No census attached.
| | S014 — PPO Access 100 4000 | S018 — PPO Access 70 4500 | B016 — S661CHC | U017 — DX-9I |
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| Plan # | S014 | S018 | B016 | U017 |
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| Plan Name | PPO Access 100 4000 | PPO Access 70 4500 | S661CHC | DX-9I |
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| Network Name | Access PPO | Access PPO | Blue Choice | Choice |
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| Network Type | PPO | PPO | PPO | EPO |
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| Plan Type | Copay | Copay | Copay | Copay |
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| Deductible - Individual | $4,000 | $4,500 | $3,650 | $4,500 |
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| Deductible - Family | $8,000 | $9,000 | $10,950 | $9,000 |
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| Coinsurance - Member | 0% | 30% | 30% | 0% |
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| Coinsurance - Plan | 100% | 70% | 70% | 100% |
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| Out-of-Pocket - Individual | $6,500 | $9,100 | $9,200 | $6,500 |
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| Out-of-Pocket - Family | $13,000 | $18,200 | $18,400 | $13,000 |
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| Virtual Visits | $0 | $0 | $55 | $0 |
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| PCP <19 | $0 | $0 | $55 | $0 |
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| Primary | $15 | $40 | $55 | $10 |
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| Specialist | $25 | $80 | $100 | $40 or $80 |
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| Urgent Care | $50 | $50 | $100 | $25 |
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| Emergency | D $750 | D $750 | $750 + D&C | $500 + D&C |
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| Lab/X-Ray | D&C | D&C | D&C | $40 |
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| Imaging | D&C | D&C | $250 + D&C | D&C |
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| Inpatient Services | D&C | D&C | $350 + D&C | D&C |
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| Outpatient Surgery | D&C | D&C | $300 + D&C | D&C |
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| Prescriptions | $3-50-125-250 | $3-50-125-250 | $5-10-50-100-150-250 | $10-40-125-300-500 |
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| OON Deductible (Individual/Family) | $8,000 / $16,000 | $9,000 / $18,000 | $7,300 / $21,900 | N/A |
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| OON Coinsurance (Member) | 50% | 50% | 50% | N/A |
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| OON Out-of-Pocket (Individual/Family) | $19,500 / $39,000 | $27,300 / $54,600 | Unlimited / Unlimited | N/A |
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