| BCBSTX | B063 | B661ADT | FI | B | Blue Advantage | HMO | Copay | $8,650 | $17,300 | 0% | 100% | $8,650 | $17,300 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B064 | G9E1ADT | FI | G | Blue Advantage | HMO | HSA | $3,500 | $10,500 | 0% | 100% | $3,500 | $10,500 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B065 | G666ADT | FI | G | Blue Advantage | HMO | HSA | $4,100 | $12,300 | 0% | 100% | $4,100 | $12,300 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B066 | S9J5ADT | FI | S | Blue Advantage | HMO | HSA | $3,600 | $7,200 | 20% | 80% | $7,200 | $14,400 | $40 | $40 | $40 | $80 | Ded, $5-15-50-100-250-350 | |||||
| BCBSTX | B067 | S9J3ADT | FI | S | Blue Advantage | HMO | HSA | $4,100 | $12,300 | 20% | 80% | $7,000 | $14,000 | D&C | D&C | D&C | D&C | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B068 | S9E1ADT | FI | S | Blue Advantage | HMO | HSA | $5,500 | $11,000 | 0% | 100% | $5,500 | $11,000 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B069 | S9K2ADT | FI | S | Blue Advantage | HMO | HSA | $6,100 | $12,200 | 0% | 100% | $6,100 | $12,200 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B070 | B9E1ADT | FI | B | Blue Advantage | HMO | HSA | $6,750 | $13,500 | 30% | 70% | $7,750 | $15,500 | D&C | D&C | D&C | D&C | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B071 | B660ADT | FI | B | Blue Advantage | HMO | HSA | $7,500 | $15,000 | 0% | 100% | $7,500 | $15,000 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S001 | PPO Access Copay 0 7000 | FI | G | Access PPO | PPO | Copay | $0 | $0 | 10% | 90% | $7,000 | $14,000 | $0 | $0 | $20 | $55 | $3-50-125-250 | |||||
| BSW | S002 | PPO Access 80 750 | FI | G | Access PPO | PPO | Copay | $750 | $1,500 | 20% | 80% | $8,250 | $16,500 | $0 | $0 | $40 | $70 | $3-50-125-250 | |||||
| BSW | S003 | PPO Access 90 750 | FI | S | Access PPO | PPO | Copay | $750 | $1,500 | 10% | 90% | $9,200 | $18,400 | $0 | $0 | $50 | $100 | $3-50-125-250 | |||||
| BSW | S004 | PPO Access 80 1000 | FI | G | Access PPO | PPO | Copay | $1,000 | $2,000 | 20% | 80% | $8,200 | $16,400 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S005 | PPO Access 80 1500 | FI | G | Access PPO | PPO | Copay | $1,500 | $3,000 | 20% | 80% | $7,000 | $14,000 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S006 | PPO Access 90 1900 | FI | G | Access PPO | PPO | Copay | $1,900 | $3,800 | 10% | 90% | $7,500 | $15,000 | $0 | $0 | $0 | $60 | $3-50-125-250 | |||||
| BSW | S007 | PPO Access 90 2000 | FI | G | Access PPO | PPO | Copay | $2,000 | $4,000 | 10% | 90% | $5,500 | $11,000 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S008 | PPO Access 100 2300 | FI | G | Access PPO | PPO | Copay | $2,300 | $4,600 | 100% | 0% | $8,500 | $17,000 | $0 | $0 | $0 | $70 | $3-50-125-250 | |||||
| BSW | S009 | PPO Access 100 3000 | FI | G | Access PPO | PPO | Copay | $3,000 | $6,000 | 0% | 100% | $4,400 | $8,800 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S010 | PPO Access 80 3000 | FI | G | Access PPO | PPO | Copay | $3,000 | $6,000 | 20% | 80% | $5,500 | $11,000 | $0 | $0 | $35 | $80 | $3-50-125-250 | |||||
| BSW | S011 | PPO Access 60 3250 | FI | S | Access PPO | PPO | Copay | $3,250 | $6,500 | 40% | 60% | $9,100 | $18,200 | $0 | $0 | $55 | $95 | $3-50-125-250 | |||||
| BSW | S012 | PPO Access 100 3500 | FI | G | Access PPO | PPO | Copay | $3,500 | $7,000 | 0% | 100% | $6,900 | $13,800 | $0 | $0 | $0 | $65 | $3-50-125-250 | |||||
| BSW | S013 | PPO Access 70 3800 | FI | S | Access PPO | PPO | Copay | $3,800 | $7,600 | 30% | 70% | $9,100 | $18,200 | $0 | $0 | $50 | $95 | $3-50-125-250 | |||||
| BSW | S014 | PPO Access 100 4000 | FI | G | Access PPO | PPO | Copay | $4,000 | $8,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $25 | $3-50-125-250 | |||||
| BSW | S015 | PPO Access 60 4200 | FI | S | Access PPO | PPO | Copay | $4,200 | $8,400 | 40% | 60% | $9,200 | $18,400 | $0 | $0 | D $45 | D $80 | $3-50-125-250 | |||||
| BSW | S016 | PPO Access 80 4250 | FI | S | Access PPO | PPO | Copay | $4,250 | $8,500 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $50 | $95 | $3-50-125-250 | |||||
| BSW | S017 | PPO Access 90 4500 | FI | G | Access PPO | PPO | Copay | $4,500 | $9,000 | 10% | 90% | $6,300 | $12,600 | $0 | $0 | $5 | $40 | $3-50-125-250 | |||||
| BSW | S018 | PPO Access 70 4500 | FI | S | Access PPO | PPO | Copay | $4,500 | $9,000 | 30% | 70% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S019 | PPO Access 80 5000 | FI | S | Access PPO | PPO | Copay | $5,000 | $10,000 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S020 | PPO Access 90 5900 | FI | S | Access PPO | PPO | Copay | $5,900 | $11,800 | 10% | 90% | $9,100 | $18,200 | $0 | $0 | $35 | $70 | $3-50-125-250 | |||||
| BSW | S021 | PPO Access 80 6250 | FI | S | Access PPO | PPO | Copay | $6,250 | $12,500 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $40 | $75 | $3-50-125-250 | |||||
| BSW | S022 | PPO Access 90 6500 | FI | S | Access PPO | PPO | Copay | $6,500 | $13,000 | 10% | 90% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S023 | PPO Access 70 6700 | FI | S | Access PPO | PPO | Copay | $6,700 | $13,400 | 30% | 70% | $9,200 | $18,400 | $0 | $0 | $45 | $85 | $3-50-125-250 | |||||
| BSW | S024 | PPO Access 80 6900 | FI | S | Access PPO | PPO | Copay | $6,900 | $13,800 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $45 | $85 | $3-50-125-250 | |||||
| BSW | S025 | PPO Access 90 7000 | FI | S | Access PPO | PPO | Copay | $7,000 | $14,000 | 10% | 90% | $8,200 | $16,400 | $0 | $0 | D&C | D&C | $3-50-125-250 | |||||
| BSW | S026 | PPO Access 100 7300 | FI | S | Access PPO | PPO | Copay | $7,300 | $14,600 | 0% | 100% | $9,200 | $18,400 | $0 | $0 | $25 | $70 | $3-50-125-250 | |||||
| BSW | S027 | PPO Access 80 7500 | FI | S | Access PPO | PPO | Copay | $7,500 | $15,000 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $45 | $80 | $3-50-125-250 | |||||
| BSW | S028 | PPO Access 80 7500 | FI | B | Access PPO | PPO | Copay | $7,500 | $15,000 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $55 | $60 | $3-50-125-250 | |||||
| BSW | S029 | PPO Access 90 7900 | FI | B | Access PPO | PPO | Copay | $7,900 | $15,800 | 10% | 90% | $9,200 | $18,400 | $0 | $0 | $45 | $50 | $3-50-125-250 | |||||
| BSW | S030 | PPO Access 80 8900 | FI | S | Access PPO | PPO | Copay | $8,900 | $17,800 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $50 | $100 | $3-50-125-250 | |||||
| BSW | S031 | PPO Access 100 9200 | FI | B | Access PPO | PPO | Copay | $9,200 | $18,400 | 0% | 100% | $9,200 | $18,400 | $0 | $0 | D&C | D&C | $3-50-125-250 | |||||
| BSW | S032 | PPO Access HSA 3300 | FI | G | Access PPO | PPO | HSA | $3,300 | $6,600 | 0% | 100% | $3,300 | $6,600 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S033 | PPO Access HSA 3700 | FI | G | Access PPO | PPO | HSA | $3,700 | $7,400 | 0% | 100% | $3,700 | $7,400 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S034 | PPO Access HSA 5100 | FI | S | Access PPO | PPO | HSA | $5,100 | $10,200 | 0% | 100% | $5,100 | $10,200 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S035 | PPO Access HSA 6200 | FI | S | Access PPO | PPO | HSA | $6,200 | $12,400 | 0% | 100% | $6,200 | $12,400 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S036 | PPO Access HSA 7300 | FI | B | Access PPO | PPO | HSA | $7,300 | $14,600 | 0% | 100% | $7,300 | $14,600 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S037 | PPO+ Copay 0 7000 | FI | G | BSW+ PPO | PPO | Copay | $0 | $0 | 10% | 90% | $7,000 | $14,000 | $0 | $0 | $20 | $55 | $3-50-125-250 | |||||
| BSW | S038 | PPO+ 80 750 | FI | G | BSW+ PPO | PPO | Copay | $750 | $1,500 | 20% | 80% | $8,250 | $16,500 | $0 | $0 | $40 | $70 | $3-50-125-250 | |||||
| BSW | S039 | PPO+ 90 750 | FI | S | BSW+ PPO | PPO | Copay | $750 | $1,500 | 10% | 90% | $9,200 | $18,400 | $0 | $0 | $50 | $100 | $3-50-125-250 | |||||
| BSW | S040 | PPO+ 80 1000 | FI | G | BSW+ PPO | PPO | Copay | $1,000 | $2,000 | 20% | 80% | $8,200 | $16,400 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S041 | PPO+ 80 1500 | FI | G | BSW+ PPO | PPO | Copay | $1,500 | $3,000 | 20% | 80% | $7,000 | $14,000 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S042 | PPO+ 90 1900 | FI | G | BSW+ PPO | PPO | Copay | $1,900 | $3,800 | 10% | 90% | $7,500 | $15,000 | $0 | $0 | $0 | $60 | $3-50-125-250 | |||||
| BSW | S043 | PPO+ 90 2000 | FI | G | BSW+ PPO | PPO | Copay | $2,000 | $4,000 | 10% | 90% | $5,500 | $11,000 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S044 | PPO+ 100 2300 | FI | G | BSW+ PPO | PPO | Copay | $2,300 | $4,600 | 100% | 0% | $8,500 | $17,000 | $0 | $0 | $0 | $70 | $3-50-125-250 | |||||
| BSW | S045 | PPO+ 100 3000 | FI | G | BSW+ PPO | PPO | Copay | $3,000 | $6,000 | 0% | 100% | $4,400 | $8,800 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S046 | PPO+ 80 3000 | FI | G | BSW+ PPO | PPO | Copay | $3,000 | $6,000 | 20% | 80% | $5,500 | $11,000 | $0 | $0 | $35 | $80 | $3-50-125-250 | |||||
| BSW | S047 | PPO+ 60 3250 | FI | S | BSW+ PPO | PPO | Copay | $3,250 | $6,500 | 40% | 60% | $9,100 | $18,200 | $0 | $0 | $55 | $95 | $3-50-125-250 | |||||
| BSW | S048 | PPO+ 100 3500 | FI | G | BSW+ PPO | PPO | Copay | $3,500 | $7,000 | 0% | 100% | $6,900 | $13,800 | $0 | $0 | $0 | $65 | $3-50-125-250 | |||||
| BSW | S049 | PPO+ 70 3800 | FI | S | BSW+ PPO | PPO | Copay | $3,800 | $7,600 | 30% | 70% | $9,100 | $18,200 | $0 | $0 | $50 | $95 | $3-50-125-250 | |||||
| BSW | S050 | PPO+ 100 4000 | FI | G | BSW+ PPO | PPO | Copay | $4,000 | $8,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $25 | $3-50-125-250 | |||||
| BSW | S051 | PPO+ 60 4200 | FI | S | BSW+ PPO | PPO | Copay | $4,200 | $8,400 | 40% | 60% | $9,200 | $18,400 | $0 | $0 | D $45 | D $80 | $3-50-125-250 | |||||
| BSW | S052 | PPO+ 80 4250 | FI | S | BSW+ PPO | PPO | Copay | $4,250 | $8,500 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $50 | $95 | $3-50-125-250 | |||||
| BSW | S053 | PPO+ 90 4500 | FI | G | BSW+ PPO | PPO | Copay | $4,500 | $9,000 | 10% | 90% | $6,300 | $12,600 | $0 | $0 | $5 | $40 | $3-50-125-250 | |||||
| BSW | S054 | PPO+ 70 4500 | FI | S | BSW+ PPO | PPO | Copay | $4,500 | $9,000 | 30% | 70% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S055 | PPO+ 80 5000 | FI | S | BSW+ PPO | PPO | Copay | $5,000 | $10,000 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S056 | PPO+ 90 5900 | FI | S | BSW+ PPO | PPO | Copay | $5,900 | $11,800 | 10% | 90% | $9,100 | $18,200 | $0 | $0 | $35 | $70 | $3-50-125-250 | |||||
| BSW | S057 | PPO+ 80 6250 | FI | S | BSW+ PPO | PPO | Copay | $6,250 | $12,500 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $40 | $75 | $3-50-125-250 | |||||
