No census attached.
| | B009 — G653CHC | B010 — G9K6CHC | B034 — B660CHC |
|---|
| Plan # | B009 | B010 | B034 |
|---|
| Plan Name | G653CHC | G9K6CHC | B660CHC |
|---|
| Network Name | Blue Choice | Blue Choice | Blue Choice |
|---|
| Network Type | PPO | PPO | PPO |
|---|
| Plan Type | Copay | Copay | HSA |
|---|
| Deductible - Individual | $1,750 | $2,100 | $6,750 |
|---|
| Deductible - Family | $5,250 | $6,300 | $13,500 |
|---|
| Coinsurance - Member | 20% | 10% | 30% |
|---|
| Coinsurance - Plan | 80% | 90% | 70% |
|---|
| Out-of-Pocket - Individual | $6,750 | $4,200 | $7,750 |
|---|
| Out-of-Pocket - Family | $18,400 | $12,600 | $15,500 |
|---|
| Virtual Visits | $45 | DC | D&C |
|---|
| PCP <19 | $45 | DC | D&C |
|---|
| Primary | $45 | DC | D&C |
|---|
| Specialist | $90 | DC | D&C |
|---|
| Urgent Care | $75 | D&C | D&C |
|---|
| Emergency | $500 + D&C | D&C | $650 + D&C |
|---|
| Lab/X-Ray | D&C | D&C | D&C |
|---|
| Imaging | $100 | D&C | D&C |
|---|
| Inpatient Services | D&C | D&C | D&C |
|---|
| Outpatient Surgery | D&C | D&C | D&C |
|---|
| Prescriptions | $0-10-50-100-150-250 | Ded, 10-10-20-30-40-50% | Ded, 10-10-20-30-40-50% |
|---|
| OON Deductible (Individual/Family) | $3,500 / $10,500 | $4,200 / $12,600 | $13,500 / $27,000 |
|---|
| OON Coinsurance (Member) | 40% | 30% | 50% |
|---|
| OON Out-of-Pocket (Individual/Family) | Unlimited / Unlimited | Unlimited / Unlimited | Unlimited / Unlimited |
|---|