No census attached.
| | B013 — G9L5CHC | S019 — PPO Access 80 5000 |
|---|
| Plan # | B013 | S019 |
|---|
| Plan Name | G9L5CHC | PPO Access 80 5000 |
|---|
| Network Name | Blue Choice | Access PPO |
|---|
| Network Type | PPO | PPO |
|---|
| Plan Type | Copay | Copay |
|---|
| Deductible - Individual | $3,100 | $5,000 |
|---|
| Deductible - Family | $9,300 | $10,000 |
|---|
| Coinsurance - Member | 20% | 20% |
|---|
| Coinsurance - Plan | 80% | 80% |
|---|
| Out-of-Pocket - Individual | $8,800 | $9,100 |
|---|
| Out-of-Pocket - Family | $17,600 | $18,200 |
|---|
| Virtual Visits | $0 | $0 |
|---|
| PCP <19 | $0 | $0 |
|---|
| Primary | $0 | $40 |
|---|
| Specialist | $80 | $80 |
|---|
| Urgent Care | $150 | $50 |
|---|
| Emergency | D&C | D $750 |
|---|
| Lab/X-Ray | D&C | D&C |
|---|
| Imaging | D&C | D&C |
|---|
| Inpatient Services | D&C | D&C |
|---|
| Outpatient Surgery | D&C | D&C |
|---|
| Prescriptions | $0-10-50-100-150-250 | $3-50-125-250 |
|---|
| OON Deductible (Individual/Family) | $6,200 / $18,600 | $10,000 / $20,000 |
|---|
| OON Coinsurance (Member) | 50% | 50% |
|---|
| OON Out-of-Pocket (Individual/Family) | Unlimited / Unlimited | $27,300 / $54,600 |
|---|