| BSW | S058 | PPO+ 90 6500 | FI | S | BSW+ PPO | PPO | Copay | $6,500 | $13,000 | 10% | 90% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S059 | PPO+ 70 6700 | FI | S | BSW+ PPO | PPO | Copay | $6,700 | $13,400 | 30% | 70% | $9,200 | $18,400 | $0 | $0 | $45 | $85 | $3-50-125-250 | |||||
| BSW | S060 | PPO+ 80 6900 | FI | S | BSW+ PPO | PPO | Copay | $6,900 | $13,800 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $45 | $85 | $3-50-125-250 | |||||
| BSW | S061 | PPO+ 90 7000 | FI | S | BSW+ PPO | PPO | Copay | $7,000 | $14,000 | 10% | 90% | $8,200 | $16,400 | $0 | $0 | D&C | D&C | $3-50-125-250 | |||||
| BSW | S062 | PPO+ 100 7300 | FI | S | BSW+ PPO | PPO | Copay | $7,300 | $14,600 | 0% | 100% | $9,200 | $18,400 | $0 | $0 | $25 | $70 | $3-50-125-250 | |||||
| BSW | S063 | PPO+ 80 7500 | FI | S | BSW+ PPO | PPO | Copay | $7,500 | $15,000 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $45 | $80 | $3-50-125-250 | |||||
| BSW | S064 | PPO+ 80 7500 | FI | B | BSW+ PPO | PPO | Copay | $7,500 | $15,000 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $55 | $60 | $3-50-125-250 | |||||
| BSW | S065 | PPO+ 90 7900 | FI | B | BSW+ PPO | PPO | Copay | $7,900 | $15,800 | 10% | 90% | $9,200 | $18,400 | $0 | $0 | $45 | $50 | $3-50-125-250 | |||||
| BSW | S066 | PPO+ 80 8900 | FI | S | BSW+ PPO | PPO | Copay | $8,900 | $17,800 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $50 | $100 | $3-50-125-250 | |||||
| BSW | S067 | PPO+ 100 9200 | FI | B | BSW+ PPO | PPO | Copay | $9,200 | $18,400 | 0% | 100% | $9,200 | $18,400 | $0 | $0 | D&C | D&C | $3-50-125-250 | |||||
| BSW | S068 | PPO+ HSA 3300 | FI | G | BSW+ PPO | PPO | HSA | $3,300 | $6,600 | 0% | 100% | $3,300 | $6,600 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S069 | PPO+ HSA 3700 | FI | G | BSW+ PPO | PPO | HSA | $3,700 | $7,400 | 0% | 100% | $3,700 | $7,400 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S070 | PPO+ HSA 5100 | FI | S | BSW+ PPO | PPO | HSA | $5,100 | $10,200 | 0% | 100% | $5,100 | $10,200 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S071 | PPO+ HSA 6200 | FI | S | BSW+ PPO | PPO | HSA | $6,200 | $12,400 | 0% | 100% | $6,200 | $12,400 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S072 | PPO+ HSA 7300 | FI | B | BSW+ PPO | PPO | HSA | $7,300 | $14,600 | 0% | 100% | $7,300 | $14,600 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S073 | HMO+ Copay 0 7000 | FI | G | BSW+ HMO | HMO | Copay | $0 | $0 | 10% | 90% | $7,000 | $14,000 | $0 | $0 | $20 | $55 | $3-50-125-250 | |||||
| BSW | S074 | HMO+ SM 0 9200 | FI | G | BSW+ HMO | HMO | Copay | $0 | $0 | 30% | 70% | $9,200 | $18,400 | $0 | $0 | $50 | $85 | $3-50-125-250 | |||||
| BSW | S075 | HMO+ 80 750 | FI | G | BSW+ HMO | HMO | Copay | $750 | $1,500 | 20% | 80% | $8,250 | $16,500 | $0 | $0 | $40 | $70 | $3-50-125-250 | |||||
| BSW | S076 | HMO+ 90 750 | FI | S | BSW+ HMO | HMO | Copay | $750 | $1,500 | 10% | 90% | $9,200 | $18,400 | $0 | $0 | $50 | $100 | $3-50-125-250 | |||||
| BSW | S077 | HMO+ 80 1000 | FI | G | BSW+ HMO | HMO | Copay | $1,000 | $2,000 | 20% | 80% | $8,200 | $16,400 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S078 | HMO+ 80 1500 | FI | G | BSW+ HMO | HMO | Copay | $1,500 | $3,000 | 20% | 80% | $7,000 | $14,000 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S079 | HMO+ 90 1900 | FI | G | BSW+ HMO | HMO | Copay | $1,900 | $3,800 | 10% | 90% | $7,500 | $15,000 | $0 | $0 | $0 | $60 | $3-50-125-250 | |||||
| BSW | S080 | HMO+ 90 2000 | FI | G | BSW+ HMO | HMO | Copay | $2,000 | $4,000 | 10% | 90% | $5,500 | $11,000 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S081 | HMO+ 100 2300 | FI | G | BSW+ HMO | HMO | Copay | $2,300 | $4,600 | 100% | 0% | $8,500 | $17,000 | $0 | $0 | $0 | $70 | $3-50-125-250 | |||||
| BSW | S082 | HMO+ 100 3000 | FI | G | BSW+ HMO | HMO | Copay | $3,000 | $6,000 | 0% | 100% | $4,400 | $8,800 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S083 | HMO+ 80 3000 | FI | G | BSW+ HMO | HMO | Copay | $3,000 | $6,000 | 20% | 80% | $5,500 | $11,000 | $0 | $0 | $35 | $80 | $3-50-125-250 | |||||
| BSW | S084 | HMO+ 60 3250 | FI | S | BSW+ HMO | HMO | Copay | $3,250 | $6,500 | 40% | 60% | $9,100 | $18,200 | $0 | $0 | $55 | $95 | $3-50-125-250 | |||||
| BSW | S085 | HMO+ 100 3500 | FI | G | BSW+ HMO | HMO | Copay | $3,500 | $7,000 | 0% | 100% | $6,900 | $13,800 | $0 | $0 | $0 | $65 | $3-50-125-250 | |||||
| BSW | S086 | HMO+ 70 3800 | FI | S | BSW+ HMO | HMO | Copay | $3,800 | $7,600 | 30% | 70% | $9,100 | $18,200 | $0 | $0 | $50 | $95 | $3-50-125-250 | |||||
| BSW | S087 | HMO+ 100 4000 | FI | G | BSW+ HMO | HMO | Copay | $4,000 | $8,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $25 | $3-50-125-250 | |||||
| BSW | S088 | HMO+ 60 4200 | FI | S | BSW+ HMO | HMO | Copay | $4,200 | $8,400 | 40% | 60% | $9,200 | $18,400 | $0 | $0 | D $45 | D $80 | $3-50-125-250 | |||||
| BSW | S089 | HMO+ 80 4250 | FI | S | BSW+ HMO | HMO | Copay | $4,250 | $8,500 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $50 | $95 | $3-50-125-250 | |||||
| BSW | S090 | HMO+ 90 4500 | FI | G | BSW+ HMO | HMO | Copay | $4,500 | $9,000 | 10% | 90% | $6,300 | $12,600 | $0 | $0 | $5 | $40 | $3-50-125-250 | |||||
| BSW | S091 | HMO+ 70 4500 | FI | S | BSW+ HMO | HMO | Copay | $4,500 | $9,000 | 30% | 70% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S092 | HMO+ 80 5000 | FI | S | BSW+ HMO | HMO | Copay | $5,000 | $10,000 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S093 | HMO+ 90 5900 | FI | S | BSW+ HMO | HMO | Copay | $5,900 | $11,800 | 10% | 90% | $9,100 | $18,200 | $0 | $0 | $35 | $70 | $3-50-125-250 | |||||
| BSW | S094 | HMO+ 80 6250 | FI | S | BSW+ HMO | HMO | Copay | $6,250 | $12,500 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $40 | $75 | $3-50-125-250 | |||||
| BSW | S095 | HMO+ 90 6500 | FI | S | BSW+ HMO | HMO | Copay | $6,500 | $13,000 | 10% | 90% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S096 | HMO+ 70 6700 | FI | S | BSW+ HMO | HMO | Copay | $6,700 | $13,400 | 30% | 70% | $9,200 | $18,400 | $0 | $0 | $45 | $85 | $3-50-125-250 | |||||
| BSW | S097 | HMO+ 80 6900 | FI | S | BSW+ HMO | HMO | Copay | $6,900 | $13,800 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $45 | $85 | $3-50-125-250 | |||||
| BSW | S098 | HMO+ 90 7000 | FI | S | BSW+ HMO | HMO | Copay | $7,000 | $14,000 | 10% | 90% | $8,200 | $16,400 | $0 | $0 | D&C | D&C | $3-50-125-250 | |||||
| BSW | S099 | HMO+ 100 7300 | FI | S | BSW+ HMO | HMO | Copay | $7,300 | $14,600 | 0% | 100% | $9,200 | $18,400 | $0 | $0 | $25 | $70 | $3-50-125-250 | |||||
| BSW | S100 | HMO+ 80 7500 | FI | S | BSW+ HMO | HMO | Copay | $7,500 | $15,000 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $45 | $80 | $3-50-125-250 | |||||
| BSW | S101 | HMO+ 80 7500 | FI | B | BSW+ HMO | HMO | Copay | $7,500 | $15,000 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $55 | $60 | $3-50-125-250 | |||||
| BSW | S102 | HMO+ 90 7900 | FI | B | BSW+ HMO | HMO | Copay | $7,900 | $15,800 | 10% | 90% | $9,200 | $18,400 | $0 | $0 | $45 | $50 | $3-50-125-250 | |||||
| BSW | S103 | HMO+ 80 8900 | FI | S | BSW+ HMO | HMO | Copay | $8,900 | $17,800 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $50 | $100 | $3-50-125-250 | |||||
| BSW | S104 | HMO+ 100 9200 | FI | B | BSW+ HMO | HMO | Copay | $9,200 | $18,400 | 0% | 100% | $9,200 | $18,400 | $0 | $0 | D&C | D&C | $3-50-125-250 | |||||
| BSW | S105 | HMO+ HSA 3300 | FI | G | BSW+ HMO | HMO | HSA | $3,300 | $6,600 | 0% | 100% | $3,300 | $6,600 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S106 | HMO+ HSA 3700 | FI | G | BSW+ HMO | HMO | HSA | $3,700 | $7,400 | 0% | 100% | $3,700 | $7,400 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S107 | HMO+ HSA 5100 | FI | S | BSW+ HMO | HMO | HSA | $5,100 | $10,200 | 0% | 100% | $5,100 | $10,200 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S108 | HMO+ HSA 6200 | FI | S | BSW+ HMO | HMO | HSA | $6,200 | $12,400 | 0% | 100% | $6,200 | $12,400 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S109 | HMO+ HSA 7300 | FI | B | BSW+ HMO | HMO | HSA | $7,300 | $14,600 | 0% | 100% | $7,300 | $14,600 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S110 | HMO Premier Copay 0 7000 | FI | G | Premier HMO | HMO | Copay | $0 | $0 | 10% | 90% | $7,000 | $14,000 | $0 | $0 | $20 | $55 | $3-50-125-250 | |||||
| BSW | S111 | HMO Premier SM 0 9200 | FI | G | Premier HMO | HMO | Copay | $0 | $0 | 30% | 70% | $9,200 | $18,400 | $0 | $0 | $50 | $85 | $3-50-125-250 | |||||
| BSW | S112 | HMO Premier 80 750 | FI | G | Premier HMO | HMO | Copay | $750 | $1,500 | 20% | 80% | $8,250 | $16,500 | $0 | $0 | $40 | $70 | $3-50-125-250 | |||||
| BSW | S113 | HMO Premier 90 750 | FI | S | Premier HMO | HMO | Copay | $750 | $1,500 | 10% | 90% | $9,200 | $18,400 | $0 | $0 | $50 | $100 | $3-50-125-250 | |||||
| BSW | S114 | HMO Premier 80 1000 | FI | G | Premier HMO | HMO | Copay | $1,000 | $2,000 | 20% | 80% | $8,200 | $16,400 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S115 | HMO Premier 80 1500 | FI | G | Premier HMO | HMO | Copay | $1,500 | $3,000 | 20% | 80% | $7,000 | $14,000 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S116 | HMO Premier 90 1900 | FI | G | Premier HMO | HMO | Copay | $1,900 | $3,800 | 10% | 90% | $7,500 | $15,000 | $0 | $0 | $0 | $60 | $3-50-125-250 | |||||
| BSW | S117 | HMO Premier 90 2000 | FI | G | Premier HMO | HMO | Copay | $2,000 | $4,000 | 10% | 90% | $5,500 | $11,000 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S118 | HMO Premier 100 2300 | FI | G | Premier HMO | HMO | Copay | $2,300 | $4,600 | 100% | 0% | $8,500 | $17,000 | $0 | $0 | $0 | $70 | $3-50-125-250 | |||||
| BSW | S119 | HMO Premier 100 3000 | FI | G | Premier HMO | HMO | Copay | $3,000 | $6,000 | 0% | 100% | $4,400 | $8,800 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S120 | HMO Premier 80 3000 | FI | G | Premier HMO | HMO | Copay | $3,000 | $6,000 | 20% | 80% | $5,500 | $11,000 | $0 | $0 | $35 | $80 | $3-50-125-250 | |||||
| BSW | S121 | HMO Premier 60 3250 | FI | S | Premier HMO | HMO | Copay | $3,250 | $6,500 | 40% | 60% | $9,100 | $18,200 | $0 | $0 | $55 | $95 | $3-50-125-250 | |||||
| BSW | S122 | HMO Premier 100 3500 | FI | G | Premier HMO | HMO | Copay | $3,500 | $7,000 | 0% | 100% | $6,900 | $13,800 | $0 | $0 | $0 | $65 | $3-50-125-250 | |||||
| BSW | S123 | HMO Premier 70 3800 | FI | S | Premier HMO | HMO | Copay | $3,800 | $7,600 | 30% | 70% | $9,100 | $18,200 | $0 | $0 | $50 | $95 | $3-50-125-250 | |||||
