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sample plans

2019 exhibit

PPO HIGH-DEDUCTIBLE

National PPO Network

$6,000 Med/Rx Deductible

$6,500 Annual Maximum

40% Primary / 40% Specialist

40% Labs / 40% X-Rays

40% Complex Imaging

40% Urgent / 40% ER

40% Ambulance

40% Surgery – ASC

40% Outpatient Hospital

40% Inpatient Hospital

$6,000 Med/Rx Deductible

40% Generic / 40% Brand

40% Non-Pref / 40% Special

$ ___ / EMPLOYEE (EE)

$ ___ / EE + SPOUSE

$ ___ / EE + CHILD(REN)

$ ___ / EE + FAMILY

PPO SPLIT-DEDUCTIBLE

National PPO Network

$2,500 Medical Deductible

$6,500 Annual Maximum

$45 Primary / $70 Specialist

30% Labs / 30% X-Rays

30% Complex Imaging

$90 Urgent / $250+30% ER

30% Ambulance

30% Surgery – ASC

30% Outpatient Hospital

30% Inpatient Hospital

$250 Rx Deductible

$15 Generic / $30 Brand

$75 Non-Pref / 30% Special

$ ___ / EMPLOYEE (EE)

$ ___ / EE + SPOUSE

$ ___ / EE + CHILD(REN)

$ ___ / EE + FAMILY

PPO ZERO-DEDUCTIBLE

National PPO Network

$0 Deductible

$4,000 Annual Maximum

$20 Primary / $40 Specialist

10% Labs / $40 X-Rays

$250 Complex Imaging

$20 Urgent / $100 ER

$250 Ambulance

$500 Surgery – ASC

$500 Outpatient Hospital

$500/ Day Inpatient Hospital

$100 Rx Deductible

$10 Generic / $30 Brand

$50 Non-Pref / 30% Special

$ ___ / EMPLOYEE (EE)

$ ___ / EE + SPOUSE

$ ___ / EE + CHILD(REN)

$ ___ / EE + FAMILY

benefitCOMPARE footnotes

* benefitCOMPARE on-demand illustrates in-network benefit highlights. Text contained within the illustration is sourced from various plan documents including the plan Certificate of Coverage/Evidence of Coverage, Summary of Benefits & Coverage, Summary of Plan Description, and Benefit Summary. While every effort was taken to accurately display the highlighted benefits, discrepancies or errors are always possible. In case of discrepancy between the illustration and the actual plan documents; the actual plan documents will prevail. For questions regarding benefit citations or clarification, please contact us at 800-272-2497.

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