| | B011 — G9L1CHC | U017 — DX-9I |
|---|
| Plan # | B011 | U017 |
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| Plan Name | G9L1CHC | DX-9I |
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| Network Name | Blue Choice | Choice |
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| Network Type | PPO | EPO |
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| Plan Type | Copay | Copay |
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| Deductible - Individual | $2,250 | $4,500 |
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| Deductible - Family | $6,750 | $9,000 |
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| Coinsurance - Member | 20% | 0% |
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| Coinsurance - Plan | 80% | 100% |
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| Out-of-Pocket - Individual | $6,750 | $6,500 |
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| Out-of-Pocket - Family | $18,400 | $13,000 |
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| Virtual Visits | $35 | $0 |
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| PCP <19 | $35 | $0 |
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| Primary | $35 | $10 |
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| Specialist | $70 | $40 or $80 |
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| Urgent Care | $75 | $25 |
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| Emergency | $500 + D&C | $500 + D&C |
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| Lab/X-Ray | D&C | $40 |
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| Imaging | $250 | D&C |
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| Inpatient Services | $300 + D&C | D&C |
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| Outpatient Surgery | $100 + D&C | D&C |
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| Prescriptions | $0-10-50-100-150-250 | $10-40-125-300-500 |
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| OON Deductible (Individual/Family) | $4,500 / $13,500 | N/A |
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| OON Coinsurance (Member) | 30% | N/A |
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| OON Out-of-Pocket (Individual/Family) | Unlimited / Unlimited | N/A |
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| Monthly Rate — EO | $595.75 | $594.46 |
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| Monthly Rate — ES | $1,191.49 | $1,188.92 |
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| Monthly Rate — EC | $1,191.49 | $1,188.92 |
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| Monthly Rate — EF | $1,787.24 | $1,783.38 |
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| Monthly Total (group) | $4,765.98 | $4,755.68 |
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