| BSW | S124 | HMO Premier 100 4000 | FI | G | Premier HMO | HMO | Copay | $4,000 | $8,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $25 | $3-50-125-250 | |||||
| BSW | S125 | HMO Premier 60 4200 | FI | S | Premier HMO | HMO | Copay | $4,200 | $8,400 | 40% | 60% | $9,200 | $18,400 | $0 | $0 | D $45 | D $80 | $3-50-125-250 | |||||
| BSW | S126 | HMO Premier 80 4250 | FI | S | Premier HMO | HMO | Copay | $4,250 | $8,500 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $50 | $95 | $3-50-125-250 | |||||
| BSW | S127 | HMO Premier 90 4500 | FI | G | Premier HMO | HMO | Copay | $4,500 | $9,000 | 10% | 90% | $6,300 | $12,600 | $0 | $0 | $5 | $40 | $3-50-125-250 | |||||
| BSW | S128 | HMO Premier 70 4500 | FI | S | Premier HMO | HMO | Copay | $4,500 | $9,000 | 30% | 70% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S129 | HMO Premier 80 5000 | FI | S | Premier HMO | HMO | Copay | $5,000 | $10,000 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S130 | HMO Premier 90 5900 | FI | S | Premier HMO | HMO | Copay | $5,900 | $11,800 | 10% | 90% | $9,100 | $18,200 | $0 | $0 | $35 | $70 | $3-50-125-250 | |||||
| BSW | S131 | HMO Premier 80 6250 | FI | S | Premier HMO | HMO | Copay | $6,250 | $12,500 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $40 | $75 | $3-50-125-250 | |||||
| BSW | S132 | HMO Premier 90 6500 | FI | S | Premier HMO | HMO | Copay | $6,500 | $13,000 | 10% | 90% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S133 | HMO Premier 70 6700 | FI | S | Premier HMO | HMO | Copay | $6,700 | $13,400 | 30% | 70% | $9,200 | $18,400 | $0 | $0 | $45 | $85 | $3-50-125-250 | |||||
| BSW | S134 | HMO Premier 80 6900 | FI | S | Premier HMO | HMO | Copay | $6,900 | $13,800 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $45 | $85 | $3-50-125-250 | |||||
| BSW | S135 | HMO Premier 90 7000 | FI | S | Premier HMO | HMO | Copay | $7,000 | $14,000 | 10% | 90% | $8,200 | $16,400 | $0 | $0 | D&C | D&C | $3-50-125-250 | |||||
| BSW | S136 | HMO Premier 100 7300 | FI | S | Premier HMO | HMO | Copay | $7,300 | $14,600 | 0% | 100% | $9,200 | $18,400 | $0 | $0 | $25 | $70 | $3-50-125-250 | |||||
| BSW | S137 | HMO Premier 80 7500 | FI | S | Premier HMO | HMO | Copay | $7,500 | $15,000 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $45 | $80 | $3-50-125-250 | |||||
| BSW | S138 | HMO Premier 80 7500 | FI | B | Premier HMO | HMO | Copay | $7,500 | $15,000 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $55 | $60 | $3-50-125-250 | |||||
| BSW | S139 | HMO Premier 90 7900 | FI | B | Premier HMO | HMO | Copay | $7,900 | $15,800 | 10% | 90% | $9,200 | $18,400 | $0 | $0 | $45 | $50 | $3-50-125-250 | |||||
| BSW | S140 | HMO Premier 80 8900 | FI | S | Premier HMO | HMO | Copay | $8,900 | $17,800 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $50 | $100 | $3-50-125-250 | |||||
| BSW | S141 | HMO Premier 100 9200 | FI | B | Premier HMO | HMO | Copay | $9,200 | $18,400 | 0% | 100% | $9,200 | $18,400 | $0 | $0 | D&C | D&C | $3-50-125-250 | |||||
| BSW | S142 | HMO Premier HSA 3300 | FI | G | Premier HMO | HMO | HSA | $3,300 | $6,600 | 0% | 100% | $3,300 | $6,600 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S143 | HMO Premier HSA 3700 | FI | G | Premier HMO | HMO | HSA | $3,700 | $7,400 | 0% | 100% | $3,700 | $7,400 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S144 | HMO Premier HSA 5100 | FI | S | Premier HMO | HMO | HSA | $5,100 | $10,200 | 0% | 100% | $5,100 | $10,200 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S145 | HMO Premier HSA 6200 | FI | S | Premier HMO | HMO | HSA | $6,200 | $12,400 | 0% | 100% | $6,200 | $12,400 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S146 | HMO Premier HSA 7300 | FI | B | Premier HMO | HMO | HSA | $7,300 | $14,600 | 0% | 100% | $7,300 | $14,600 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| UHC | U001 | DY-AK | FI | P | Choice + | PPO | Copay | $500 | $1,500 | 0% | 100% | $2,500 | $7,500 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U002 | DX-9J | FI | P | Choice | EPO | Copay | $500 | $1,500 | 0% | 100% | $2,500 | $7,500 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U003 | DY-A3 | FI | P | Navigate | HMO | Copay | $500 | $1,500 | 0% | 100% | $2,500 | $7,500 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U004 | DX-9Q | FI | P | Choice + | PPO | Copay | $1,000 | $3,000 | 0% | 100% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U005 | DX-9R | FI | P | Choice | EPO | Copay | $1,000 | $3,000 | 0% | 100% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U006 | DY-AP | FI | P | Navigate | HMO | Copay | $1,000 | $3,000 | 0% | 100% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U007 | DX-9U | FI | P | Choice + | PPO | Copay | $1,350 | $4,050 | 0% | 100% | $1,350 | $4,050 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U008 | DX-9V | FI | P | Choice | EPO | Copay | $1,350 | $4,050 | 0% | 100% | $1,350 | $4,050 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U009 | DY-AR | FI | P | Navigate | HMO | Copay | $1,350 | $4,050 | 0% | 100% | $1,350 | $4,050 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U010 | DX-95 | FI | G | Choice + | PPO | Copay | $3,000 | $9,000 | 0% | 100% | $5,500 | $11,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U011 | DX-96 | FI | G | Choice | EPO | Copay | $3,000 | $9,000 | 0% | 100% | $5,500 | $11,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U012 | DY-AW | FI | G | Navigate | HMO | Copay | $3,000 | $9,000 | 0% | 100% | $5,500 | $11,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U013 | DY-AB | FI | G | Choice + | PPO | Copay | $4,000 | $8,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U014 | DY-AC | FI | G | Choice | EPO | Copay | $4,000 | $8,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U015 | DY-A8 | FI | G | Navigate | HMO | Copay | $4,000 | $8,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U016 | DX-9H | FI | G | Choice + | PPO | Copay | $4,500 | $9,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U017 | DX-9I | FI | G | Choice | EPO | Copay | $4,500 | $9,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U018 | DY-A2 | FI | G | Navigate | HMO | Copay | $4,500 | $9,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U019 | DX-9M | FI | G | Choice + | PPO | Copay | $5,000 | $10,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U020 | DY-AF | FI | G | Choice | EPO | Copay | $5,000 | $10,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U021 | DY-A5 | FI | G | Navigate | HMO | Copay | $5,000 | $10,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U022 | DX-92 | FI | P | Choice + | PPO | Copay | $250 | $750 | 20% | 80% | $1,500 | $4,500 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U023 | DX-93 | FI | P | Choice | EPO | Copay | $250 | $750 | 20% | 80% | $1,500 | $4,500 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U024 | DY-AU | FI | P | Navigate | HMO | Copay | $250 | $750 | 20% | 80% | $1,500 | $4,500 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U025 | DX-9L | FI | P | Choice + | PPO | Copay | $500 | $1,500 | 20% | 80% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U026 | DX-9K | FI | P | Choice | EPO | Copay | $500 | $1,500 | 20% | 80% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U027 | DY-A4 | FI | P | Navigate | HMO | Copay | $500 | $1,500 | 20% | 80% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U028 | DY-AM | FI | P | Choice + | PPO | Copay | $500 | $1,500 | 20% | 80% | $2,250 | $6,750 | $0 | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U029 | DX-9S | FI | P | Choice + | PPO | Copay | $1,000 | $3,000 | 20% | 80% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U030 | DX-9T | FI | P | Choice | EPO | Copay | $1,000 | $3,000 | 20% | 80% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U031 | DY-AQ | FI | P | Navigate | HMO | Copay | $1,000 | $3,000 | 20% | 80% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U032 | DX-9W | FI | G | Choice + | PPO | Copay | $1,500 | $4,500 | 20% | 80% | $6,200 | $12,400 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U033 | DX-9X | FI | G | Choice | EPO | Copay | $1,500 | $4,500 | 20% | 80% | $6,200 | $12,400 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U034 | DY-AS | FI | G | Navigate | HMO | Copay | $1,500 | $4,500 | 20% | 80% | $6,200 | $12,400 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U035 | DX-9Y | FI | G | Choice + | PPO | Copay | $2,000 | $6,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U036 | DX-9Z | FI | G | Choice | EPO | Copay | $2,000 | $6,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U037 | DY-AT | FI | G | Navigate | HMO | Copay | $2,000 | $6,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U038 | DY-AL | FI | G | Choice + | PPO | Copay | $2,500 | $7,500 | 20% | 80% | $7,200 | $14,400 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U039 | DX-94 | FI | G | Choice | EPO | Copay | $2,500 | $7,500 | 20% | 80% | $7,200 | $14,400 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U040 | DY-AV | FI | G | Navigate | HMO | Copay | $2,500 | $7,500 | 20% | 80% | $7,200 | $14,400 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U041 | DX-97 | FI | G | Choice + | PPO | Copay | $3,000 | $9,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U042 | DX-98 | FI | G | Choice | EPO | Copay | $3,000 | $9,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U043 | DY-AX | FI | G | Navigate | HMO | Copay | $3,000 | $9,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U044 | DY-AA | FI | G | Choice + | PPO | Copay | $3,000 | $9,000 | 20% | 80% | $7,000 | $14,000 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U045 | DX-99 | FI | G | Choice | EPO | Copay | $3,000 | $9,000 | 20% | 80% | $7,000 | $14,000 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U046 | DY-A9 | FI | G | Navigate | HMO | Copay | $3,000 | $9,000 | 20% | 80% | $7,000 | $14,000 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U047 | DY-AN | FI | G | Choice + | PPO | Copay | $3,000 | $9,000 | 20% | 80% | $6,200 | $12,400 | $0 | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U048 | DX-9F | FI | G | Choice + | PPO | Copay | $4,000 | $8,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U049 | DX-9G | FI | G | Choice | EPO | Copay | $4,000 | $8,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U050 | DY-AY | FI | G | Navigate | HMO | Copay | $4,000 | $8,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U051 | DY-AE | FI | G | Choice + | PPO | Copay | $4,000 | $8,000 | 20% | 80% | $6,200 | $12,400 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U052 | DY-AD | FI | G | Choice | EPO | Copay | $4,000 | $8,000 | 20% | 80% | $6,200 | $12,400 