No census attached.
| | B018 — S9M2CHC | S007 — PPO Access 90 2000 | U015 — DY-A8 |
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| Plan # | B018 | S007 | U015 |
|---|
| Plan Name | S9M2CHC | PPO Access 90 2000 | DY-A8 |
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| Network Name | Blue Choice | Access PPO | Navigate |
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| Network Type | PPO | PPO | HMO |
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| Plan Type | Copay | Copay | Copay |
|---|
| Deductible - Individual | $3,850 | $2,000 | $4,000 |
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| Deductible - Family | $11,550 | $4,000 | $8,000 |
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| Coinsurance - Member | 20% | 10% | 0% |
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| Coinsurance - Plan | 80% | 90% | 100% |
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| Out-of-Pocket - Individual | $9,100 | $5,500 | $6,500 |
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| Out-of-Pocket - Family | $18,200 | $11,000 | $13,000 |
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| Virtual Visits | $50 | $0 | $0 |
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| PCP <19 | $50 | $0 | $0 |
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| Primary | $50 | $25 | $15 |
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| Specialist | $100 | $60 | $50 or $100 |
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| Urgent Care | $75 | $50 | $25 |
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| Emergency | $500 + D&C | D $750 | $500 + D&C |
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| Lab/X-Ray | D&C | D&C | D&C |
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| Imaging | $200 + D&C | D&C | D&C |
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| Inpatient Services | $300 + D&C | D&C | D&C |
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| Outpatient Surgery | $250 + D&C | D&C | D&C |
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| Prescriptions | $0-10-50-100-150-250 | $3-50-125-250 | $10-40-125-300-500 |
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| OON Deductible (Individual/Family) | $7,700 / $23,100 | $4,000 / $8,000 | N/A |
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| OON Coinsurance (Member) | 40% | 50% | N/A |
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| OON Out-of-Pocket (Individual/Family) | Unlimited / Unlimited | $16,500 / $33,000 | N/A |
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| Monthly Rate — EO | $560.19 | $537.67 | $564.21 |
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| Monthly Rate — ES | $1,120.37 | $1,075.34 | $1,128.42 |
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| Monthly Rate — EC | $1,120.37 | $1,075.34 | $1,128.42 |
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| Monthly Rate — EF | $1,680.56 | $1,613.01 | $1,692.63 |
|---|
| Monthly Total (group) | $7,842.61 | $7,527.38 | $7,898.94 |
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| Group Total Δ vs Renewal | +1% | -3.1% | +1.7% |
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