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U053 | DY-AZ | FI | G | Navigate | HMO | Copay | $4,000 | $8,000 | 20% | 80% | $6,200 | $12,400 | 0% | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U054 | DY-AO | FI | G | Choice + | PPO | Copay | $5,000 | $10,000 | 20% | 80% | $9,200 | $18,400 | 0% | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U055 | DY-AG | FI | S | Choice + | PPO | Copay | $6,000 | $12,000 | 20% | 80% | $9,200 | $18,400 | 0% | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U056 | DY-AH | FI | S | Choice | EPO | Copay | $6,000 | $12,000 | 20% | 80% | $9,200 | $18,400 | 0% | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U057 | DY-A6 | FI | S | Navigate | HMO | Copay | $6,000 | $12,000 | 20% | 80% | $9,200 | $18,400 | 0% | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U058 | DY-AI | FI | S | Choice + | PPO | Copay | $7,000 | $14,000 | 20% | 80% | $9,100 | $18,200 | 0% | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U059 | DY-AJ | FI | S | Choice | EPO | Copay | $7,000 | $14,000 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U060 | DY-A7 | FI | S | Navigate | HMO | Copay | $7,000 | $14,000 | 20% | 80% | $9,100 | $18,200 | 0% | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U061 | DX-83 | FI | G | Choice + | PPO | HSA | $3,500 | $7,000 | 0% | 100% | $6,500 | $13,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U062 | DX-84 | FI | G | Choice | EPO | HSA | $3,500 | $7,000 | 0% | 100% | $6,500 | $13,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U063 | DX-9B | FI | G | Navigate | HMO | HSA | $3,500 | $7,000 | 0% | 100% | $6,500 | $13,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U064 | DX-8R | FI | S | Choice + | PPO | HSA | $4,000 | $8,000 | 0% | 100% | $7,400 | $14,800 | D&C | Ded $35 | Ded $35 | Ded $70 | Ded, $10-40-125-300-500 | |||||
| UHC | U065 | DX-8S | FI | S | Choice | EPO | HSA | $4,000 | $8,000 | 0% | 100% | $7,400 | $14,800 | D&C | Ded $35 | Ded $35 | Ded $70 | Ded, $10-40-125-300-500 | |||||
| UHC | U066 | DX-9A | FI | S | Navigate | HMO | HSA | $4,000 | $8,000 | 0% | 100% | $7,400 | $14,800 | D&C | Ded $35 | Ded $35 | Ded $70 | Ded, $10-40-125-300-500 | |||||
| UHC | U067 | DX-8V | FI | S | Choice + | PPO | HSA | $5,000 | $10,000 | 0% | 100% | $6,500 | $13,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U068 | DX-8W | FI | S | Choice | EPO | HSA | $5,000 | $10,000 | 0% | 100% | $6,500 | $13,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U069 | DX-86 | FI | S | Navigate | HMO | HSA | $5,000 | $10,000 | 0% | 100% | $6,500 | $13,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U070 | DX-8Z | FI | B | Choice + | PPO | HSA | $7,300 | $14,600 | 0% | 100% | $7,300 | $14,600 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| UHC | U071 | DX-82 | FI | B | Choice | EPO | HSA | $7,300 | $14,600 | 0% | 100% | $7,300 | $14,600 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| UHC | U072 | DX-88 | FI | B | Navigate | HMO | HSA | $7,300 | $14,600 | 0% | 100% | $7,300 | $14,600 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| UHC | U073 | DX-8T | FI | S | Choice + | PPO | HSA | $4,000 | $8,000 | 20% | 80% | $7,000 | $14,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U074 | DX-8U | FI | S | Choice | EPO | HSA | $4,000 | $8,000 | 20% | 80% | $7,000 | $14,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U075 | DX-85 | FI | S | Navigate | HMO | HSA | $4,000 | $8,000 | 20% | 80% | $7,000 | $14,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U076 | DX-8X | FI | S | Choice + | PPO | HSA | $5,000 | $10,000 | 30% | 70% | $6,000 | $12,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U077 | DX-8Y | FI | S | Choice | EPO | HSA | $5,000 | $10,000 | 30% | 70% | $6,000 | $12,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U078 | DX-87 | FI | S | Navigate | HMO | HSA | $5,000 | $10,000 | 30% | 70% | $6,000 | $12,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U079 | DX-9C | FI | G | Choice + | PPO | Copay | $2,000 | $6,000 | 30% | 70% | $5,000 | $10,000 | 0% | $30 or $50 | $30 or $50 | $60 or $100 | $10-65, $300 Ded then $125-250-500 | |||||
| UHC | U080 | DX-9D | FI | G | Choice | EPO | Copay | $2,000 | $6,000 | 30% | 70% | $5,000 | $10,000 | 0% | $30 or $50 | $30 or $50 | $60 or $100 | $10-65, $300 Ded then $125-250-500 | |||||
| UHC | U081 | DX-9E | FI | S | Choice + | PPO | Copay | $4,000 | $8,000 | 30% | 70% | $8,700 | $17,400 | 0% | $30 or $70 | $30 or $70 | $60 or $120 | $10-65, $300 Ded then $125-250-500 | |||||
| UHC | U082 | DX-9N | FI | S | Choice | EPO | Copay | $4,000 | $8,000 | 30% | 70% | $8,700 | $17,400 | $0 | $30 or $70 | $30 or $70 | $60 or $120 | $10-65, $300 Ded then $125-250-500 | |||||
| UHC | U083 | DX-9O | FI | S | Choice + | PPO | Copay | $6,000 | $12,000 | 30% | 70% | $8,500 | $17,000 | 0% | $40 or $75 | $40 or $75 | $80 or $150 | $10-65, $300 Ded then $125-250-500 | |||||
| UHC | U084 | DX-9P | FI | S | Choice | EPO | Copay | $6,000 | $12,000 | 30% | 70% | $8,500 | $17,000 | 0% | $40 or $75 | $40 or $75 | $80 or $150 | $10-65, $300 Ded then $125-250-500 |
| Carrier | Plan # | Plan Name | Funding | Tier | Network Name | Network Type | Plan Type | Deductible - Individual | Deductible - Family | Coinsurance - Member | Coinsurance - Plan | Out-of-Pocket - Individual | Out-of-Pocket - Family | Virtual Visits | PCP <19 | Primary | Specialist | Prescriptions | EO | ES | EC | EF | Total |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| BCBSTX | B001 | P9M1CHC | FI | P | Blue Choice | PPO | Copay | $0 | $0 | 10% | 90% | $6,300 | $12,600 | $20 | $20 | $20 | $40 | $0-10-50-100-150-250 | |||||
| BCBSTX | B002 | P620CHC | FI | P | Blue Choice | PPO | Copay | $350 | $1,050 | 20% | 80% | $1,600 | $4,800 | $35 | $35 | $35 | $70 | $0-10-35-75-150-250 | |||||
| BCBSTX | B003 | P9K3CHC | FI | P | Blue Choice | PPO | Copay | $600 | $1,200 | 20% | 80% | $1,800 | $3,600 | $35 | $35 | $35 | $70 | $0-10-50-100-150-250 | |||||
| BCBSTX | B004 | P9O3CHC | FI | P | Blue Choice | PPO | Copay | $1,000 | $3,000 | 20% | 80% | $3,000 | $6,000 | $0 | $0 | $0 | $40 | $0-10-50-100-150-250 | |||||
| BCBSTX | B005 | P621CHC | FI | P | Blue Choice | PPO | Copay | $1,350 | $4,050 | 0% | 100% | $1,350 | $4,050 | $30 | $30 | $30 | $55 | $0-10-35-75-150-250 | |||||
| BCBSTX | B006 | G9K8CHC | FI | G | Blue Choice | PPO | Copay | $1,050 | $3,150 | 20% | 80% | $6,300 | $12,600 | $55 | $55 | $55 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B007 | G654CHC | FI | G | Blue Choice | PPO | Copay | $1,300 | $3,900 | 20% | 80% | $5,250 | $10,500 | $55 | $55 | $55 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B008 | G652CHC | FI | G | Blue Choice | PPO | Copay | $1,600 | $4,800 | 20% | 80% | $5,350 | $10,705 | $50 | $50 | $50 | $100 | $5-15-50-100-150-250 | |||||
| BCBSTX | B009 | G653CHC | FI | G | Blue Choice | PPO | Copay | $1,750 | $5,250 | 20% | 80% | $6,750 | $18,400 | $45 | $45 | $45 | $90 | $0-10-50-100-150-250 | |||||
| BCBSTX | B010 | G9K6CHC | FI | G | Blue Choice | PPO | Copay | $2,100 | $6,300 | 10% | 90% | $4,200 | $12,600 | DC | DC | DC | DC | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B011 | G9L1CHC | FI | G | Blue Choice | PPO | Copay | $2,250 | $6,750 | 20% | 80% | $6,750 | $18,400 | $35 | $35 | $35 | $70 | $0-10-50-100-150-250 | |||||
| BCBSTX | B012 | G9L7CHC | FI | G | Blue Choice | PPO | Copay | $3,000 | $9,000 | 10% | 90% | $5,500 | $11,000 | $30 | $30 | $30 | $50 | $0-10-50-100-150-250 | |||||
| BCBSTX | B013 | G9L5CHC | FI | G | Blue Choice | PPO | Copay | $3,100 | $9,300 | 20% | 80% | $8,800 | $17,600 | $0 | $0 | $0 | $80 | $0-10-50-100-150-250 | |||||
| BCBSTX | B014 | G650CHC | FI | G | Blue Choice | PPO | Copay | $3,350 | $10,050 | 0% | 100% | $3,350 | $10,050 | $55 | $55 | $55 | $100 | Ded & Coins | |||||
| BCBSTX | B015 | S663CHC | FI | S | Blue Choice | PPO | Copay | $3,100 | $9,200 | 30% | 70% | $9,200 | $18,400 | $50 | $50 | $50 | $100 | $5-10-50-100-150-250 | |||||
| BCBSTX | B016 | S661CHC | FI | S | Blue Choice | PPO | Copay | $3,650 | $10,950 | 30% | 70% | $9,200 | $18,400 | $55 | $55 | $55 | $100 | $5-10-50-100-150-250 | |||||
| BCBSTX | B017 | S665CHC | FI | S | Blue Choice | PPO | Copay | $3,650 | $10,950 | 40% | 60% | $9,200 | $18,400 | $55 | $55 | $55 | $100 | $5-10-50-100-150-250 | |||||
| BCBSTX | B018 | S9M2CHC | FI | S | Blue Choice | PPO | Copay | $3,850 | $11,550 | 20% | 80% | $9,100 | $18,200 | $50 | $50 | $50 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B019 | S9L9CHC | FI | S | Blue Choice | PPO | Copay | $3,850 | $11,550 | 30% | 70% | $9,100 | $18,200 | $55 | $55 | $55 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B020 | S9N3CHC | FI | S | Blue Choice | PPO | Copay | $4,100 | $12,300 | 20% | 80% | $8,200 | $16,400 | $0 | $0 | $0 | $110 | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B021 | S9N1CHC | FI | S | Blue Choice | PPO | Copay | $4,100 | $12,300 | 40% | 60% | $9,200 | $18,400 | $0 | $0 | $0 | $90 | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B022 | S666CHC | FI | S | Blue Choice | PPO | Copay | $4,350 | $13,050 | 30% | 70% | $9,100 | $18,200 | $55 | $55 | $55 | $100 | $5-15-50-100-250-350 | |||||
| BCBSTX | B023 | S9K1CHC | FI | S | Blue Choice | PPO | Copay | $5,100 | $15,300 | 30% | 70% | $9,100 | $18,200 | $45 | $45 | $45 | $90 | $0-10-50-100-150-250 | |||||
| BCBSTX | B024 | S667CHC | FI | S | Blue Choice | PPO | Copay | $6,100 | $12,200 | 20% | 80% | $8,350 | $16,700 | $55 | $55 | $55 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B025 | S660CHC | FI | S | Blue Choice | PPO | Copay | $6,500 | $13,000 | 10% | 90% | $9,200 | $18,400 | $50 | $50 | $50 | $100 | $5-10-50-100-150-250 | |||||
| BCBSTX | B026 | S9L7CHC | FI | S | Blue Choice | PPO | Copay | $8,200 | $16,400 | 0% | 100% | $8,200 | $16,400 | $55 | $55 | $55 | $110 | $0-10-50-100-150-250 | |||||
| BCBSTX | B027 | B662CHC | FI | B | Blue Choice | PPO | Copay | $8,650 | $17,300 | 0% | 100% | $8,650 | $17,300 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B028 | G651CHC | FI | G | Blue Choice | PPO | HSA | $3,500 | $10,500 | 0% | 100% | $3,500 | $10,500 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B029 | G656CHC | FI | G | Blue Choice | PPO | HSA | $4,100 | $12,300 | 0% | 100% | $4,100 | $12,300 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B030 | S9L5CHC | FI | S | Blue Choice | PPO | HSA | $3,600 | $7,200 | 20% | 80% | $7,200 | $14,400 | $40 | $40 | $40 | $80 | Ded, $5-15-50-100-250-350 | |||||
| BCBSTX | B031 | S9L3CHC | FI | S | Blue Choice | PPO | HSA | $4,100 | $12,300 | 20% | 80% | $7,000 | $14,000 | D&C | D&C | D&C | D&C | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B032 | S662CHC | FI | S | Blue Choice | PPO | HSA | $5,500 | $11,000 | 0% | 100% | $5,500 | $11,000 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B033 | S9M4CHC | FI | S | Blue Choice | PPO | HSA | $6,100 | $12,200 | 0% | 100% | $6,100 | $12,200 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B034 | B660CHC | FI | B | Blue Choice | PPO | HSA | $6,750 | $13,500 | 30% | 70% | $7,750 | $15,500 | D&C | D&C | D&C | D&C | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B035 | B661CHC | FI | B | Blue Choice | PPO | HSA | $7,500 | $15,000 | 0% | 100% | $7,500 | $15,000 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B036 | P9M1ADT | FI | P | Blue Advantage | HMO | Copay | $0 | $0 | 10% | 90% | $6,300 | $12,600 | $20 | $20 | $20 | $40 | $0-10-50-100-150-250 | |||||
| BCBSTX | B037 | P610ADT | FI | P | Blue Advantage | HMO | Copay | $350 | $1,050 | 20% | 80% | $1,600 | $4,800 | $35 | $35 | $35 | $70 | $0-10-35-75-150-250 | |||||
| BCBSTX | B038 | P9K3ADT | FI | P | Blue Advantage | HMO | Copay | $600 | $1,200 | 20% | 80% | $1,800 | $3,600 | $35 | $35 | $35 | $70 | $0-10-50-100-150-250 | |||||
| BCBSTX | B039 | P9O5ADT | FI | P | Blue Advantage | HMO | Copay | $1,000 | $3,000 | 20% | 80% | $3,000 | $6,000 | $0 | $0 | $0 | $40 | $0-10-50-100-150-250 | |||||
| BCBSTX | B040 | P611ADT | FI | P | Blue Advantage | HMO | Copay | $1,350 | $4,050 | 0% | 100% | $1,350 | $4,050 | $30 | $30 | $30 | $55 | $0-10-35-75-150-250 | |||||
| BCBSTX | B041 | G665ADT | FI | G | Blue Advantage | HMO | Copay | $0 | $0 | 0% | 100% | $9,200 | $18,400 | $50 | $50 | $50 | $90 | $5-15-50-100-150-250 | |||||
| BCBSTX | B042 | G662ADT | FI | G | Blue Advantage | HMO | Copay | $1,050 | $3,150 | 20% | 80% | $6,300 | $12,600 | $55 | $55 | $55 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B043 | G9E5ADT | FI | G | Blue Advantage | HMO | Copay | $1,300 | $3,900 | 20% | 80% | $5,250 | $10,500 | $55 | $55 | $55 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B044 | G663ADT | FI | G | Blue Advantage | HMO | Copay | $1,600 | $4,800 | 20% | 80% | $5,350 | $10,705 | $50 | $50 | $50 | $100 | $5-15-50-100-150-250 | |||||
| BCBSTX | B045 | G9E3ADT | FI | G | Blue Advantage | HMO | Copay | $1,750 | $5,250 | 20% | 80% | $6,750 | $18,400 | $45 | $45 | $45 | $90 | $0-10-50-100-150-250 | |||||
| BCBSTX | B046 | G661ADT | FI | G | Blue Advantage | HMO | Copay | $2,100 | $6,300 | 10% | 90% | $4,200 | $12,600 | DC | DC | DC | DC | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B047 | G664ADT | FI | G | Blue Advantage | HMO | Copay | $2,250 | $6,750 | 20% | 80% | $6,750 | $18,400 | $35 | $35 | $35 | $70 | $0-10-50-100-150-250 | |||||
| BCBSTX | B048 | G9K7ADT | FI | G | Blue Advantage | HMO | Copay | $3,000 | $9,000 | 10% | 90% | $5,500 | $11,000 | $30 | $30 | $30 | $50 | $0-10-50-100-150-250 | |||||
| BCBSTX | B049 | G9K5ADT | FI | G | Blue Advantage | HMO | Copay | $3,100 | $9,300 | 20% | 80% | $8,800 | $17,600 | $0 | $0 | $0 | $80 | $0-10-50-100-150-250 | |||||
| BCBSTX | B050 | G660ADT | FI | G | Blue Advantage | HMO | Copay | $3,350 | $10,050 | 0% | 100% | $3,350 | $10,050 | $55 | $55 | $55 | $100 | Ded & Coins | |||||
| BCBSTX | B051 | S9J7ADT | FI | S | Blue Advantage | HMO | Copay | $3,100 | $9,200 | 30% | 70% | $9,200 | $18,400 | $50 | $50 | $50 | $100 | $5-10-50-100-150-250 | |||||
| BCBSTX | B052 | S643ADT | FI | S | Blue Advantage | HMO | Copay | $3,650 | $10,950 | 30% | 70% | $9,200 | $18,400 | $55 | $55 | $55 | $100 | $5-10-50-100-150-250 | |||||
| BCBSTX | B053 | S9J9ADT | FI | S | Blue Advantage | HMO | Copay | $3,650 | $10,950 | 40% | 60% | $9,200 | $18,400 | $55 | $55 | $55 | $100 | $5-10-50-100-150-250 | |||||
| BCBSTX | B054 | S9E3ADT | FI | S | Blue Advantage | HMO | Copay | $3,850 | $11,550 | 20% | 80% | $9,100 | $18,200 | $50 | $50 | $50 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B055 | S642ADT | FI | S | Blue Advantage | HMO | Copay | $3,850 | $11,550 | 30% | 70% | $9,100 | $18,200 | $55 | $55 | $55 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B056 | S9N3ADT | FI | S | Blue Advantage | HMO | Copay | $4,100 | $12,300 | 20% | 80% | $8,200 | $16,400 | $0 | $0 | $0 | $110 | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B057 | S9N1ADT | FI | S | Blue Advantage | HMO | Copay | $4,100 | $12,300 | 40% | 60% | $9,200 | $18,400 | $0 | $0 | $0 | $90 | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B058 | S641ADT | FI | S | Blue Advantage | HMO | Copay | $4,350 | $13,050 | 30% | 70% | $9,100 | $18,200 | $55 | $55 | $55 | $100 | $5-15-50-100-250-350 | |||||
| BCBSTX | B059 | S9L1ADT | FI | S | Blue Advantage | HMO | Copay | $5,100 | $15,300 | 30% | 70% | $9,100 | $18,200 | $45 | $45 | $45 | $90 | $0-10-50-100-150-250 | |||||
| BCBSTX | B060 | S9E5ADT | FI | S | Blue Advantage | HMO | Copay | $6,100 | $12,200 | 20% | 80% | $8,350 | $16,700 | $55 | $55 | $55 | $100 | $0-10-50-100-150-250 | |||||
| BCBSTX | B061 | S640ADT | FI | S | Blue Advantage | HMO | Copay | $6,500 | $13,000 | 10% | 90% | $9,200 | $18,400 | $50 | $50 | $50 | $100 | $5-10-50-100-150-250 | |||||
| BCBSTX | B062 | S644ADT | FI | S | Blue Advantage | HMO | Copay | $8,200 | $16,400 | 0% | 100% | $8,200 | $16,400 | $55 | $55 | $55 | $110 | $0-10-50-100-150-250 | |||||
| BCBSTX | B063 | B661ADT | FI | B | Blue Advantage | HMO | Copay | $8,650 | $17,300 | 0% | 100% | $8,650 | $17,300 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B064 | G9E1ADT | FI | G | Blue Advantage | HMO | HSA | $3,500 | $10,500 | 0% | 100% | $3,500 | $10,500 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B065 | G666ADT | FI | G | Blue Advantage | HMO | HSA | $4,100 | $12,300 | 0% | 100% | $4,100 | $12,300 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B066 | S9J5ADT | FI | S | Blue Advantage | HMO | HSA | $3,600 | $7,200 | 20% | 80% | $7,200 | $14,400 | $40 | $40 | $40 | $80 | Ded, $5-15-50-100-250-350 | |||||
| BCBSTX | B067 | S9J3ADT | FI | S | Blue Advantage | HMO | HSA | $4,100 | $12,300 | 20% | 80% | $7,000 | $14,000 | D&C | D&C | D&C | D&C | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B068 | S9E1ADT | FI | S | Blue Advantage | HMO | HSA | $5,500 | $11,000 | 0% | 100% | $5,500 | $11,000 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B069 | S9K2ADT | FI | S | Blue Advantage | HMO | HSA | $6,100 | $12,200 | 0% | 100% | $6,100 | $12,200 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BCBSTX | B070 | B9E1ADT | FI | B | Blue Advantage | HMO | HSA | $6,750 | $13,500 | 30% | 70% | $7,750 | $15,500 | D&C | D&C | D&C | D&C | Ded, 10-10-20-30-40-50% | |||||
| BCBSTX | B071 | B660ADT | FI | B | Blue Advantage | HMO | HSA | $7,500 | $15,000 | 0% | 100% | $7,500 | $15,000 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S001 | PPO Access Copay 0 7000 | FI | G | Access PPO | PPO | Copay | $0 | $0 | 10% | 90% | $7,000 | $14,000 | $0 | $0 | $20 | $55 | $3-50-125-250 | |||||
| BSW | S002 | PPO Access 80 750 | FI | G | Access PPO | PPO | Copay | $750 | $1,500 | 20% | 80% | $8,250 | $16,500 | $0 | $0 | $40 | $70 | $3-50-125-250 | |||||
| BSW | S003 | PPO Access 90 750 | FI | S | Access PPO | PPO | Copay | $750 | $1,500 | 10% | 90% | $9,200 | $18,400 | $0 | $0 | $50 | $100 | $3-50-125-250 | |||||
| BSW | S004 | PPO Access 80 1000 | FI | G | Access PPO | PPO | Copay | $1,000 | $2,000 | 20% | 80% | $8,200 | $16,400 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S005 | PPO Access 80 1500 | FI | G | Access PPO | PPO | Copay | $1,500 | $3,000 | 20% | 80% | $7,000 | $14,000 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S006 | PPO Access 90 1900 | FI | G | Access PPO | PPO | Copay | $1,900 | $3,800 | 10% | 90% | $7,500 | $15,000 | $0 | $0 | $0 | $60 | $3-50-125-250 | |||||
| BSW | S007 | PPO Access 90 2000 | FI | G | Access PPO | PPO | Copay | $2,000 | $4,000 | 10% | 90% | $5,500 | $11,000 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S008 | PPO Access 100 2300 | FI | G | Access PPO | PPO | Copay | $2,300 | $4,600 | 100% | 0% | $8,500 | $17,000 | $0 | $0 | $0 | $70 | $3-50-125-250 | |||||
| BSW | S009 | PPO Access 100 3000 | FI | G | Access PPO | PPO | Copay | $3,000 | $6,000 | 0% | 100% | $4,400 | $8,800 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S010 | PPO Access 80 3000 | FI | G | Access PPO | PPO | Copay | $3,000 | $6,000 | 20% | 80% | $5,500 | $11,000 | $0 | $0 | $35 | $80 | $3-50-125-250 | |||||
| BSW | S011 | PPO Access 60 3250 | FI | S | Access PPO | PPO | Copay | $3,250 | $6,500 | 40% | 60% | $9,100 | $18,200 | $0 | $0 | $55 | $95 | $3-50-125-250 | |||||
| BSW | S012 | PPO Access 100 3500 | FI | G | Access PPO | PPO | Copay | $3,500 | $7,000 | 0% | 100% | $6,900 | $13,800 | $0 | $0 | $0 | $65 | $3-50-125-250 | |||||
| BSW | S013 | PPO Access 70 3800 | FI | S | Access PPO | PPO | Copay | $3,800 | $7,600 | 30% | 70% | $9,100 | $18,200 | $0 | $0 | $50 | $95 | $3-50-125-250 | |||||
| BSW | S014 | PPO Access 100 4000 | FI | G | Access PPO | PPO | Copay | $4,000 | $8,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $25 | $3-50-125-250 | |||||
| BSW | S015 | PPO Access 60 4200 | FI | S | Access PPO | PPO | Copay | $4,200 | $8,400 | 40% | 60% | $9,200 | $18,400 | $0 | $0 | D $45 | D $80 | $3-50-125-250 | |||||
| BSW | S016 | PPO Access 80 4250 | FI | S | Access PPO | PPO | Copay | $4,250 | $8,500 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $50 | $95 | $3-50-125-250 | |||||
| BSW | S017 | PPO Access 90 4500 | FI | G | Access PPO | PPO | Copay | $4,500 | $9,000 | 10% | 90% | $6,300 | $12,600 | $0 | $0 | $5 | $40 | $3-50-125-250 | |||||
| BSW | S018 | PPO Access 70 4500 | FI | S | Access PPO | PPO | Copay | $4,500 | $9,000 | 30% | 70% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S019 | PPO Access 80 5000 | FI | S | Access PPO | PPO | Copay | $5,000 | $10,000 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S020 | PPO Access 90 5900 | FI | S | Access PPO | PPO | Copay | $5,900 | $11,800 | 10% | 90% | $9,100 | $18,200 | $0 | $0 | $35 | $70 | $3-50-125-250 | |||||
| BSW | S021 | PPO Access 80 6250 | FI | S | Access PPO | PPO | Copay | $6,250 | $12,500 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $40 | $75 | $3-50-125-250 | |||||
| BSW | S022 | PPO Access 90 6500 | FI | S | Access PPO | PPO | Copay | $6,500 | $13,000 | 10% | 90% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S023 | PPO Access 70 6700 | FI | S | Access PPO | PPO | Copay | $6,700 | $13,400 | 30% | 70% | $9,200 | $18,400 | $0 | $0 | $45 | $85 | $3-50-125-250 | |||||
| BSW | S024 | PPO Access 80 6900 | FI | S | Access PPO | PPO | Copay | $6,900 | $13,800 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $45 | $85 | $3-50-125-250 | |||||
| BSW | S025 | PPO Access 90 7000 | FI | S | Access PPO | PPO | Copay | $7,000 | $14,000 | 10% | 90% | $8,200 | $16,400 | $0 | $0 | D&C | D&C | $3-50-125-250 | |||||
| BSW | S026 | PPO Access 100 7300 | FI | S | Access PPO | PPO | Copay | $7,300 | $14,600 | 0% | 100% | $9,200 | $18,400 | $0 | $0 | $25 | $70 | $3-50-125-250 | |||||
| BSW | S027 | PPO Access 80 7500 | FI | S | Access PPO | PPO | Copay | $7,500 | $15,000 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $45 | $80 | $3-50-125-250 | |||||
| BSW | S028 | PPO Access 80 7500 | FI | B | Access PPO | PPO | Copay | $7,500 | $15,000 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $55 | $60 | $3-50-125-250 | |||||
| BSW | S029 | PPO Access 90 7900 | FI | B | Access PPO | PPO | Copay | $7,900 | $15,800 | 10% | 90% | $9,200 | $18,400 | $0 | $0 | $45 | $50 | $3-50-125-250 | |||||
| BSW | S030 | PPO Access 80 8900 | FI | S | Access PPO | PPO | Copay | $8,900 | $17,800 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $50 | $100 | $3-50-125-250 | |||||
| BSW | S031 | PPO Access 100 9200 | FI | B | Access PPO | PPO | Copay | $9,200 | $18,400 | 0% | 100% | $9,200 | $18,400 | $0 | $0 | D&C | D&C | $3-50-125-250 | |||||
| BSW | S032 | PPO Access HSA 3300 | FI | G | Access PPO | PPO | HSA | $3,300 | $6,600 | 0% | 100% | $3,300 | $6,600 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S033 | PPO Access HSA 3700 | FI | G | Access PPO | PPO | HSA | $3,700 | $7,400 | 0% | 100% | $3,700 | $7,400 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S034 | PPO Access HSA 5100 | FI | S | Access PPO | PPO | HSA | $5,100 | $10,200 | 0% | 100% | $5,100 | $10,200 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S035 | PPO Access HSA 6200 | FI | S | Access PPO | PPO | HSA | $6,200 | $12,400 | 0% | 100% | $6,200 | $12,400 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S036 | PPO Access HSA 7300 | FI | B | Access PPO | PPO | HSA | $7,300 | $14,600 | 0% | 100% | $7,300 | $14,600 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S037 | PPO+ Copay 0 7000 | FI | G | BSW+ PPO | PPO | Copay | $0 | $0 | 10% | 90% | $7,000 | $14,000 | $0 | $0 | $20 | $55 | $3-50-125-250 | |||||
| BSW | S038 | PPO+ 80 750 | FI | G | BSW+ PPO | PPO | Copay | $750 | $1,500 | 20% | 80% | $8,250 | $16,500 | $0 | $0 | $40 | $70 | $3-50-125-250 | |||||
| BSW | S039 | PPO+ 90 750 | FI | S | BSW+ PPO | PPO | Copay | $750 | $1,500 | 10% | 90% | $9,200 | $18,400 | $0 | $0 | $50 | $100 | $3-50-125-250 | |||||
| BSW | S040 | PPO+ 80 1000 | FI | G | BSW+ PPO | PPO | Copay | $1,000 | $2,000 | 20% | 80% | $8,200 | $16,400 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S041 | PPO+ 80 1500 | FI | G | BSW+ PPO | PPO | Copay | $1,500 | $3,000 | 20% | 80% | $7,000 | $14,000 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S042 | PPO+ 90 1900 | FI | G | BSW+ PPO | PPO | Copay | $1,900 | $3,800 | 10% | 90% | $7,500 | $15,000 | $0 | $0 | $0 | $60 | $3-50-125-250 | |||||
| BSW | S043 | PPO+ 90 2000 | FI | G | BSW+ PPO | PPO | Copay | $2,000 | $4,000 | 10% | 90% | $5,500 | $11,000 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S044 | PPO+ 100 2300 | FI | G | BSW+ PPO | PPO | Copay | $2,300 | $4,600 | 100% | 0% | $8,500 | $17,000 | $0 | $0 | $0 | $70 | $3-50-125-250 | |||||
| BSW | S045 | PPO+ 100 3000 | FI | G | BSW+ PPO | PPO | Copay | $3,000 | $6,000 | 0% | 100% | $4,400 | $8,800 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S046 | PPO+ 80 3000 | FI | G | BSW+ PPO | PPO | Copay | $3,000 | $6,000 | 20% | 80% | $5,500 | $11,000 | $0 | $0 | $35 | $80 | $3-50-125-250 | |||||
| BSW | S047 | PPO+ 60 3250 | FI | S | BSW+ PPO | PPO | Copay | $3,250 | $6,500 | 40% | 60% | $9,100 | $18,200 | $0 | $0 | $55 | $95 | $3-50-125-250 | |||||
| BSW | S048 | PPO+ 100 3500 | FI | G | BSW+ PPO | PPO | Copay | $3,500 | $7,000 | 0% | 100% | $6,900 | $13,800 | $0 | $0 | $0 | $65 | $3-50-125-250 | |||||
| BSW | S049 | PPO+ 70 3800 | FI | S | BSW+ PPO | PPO | Copay | $3,800 | $7,600 | 30% | 70% | $9,100 | $18,200 | $0 | $0 | $50 | $95 | $3-50-125-250 | |||||
| BSW | S050 | PPO+ 100 4000 | FI | G | BSW+ PPO | PPO | Copay | $4,000 | $8,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $25 | $3-50-125-250 | |||||
| BSW | S051 | PPO+ 60 4200 | FI | S | BSW+ PPO | PPO | Copay | $4,200 | $8,400 | 40% | 60% | $9,200 | $18,400 | $0 | $0 | D $45 | D $80 | $3-50-125-250 | |||||
| BSW | S052 | PPO+ 80 4250 | FI | S | BSW+ PPO | PPO | Copay | $4,250 | $8,500 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $50 | $95 | $3-50-125-250 | |||||
| BSW | S053 | PPO+ 90 4500 | FI | G | BSW+ PPO | PPO | Copay | $4,500 | $9,000 | 10% | 90% | $6,300 | $12,600 | $0 | $0 | $5 | $40 | $3-50-125-250 | |||||
| BSW | S054 | PPO+ 70 4500 | FI | S | BSW+ PPO | PPO | Copay | $4,500 | $9,000 | 30% | 70% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S055 | PPO+ 80 5000 | FI | S | BSW+ PPO | PPO | Copay | $5,000 | $10,000 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S056 | PPO+ 90 5900 | FI | S | BSW+ PPO | PPO | Copay | $5,900 | $11,800 | 10% | 90% | $9,100 | $18,200 | $0 | $0 | $35 | $70 | $3-50-125-250 | |||||
| BSW | S057 | PPO+ 80 6250 | FI | S | BSW+ PPO | PPO | Copay | $6,250 | $12,500 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $40 | $75 | $3-50-125-250 | |||||
| BSW | S058 | PPO+ 90 6500 | FI | S | BSW+ PPO | PPO | Copay | $6,500 | $13,000 | 10% | 90% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S059 | PPO+ 70 6700 | FI | S | BSW+ PPO | PPO | Copay | $6,700 | $13,400 | 30% | 70% | $9,200 | $18,400 | $0 | $0 | $45 | $85 | $3-50-125-250 | |||||
| BSW | S060 | PPO+ 80 6900 | FI | S | BSW+ PPO | PPO | Copay | $6,900 | $13,800 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $45 | $85 | $3-50-125-250 | |||||
| BSW | S061 | PPO+ 90 7000 | FI | S | BSW+ PPO | PPO | Copay | $7,000 | $14,000 | 10% | 90% | $8,200 | $16,400 | $0 | $0 | D&C | D&C | $3-50-125-250 | |||||
| BSW | S062 | PPO+ 100 7300 | FI | S | BSW+ PPO | PPO | Copay | $7,300 | $14,600 | 0% | 100% | $9,200 | $18,400 | $0 | $0 | $25 | $70 | $3-50-125-250 | |||||
| BSW | S063 | PPO+ 80 7500 | FI | S | BSW+ PPO | PPO | Copay | $7,500 | $15,000 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $45 | $80 | $3-50-125-250 | |||||
| BSW | S064 | PPO+ 80 7500 | FI | B | BSW+ PPO | PPO | Copay | $7,500 | $15,000 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $55 | $60 | $3-50-125-250 | |||||
| BSW | S065 | PPO+ 90 7900 | FI | B | BSW+ PPO | PPO | Copay | $7,900 | $15,800 | 10% | 90% | $9,200 | $18,400 | $0 | $0 | $45 | $50 | $3-50-125-250 | |||||
| BSW | S066 | PPO+ 80 8900 | FI | S | BSW+ PPO | PPO | Copay | $8,900 | $17,800 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $50 | $100 | $3-50-125-250 | |||||
| BSW | S067 | PPO+ 100 9200 | FI | B | BSW+ PPO | PPO | Copay | $9,200 | $18,400 | 0% | 100% | $9,200 | $18,400 | $0 | $0 | D&C | D&C | $3-50-125-250 | |||||
| BSW | S068 | PPO+ HSA 3300 | FI | G | BSW+ PPO | PPO | HSA | $3,300 | $6,600 | 0% | 100% | $3,300 | $6,600 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S069 | PPO+ HSA 3700 | FI | G | BSW+ PPO | PPO | HSA | $3,700 | $7,400 | 0% | 100% | $3,700 | $7,400 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S070 | PPO+ HSA 5100 | FI | S | BSW+ PPO | PPO | HSA | $5,100 | $10,200 | 0% | 100% | $5,100 | $10,200 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S071 | PPO+ HSA 6200 | FI | S | BSW+ PPO | PPO | HSA | $6,200 | $12,400 | 0% | 100% | $6,200 | $12,400 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S072 | PPO+ HSA 7300 | FI | B | BSW+ PPO | PPO | HSA | $7,300 | $14,600 | 0% | 100% | $7,300 | $14,600 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S073 | HMO+ Copay 0 7000 | FI | G | BSW+ HMO | HMO | Copay | $0 | $0 | 10% | 90% | $7,000 | $14,000 | $0 | $0 | $20 | $55 | $3-50-125-250 | |||||
| BSW | S074 | HMO+ SM 0 9200 | FI | G | BSW+ HMO | HMO | Copay | $0 | $0 | 30% | 70% | $9,200 | $18,400 | $0 | $0 | $50 | $85 | $3-50-125-250 | |||||
| BSW | S075 | HMO+ 80 750 | FI | G | BSW+ HMO | HMO | Copay | $750 | $1,500 | 20% | 80% | $8,250 | $16,500 | $0 | $0 | $40 | $70 | $3-50-125-250 | |||||
| BSW | S076 | HMO+ 90 750 | FI | S | BSW+ HMO | HMO | Copay | $750 | $1,500 | 10% | 90% | $9,200 | $18,400 | $0 | $0 | $50 | $100 | $3-50-125-250 | |||||
| BSW | S077 | HMO+ 80 1000 | FI | G | BSW+ HMO | HMO | Copay | $1,000 | $2,000 | 20% | 80% | $8,200 | $16,400 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S078 | HMO+ 80 1500 | FI | G | BSW+ HMO | HMO | Copay | $1,500 | $3,000 | 20% | 80% | $7,000 | $14,000 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S079 | HMO+ 90 1900 | FI | G | BSW+ HMO | HMO | Copay | $1,900 | $3,800 | 10% | 90% | $7,500 | $15,000 | $0 | $0 | $0 | $60 | $3-50-125-250 | |||||
| BSW | S080 | HMO+ 90 2000 | FI | G | BSW+ HMO | HMO | Copay | $2,000 | $4,000 | 10% | 90% | $5,500 | $11,000 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S081 | HMO+ 100 2300 | FI | G | BSW+ HMO | HMO | Copay | $2,300 | $4,600 | 100% | 0% | $8,500 | $17,000 | $0 | $0 | $0 | $70 | $3-50-125-250 | |||||
| BSW | S082 | HMO+ 100 3000 | FI | G | BSW+ HMO | HMO | Copay | $3,000 | $6,000 | 0% | 100% | $4,400 | $8,800 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S083 | HMO+ 80 3000 | FI | G | BSW+ HMO | HMO | Copay | $3,000 | $6,000 | 20% | 80% | $5,500 | $11,000 | $0 | $0 | $35 | $80 | $3-50-125-250 | |||||
| BSW | S084 | HMO+ 60 3250 | FI | S | BSW+ HMO | HMO | Copay | $3,250 | $6,500 | 40% | 60% | $9,100 | $18,200 | $0 | $0 | $55 | $95 | $3-50-125-250 | |||||
| BSW | S085 | HMO+ 100 3500 | FI | G | BSW+ HMO | HMO | Copay | $3,500 | $7,000 | 0% | 100% | $6,900 | $13,800 | $0 | $0 | $0 | $65 | $3-50-125-250 | |||||
| BSW | S086 | HMO+ 70 3800 | FI | S | BSW+ HMO | HMO | Copay | $3,800 | $7,600 | 30% | 70% | $9,100 | $18,200 | $0 | $0 | $50 | $95 | $3-50-125-250 | |||||
| BSW | S087 | HMO+ 100 4000 | FI | G | BSW+ HMO | HMO | Copay | $4,000 | $8,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $25 | $3-50-125-250 | |||||
| BSW | S088 | HMO+ 60 4200 | FI | S | BSW+ HMO | HMO | Copay | $4,200 | $8,400 | 40% | 60% | $9,200 | $18,400 | $0 | $0 | D $45 | D $80 | $3-50-125-250 | |||||
| BSW | S089 | HMO+ 80 4250 | FI | S | BSW+ HMO | HMO | Copay | $4,250 | $8,500 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $50 | $95 | $3-50-125-250 | |||||
| BSW | S090 | HMO+ 90 4500 | FI | G | BSW+ HMO | HMO | Copay | $4,500 | $9,000 | 10% | 90% | $6,300 | $12,600 | $0 | $0 | $5 | $40 | $3-50-125-250 | |||||
| BSW | S091 | HMO+ 70 4500 | FI | S | BSW+ HMO | HMO | Copay | $4,500 | $9,000 | 30% | 70% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S092 | HMO+ 80 5000 | FI | S | BSW+ HMO | HMO | Copay | $5,000 | $10,000 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S093 | HMO+ 90 5900 | FI | S | BSW+ HMO | HMO | Copay | $5,900 | $11,800 | 10% | 90% | $9,100 | $18,200 | $0 | $0 | $35 | $70 | $3-50-125-250 | |||||
| BSW | S094 | HMO+ 80 6250 | FI | S | BSW+ HMO | HMO | Copay | $6,250 | $12,500 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $40 | $75 | $3-50-125-250 | |||||
| BSW | S095 | HMO+ 90 6500 | FI | S | BSW+ HMO | HMO | Copay | $6,500 | $13,000 | 10% | 90% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S096 | HMO+ 70 6700 | FI | S | BSW+ HMO | HMO | Copay | $6,700 | $13,400 | 30% | 70% | $9,200 | $18,400 | $0 | $0 | $45 | $85 | $3-50-125-250 | |||||
| BSW | S097 | HMO+ 80 6900 | FI | S | BSW+ HMO | HMO | Copay | $6,900 | $13,800 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $45 | $85 | $3-50-125-250 | |||||
| BSW | S098 | HMO+ 90 7000 | FI | S | BSW+ HMO | HMO | Copay | $7,000 | $14,000 | 10% | 90% | $8,200 | $16,400 | $0 | $0 | D&C | D&C | $3-50-125-250 | |||||
| BSW | S099 | HMO+ 100 7300 | FI | S | BSW+ HMO | HMO | Copay | $7,300 | $14,600 | 0% | 100% | $9,200 | $18,400 | $0 | $0 | $25 | $70 | $3-50-125-250 | |||||
| BSW | S100 | HMO+ 80 7500 | FI | S | BSW+ HMO | HMO | Copay | $7,500 | $15,000 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $45 | $80 | $3-50-125-250 | |||||
| BSW | S101 | HMO+ 80 7500 | FI | B | BSW+ HMO | HMO | Copay | $7,500 | $15,000 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $55 | $60 | $3-50-125-250 | |||||
| BSW | S102 | HMO+ 90 7900 | FI | B | BSW+ HMO | HMO | Copay | $7,900 | $15,800 | 10% | 90% | $9,200 | $18,400 | $0 | $0 | $45 | $50 | $3-50-125-250 | |||||
| BSW | S103 | HMO+ 80 8900 | FI | S | BSW+ HMO | HMO | Copay | $8,900 | $17,800 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $50 | $100 | $3-50-125-250 | |||||
| BSW | S104 | HMO+ 100 9200 | FI | B | BSW+ HMO | HMO | Copay | $9,200 | $18,400 | 0% | 100% | $9,200 | $18,400 | $0 | $0 | D&C | D&C | $3-50-125-250 | |||||
| BSW | S105 | HMO+ HSA 3300 | FI | G | BSW+ HMO | HMO | HSA | $3,300 | $6,600 | 0% | 100% | $3,300 | $6,600 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S106 | HMO+ HSA 3700 | FI | G | BSW+ HMO | HMO | HSA | $3,700 | $7,400 | 0% | 100% | $3,700 | $7,400 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S107 | HMO+ HSA 5100 | FI | S | BSW+ HMO | HMO | HSA | $5,100 | $10,200 | 0% | 100% | $5,100 | $10,200 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S108 | HMO+ HSA 6200 | FI | S | BSW+ HMO | HMO | HSA | $6,200 | $12,400 | 0% | 100% | $6,200 | $12,400 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S109 | HMO+ HSA 7300 | FI | B | BSW+ HMO | HMO | HSA | $7,300 | $14,600 | 0% | 100% | $7,300 | $14,600 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S110 | HMO Premier Copay 0 7000 | FI | G | Premier HMO | HMO | Copay | $0 | $0 | 10% | 90% | $7,000 | $14,000 | $0 | $0 | $20 | $55 | $3-50-125-250 | |||||
| BSW | S111 | HMO Premier SM 0 9200 | FI | G | Premier HMO | HMO | Copay | $0 | $0 | 30% | 70% | $9,200 | $18,400 | $0 | $0 | $50 | $85 | $3-50-125-250 | |||||
| BSW | S112 | HMO Premier 80 750 | FI | G | Premier HMO | HMO | Copay | $750 | $1,500 | 20% | 80% | $8,250 | $16,500 | $0 | $0 | $40 | $70 | $3-50-125-250 | |||||
| BSW | S113 | HMO Premier 90 750 | FI | S | Premier HMO | HMO | Copay | $750 | $1,500 | 10% | 90% | $9,200 | $18,400 | $0 | $0 | $50 | $100 | $3-50-125-250 | |||||
| BSW | S114 | HMO Premier 80 1000 | FI | G | Premier HMO | HMO | Copay | $1,000 | $2,000 | 20% | 80% | $8,200 | $16,400 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S115 | HMO Premier 80 1500 | FI | G | Premier HMO | HMO | Copay | $1,500 | $3,000 | 20% | 80% | $7,000 | $14,000 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S116 | HMO Premier 90 1900 | FI | G | Premier HMO | HMO | Copay | $1,900 | $3,800 | 10% | 90% | $7,500 | $15,000 | $0 | $0 | $0 | $60 | $3-50-125-250 | |||||
| BSW | S117 | HMO Premier 90 2000 | FI | G | Premier HMO | HMO | Copay | $2,000 | $4,000 | 10% | 90% | $5,500 | $11,000 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S118 | HMO Premier 100 2300 | FI | G | Premier HMO | HMO | Copay | $2,300 | $4,600 | 100% | 0% | $8,500 | $17,000 | $0 | $0 | $0 | $70 | $3-50-125-250 | |||||
| BSW | S119 | HMO Premier 100 3000 | FI | G | Premier HMO | HMO | Copay | $3,000 | $6,000 | 0% | 100% | $4,400 | $8,800 | $0 | $0 | $25 | $60 | $3-50-125-250 | |||||
| BSW | S120 | HMO Premier 80 3000 | FI | G | Premier HMO | HMO | Copay | $3,000 | $6,000 | 20% | 80% | $5,500 | $11,000 | $0 | $0 | $35 | $80 | $3-50-125-250 | |||||
| BSW | S121 | HMO Premier 60 3250 | FI | S | Premier HMO | HMO | Copay | $3,250 | $6,500 | 40% | 60% | $9,100 | $18,200 | $0 | $0 | $55 | $95 | $3-50-125-250 | |||||
| BSW | S122 | HMO Premier 100 3500 | FI | G | Premier HMO | HMO | Copay | $3,500 | $7,000 | 0% | 100% | $6,900 | $13,800 | $0 | $0 | $0 | $65 | $3-50-125-250 | |||||
| BSW | S123 | HMO Premier 70 3800 | FI | S | Premier HMO | HMO | Copay | $3,800 | $7,600 | 30% | 70% | $9,100 | $18,200 | $0 | $0 | $50 | $95 | $3-50-125-250 | |||||
| BSW | S124 | HMO Premier 100 4000 | FI | G | Premier HMO | HMO | Copay | $4,000 | $8,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $25 | $3-50-125-250 | |||||
| BSW | S125 | HMO Premier 60 4200 | FI | S | Premier HMO | HMO | Copay | $4,200 | $8,400 | 40% | 60% | $9,200 | $18,400 | $0 | $0 | D $45 | D $80 | $3-50-125-250 | |||||
| BSW | S126 | HMO Premier 80 4250 | FI | S | Premier HMO | HMO | Copay | $4,250 | $8,500 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $50 | $95 | $3-50-125-250 | |||||
| BSW | S127 | HMO Premier 90 4500 | FI | G | Premier HMO | HMO | Copay | $4,500 | $9,000 | 10% | 90% | $6,300 | $12,600 | $0 | $0 | $5 | $40 | $3-50-125-250 | |||||
| BSW | S128 | HMO Premier 70 4500 | FI | S | Premier HMO | HMO | Copay | $4,500 | $9,000 | 30% | 70% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S129 | HMO Premier 80 5000 | FI | S | Premier HMO | HMO | Copay | $5,000 | $10,000 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S130 | HMO Premier 90 5900 | FI | S | Premier HMO | HMO | Copay | $5,900 | $11,800 | 10% | 90% | $9,100 | $18,200 | $0 | $0 | $35 | $70 | $3-50-125-250 | |||||
| BSW | S131 | HMO Premier 80 6250 | FI | S | Premier HMO | HMO | Copay | $6,250 | $12,500 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $40 | $75 | $3-50-125-250 | |||||
| BSW | S132 | HMO Premier 90 6500 | FI | S | Premier HMO | HMO | Copay | $6,500 | $13,000 | 10% | 90% | $9,100 | $18,200 | $0 | $0 | $40 | $80 | $3-50-125-250 | |||||
| BSW | S133 | HMO Premier 70 6700 | FI | S | Premier HMO | HMO | Copay | $6,700 | $13,400 | 30% | 70% | $9,200 | $18,400 | $0 | $0 | $45 | $85 | $3-50-125-250 | |||||
| BSW | S134 | HMO Premier 80 6900 | FI | S | Premier HMO | HMO | Copay | $6,900 | $13,800 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $45 | $85 | $3-50-125-250 | |||||
| BSW | S135 | HMO Premier 90 7000 | FI | S | Premier HMO | HMO | Copay | $7,000 | $14,000 | 10% | 90% | $8,200 | $16,400 | $0 | $0 | D&C | D&C | $3-50-125-250 | |||||
| BSW | S136 | HMO Premier 100 7300 | FI | S | Premier HMO | HMO | Copay | $7,300 | $14,600 | 0% | 100% | $9,200 | $18,400 | $0 | $0 | $25 | $70 | $3-50-125-250 | |||||
| BSW | S137 | HMO Premier 80 7500 | FI | S | Premier HMO | HMO | Copay | $7,500 | $15,000 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $45 | $80 | $3-50-125-250 | |||||
| BSW | S138 | HMO Premier 80 7500 | FI | B | Premier HMO | HMO | Copay | $7,500 | $15,000 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $55 | $60 | $3-50-125-250 | |||||
| BSW | S139 | HMO Premier 90 7900 | FI | B | Premier HMO | HMO | Copay | $7,900 | $15,800 | 10% | 90% | $9,200 | $18,400 | $0 | $0 | $45 | $50 | $3-50-125-250 | |||||
| BSW | S140 | HMO Premier 80 8900 | FI | S | Premier HMO | HMO | Copay | $8,900 | $17,800 | 20% | 80% | $9,200 | $18,400 | $0 | $0 | $50 | $100 | $3-50-125-250 | |||||
| BSW | S141 | HMO Premier 100 9200 | FI | B | Premier HMO | HMO | Copay | $9,200 | $18,400 | 0% | 100% | $9,200 | $18,400 | $0 | $0 | D&C | D&C | $3-50-125-250 | |||||
| BSW | S142 | HMO Premier HSA 3300 | FI | G | Premier HMO | HMO | HSA | $3,300 | $6,600 | 0% | 100% | $3,300 | $6,600 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S143 | HMO Premier HSA 3700 | FI | G | Premier HMO | HMO | HSA | $3,700 | $7,400 | 0% | 100% | $3,700 | $7,400 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S144 | HMO Premier HSA 5100 | FI | S | Premier HMO | HMO | HSA | $5,100 | $10,200 | 0% | 100% | $5,100 | $10,200 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S145 | HMO Premier HSA 6200 | FI | S | Premier HMO | HMO | HSA | $6,200 | $12,400 | 0% | 100% | $6,200 | $12,400 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| BSW | S146 | HMO Premier HSA 7300 | FI | B | Premier HMO | HMO | HSA | $7,300 | $14,600 | 0% | 100% | $7,300 | $14,600 | $40 | D&C | D&C | D&C | Ded & Coins | |||||
| UHC | U001 | DY-AK | FI | P | Choice + | PPO | Copay | $500 | $1,500 | 0% | 100% | $2,500 | $7,500 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U002 | DX-9J | FI | P | Choice | EPO | Copay | $500 | $1,500 | 0% | 100% | $2,500 | $7,500 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U003 | DY-A3 | FI | P | Navigate | HMO | Copay | $500 | $1,500 | 0% | 100% | $2,500 | $7,500 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U004 | DX-9Q | FI | P | Choice + | PPO | Copay | $1,000 | $3,000 | 0% | 100% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U005 | DX-9R | FI | P | Choice | EPO | Copay | $1,000 | $3,000 | 0% | 100% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U006 | DY-AP | FI | P | Navigate | HMO | Copay | $1,000 | $3,000 | 0% | 100% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U007 | DX-9U | FI | P | Choice + | PPO | Copay | $1,350 | $4,050 | 0% | 100% | $1,350 | $4,050 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U008 | DX-9V | FI | P | Choice | EPO | Copay | $1,350 | $4,050 | 0% | 100% | $1,350 | $4,050 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U009 | DY-AR | FI | P | Navigate | HMO | Copay | $1,350 | $4,050 | 0% | 100% | $1,350 | $4,050 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U010 | DX-95 | FI | G | Choice + | PPO | Copay | $3,000 | $9,000 | 0% | 100% | $5,500 | $11,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U011 | DX-96 | FI | G | Choice | EPO | Copay | $3,000 | $9,000 | 0% | 100% | $5,500 | $11,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U012 | DY-AW | FI | G | Navigate | HMO | Copay | $3,000 | $9,000 | 0% | 100% | $5,500 | $11,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U013 | DY-AB | FI | G | Choice + | PPO | Copay | $4,000 | $8,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U014 | DY-AC | FI | G | Choice | EPO | Copay | $4,000 | $8,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U015 | DY-A8 | FI | G | Navigate | HMO | Copay | $4,000 | $8,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U016 | DX-9H | FI | G | Choice + | PPO | Copay | $4,500 | $9,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U017 | DX-9I | FI | G | Choice | EPO | Copay | $4,500 | $9,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U018 | DY-A2 | FI | G | Navigate | HMO | Copay | $4,500 | $9,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U019 | DX-9M | FI | G | Choice + | PPO | Copay | $5,000 | $10,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U020 | DY-AF | FI | G | Choice | EPO | Copay | $5,000 | $10,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U021 | DY-A5 | FI | G | Navigate | HMO | Copay | $5,000 | $10,000 | 0% | 100% | $6,500 | $13,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U022 | DX-92 | FI | P | Choice + | PPO | Copay | $250 | $750 | 20% | 80% | $1,500 | $4,500 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U023 | DX-93 | FI | P | Choice | EPO | Copay | $250 | $750 | 20% | 80% | $1,500 | $4,500 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U024 | DY-AU | FI | P | Navigate | HMO | Copay | $250 | $750 | 20% | 80% | $1,500 | $4,500 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U025 | DX-9L | FI | P | Choice + | PPO | Copay | $500 | $1,500 | 20% | 80% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U026 | DX-9K | FI | P | Choice | EPO | Copay | $500 | $1,500 | 20% | 80% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U027 | DY-A4 | FI | P | Navigate | HMO | Copay | $500 | $1,500 | 20% | 80% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U028 | DY-AM | FI | P | Choice + | PPO | Copay | $500 | $1,500 | 20% | 80% | $2,250 | $6,750 | $0 | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U029 | DX-9S | FI | P | Choice + | PPO | Copay | $1,000 | $3,000 | 20% | 80% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U030 | DX-9T | FI | P | Choice | EPO | Copay | $1,000 | $3,000 | 20% | 80% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U031 | DY-AQ | FI | P | Navigate | HMO | Copay | $1,000 | $3,000 | 20% | 80% | $2,500 | $7,500 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U032 | DX-9W | FI | G | Choice + | PPO | Copay | $1,500 | $4,500 | 20% | 80% | $6,200 | $12,400 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U033 | DX-9X | FI | G | Choice | EPO | Copay | $1,500 | $4,500 | 20% | 80% | $6,200 | $12,400 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U034 | DY-AS | FI | G | Navigate | HMO | Copay | $1,500 | $4,500 | 20% | 80% | $6,200 | $12,400 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U035 | DX-9Y | FI | G | Choice + | PPO | Copay | $2,000 | $6,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U036 | DX-9Z | FI | G | Choice | EPO | Copay | $2,000 | $6,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U037 | DY-AT | FI | G | Navigate | HMO | Copay | $2,000 | $6,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U038 | DY-AL | FI | G | Choice + | PPO | Copay | $2,500 | $7,500 | 20% | 80% | $7,200 | $14,400 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U039 | DX-94 | FI | G | Choice | EPO | Copay | $2,500 | $7,500 | 20% | 80% | $7,200 | $14,400 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U040 | DY-AV | FI | G | Navigate | HMO | Copay | $2,500 | $7,500 | 20% | 80% | $7,200 | $14,400 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U041 | DX-97 | FI | G | Choice + | PPO | Copay | $3,000 | $9,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U042 | DX-98 | FI | G | Choice | EPO | Copay | $3,000 | $9,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U043 | DY-AX | FI | G | Navigate | HMO | Copay | $3,000 | $9,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U044 | DY-AA | FI | G | Choice + | PPO | Copay | $3,000 | $9,000 | 20% | 80% | $7,000 | $14,000 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U045 | DX-99 | FI | G | Choice | EPO | Copay | $3,000 | $9,000 | 20% | 80% | $7,000 | $14,000 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U046 | DY-A9 | FI | G | Navigate | HMO | Copay | $3,000 | $9,000 | 20% | 80% | $7,000 | $14,000 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U047 | DY-AN | FI | G | Choice + | PPO | Copay | $3,000 | $9,000 | 20% | 80% | $6,200 | $12,400 | $0 | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U048 | DX-9F | FI | G | Choice + | PPO | Copay | $4,000 | $8,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U049 | DX-9G | FI | G | Choice | EPO | Copay | $4,000 | $8,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U050 | DY-AY | FI | G | Navigate | HMO | Copay | $4,000 | $8,000 | 20% | 80% | $6,000 | $12,000 | $0 | $0 | $15 | $50 or $100 | $10-40-125-300-500 | |||||
| UHC | U051 | DY-AE | FI | G | Choice + | PPO | Copay | $4,000 | $8,000 | 20% | 80% | $6,200 | $12,400 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U052 | DY-AD | FI | G | Choice | EPO | Copay | $4,000 | $8,000 | 20% | 80% | $6,200 | $12,400 | $0 | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U053 | DY-AZ | FI | G | Navigate | HMO | Copay | $4,000 | $8,000 | 20% | 80% | $6,200 | $12,400 | 0% | $0 | $10 | $40 or $80 | $10-40-125-300-500 | |||||
| UHC | U054 | DY-AO | FI | G | Choice + | PPO | Copay | $5,000 | $10,000 | 20% | 80% | $9,200 | $18,400 | 0% | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U055 | DY-AG | FI | S | Choice + | PPO | Copay | $6,000 | $12,000 | 20% | 80% | $9,200 | $18,400 | 0% | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U056 | DY-AH | FI | S | Choice | EPO | Copay | $6,000 | $12,000 | 20% | 80% | $9,200 | $18,400 | 0% | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U057 | DY-A6 | FI | S | Navigate | HMO | Copay | $6,000 | $12,000 | 20% | 80% | $9,200 | $18,400 | 0% | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U058 | DY-AI | FI | S | Choice + | PPO | Copay | $7,000 | $14,000 | 20% | 80% | $9,100 | $18,200 | 0% | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U059 | DY-AJ | FI | S | Choice | EPO | Copay | $7,000 | $14,000 | 20% | 80% | $9,100 | $18,200 | $0 | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U060 | DY-A7 | FI | S | Navigate | HMO | Copay | $7,000 | $14,000 | 20% | 80% | $9,100 | $18,200 | 0% | $0 | $35 | $70 or $100 | $10-40-125-300-500 | |||||
| UHC | U061 | DX-83 | FI | G | Choice + | PPO | HSA | $3,500 | $7,000 | 0% | 100% | $6,500 | $13,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U062 | DX-84 | FI | G | Choice | EPO | HSA | $3,500 | $7,000 | 0% | 100% | $6,500 | $13,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U063 | DX-9B | FI | G | Navigate | HMO | HSA | $3,500 | $7,000 | 0% | 100% | $6,500 | $13,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U064 | DX-8R | FI | S | Choice + | PPO | HSA | $4,000 | $8,000 | 0% | 100% | $7,400 | $14,800 | D&C | Ded $35 | Ded $35 | Ded $70 | Ded, $10-40-125-300-500 | |||||
| UHC | U065 | DX-8S | FI | S | Choice | EPO | HSA | $4,000 | $8,000 | 0% | 100% | $7,400 | $14,800 | D&C | Ded $35 | Ded $35 | Ded $70 | Ded, $10-40-125-300-500 | |||||
| UHC | U066 | DX-9A | FI | S | Navigate | HMO | HSA | $4,000 | $8,000 | 0% | 100% | $7,400 | $14,800 | D&C | Ded $35 | Ded $35 | Ded $70 | Ded, $10-40-125-300-500 | |||||
| UHC | U067 | DX-8V | FI | S | Choice + | PPO | HSA | $5,000 | $10,000 | 0% | 100% | $6,500 | $13,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U068 | DX-8W | FI | S | Choice | EPO | HSA | $5,000 | $10,000 | 0% | 100% | $6,500 | $13,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U069 | DX-86 | FI | S | Navigate | HMO | HSA | $5,000 | $10,000 | 0% | 100% | $6,500 | $13,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U070 | DX-8Z | FI | B | Choice + | PPO | HSA | $7,300 | $14,600 | 0% | 100% | $7,300 | $14,600 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| UHC | U071 | DX-82 | FI | B | Choice | EPO | HSA | $7,300 | $14,600 | 0% | 100% | $7,300 | $14,600 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| UHC | U072 | DX-88 | FI | B | Navigate | HMO | HSA | $7,300 | $14,600 | 0% | 100% | $7,300 | $14,600 | D&C | D&C | D&C | D&C | Ded & Coins | |||||
| UHC | U073 | DX-8T | FI | S | Choice + | PPO | HSA | $4,000 | $8,000 | 20% | 80% | $7,000 | $14,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U074 | DX-8U | FI | S | Choice | EPO | HSA | $4,000 | $8,000 | 20% | 80% | $7,000 | $14,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U075 | DX-85 | FI | S | Navigate | HMO | HSA | $4,000 | $8,000 | 20% | 80% | $7,000 | $14,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U076 | DX-8X | FI | S | Choice + | PPO | HSA | $5,000 | $10,000 | 30% | 70% | $6,000 | $12,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U077 | DX-8Y | FI | S | Choice | EPO | HSA | $5,000 | $10,000 | 30% | 70% | $6,000 | $12,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U078 | DX-87 | FI | S | Navigate | HMO | HSA | $5,000 | $10,000 | 30% | 70% | $6,000 | $12,000 | D&C | D&C | D&C | D&C | Ded, $10-40-125-300-500 | |||||
| UHC | U079 | DX-9C | FI | G | Choice + | PPO | Copay | $2,000 | $6,000 | 30% | 70% | $5,000 | $10,000 | 0% | $30 or $50 | $30 or $50 | $60 or $100 | $10-65, $300 Ded then $125-250-500 | |||||
| UHC | U080 | DX-9D | FI | G | Choice | EPO | Copay | $2,000 | $6,000 | 30% | 70% | $5,000 | $10,000 | 0% | $30 or $50 | $30 or $50 | $60 or $100 | $10-65, $300 Ded then $125-250-500 | |||||
| UHC | U081 | DX-9E | FI | S | Choice + | PPO | Copay | $4,000 | $8,000 | 30% | 70% | $8,700 | $17,400 | 0% | $30 or $70 | $30 or $70 | $60 or $120 | $10-65, $300 Ded then $125-250-500 | |||||
| UHC | U082 | DX-9N | FI | S | Choice | EPO | Copay | $4,000 | $8,000 | 30% | 70% | $8,700 | $17,400 | $0 | $30 or $70 | $30 or $70 | $60 or $120 | $10-65, $300 Ded then $125-250-500 | |||||
| UHC | U083 | DX-9O | FI | S | Choice + | PPO | Copay | $6,000 | $12,000 | 30% | 70% | $8,500 | $17,000 | 0% | $40 or $75 | $40 or $75 | $80 or $150 | $10-65, $300 Ded then $125-250-500 | |||||
| UHC | U084 | DX-9P | FI | S | Choice | EPO | Copay | $6,000 | $12,000 | 30% | 70% | $8,500 | $17,000 | 0% | $40 or $75 | $40 or $75 | $80 or $150 | $10-65, $300 Ded then $125-250-500 |