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*RX Coverage: Generic/Preferred Brand/Non-Preferred Brand Copay.
When you click on one of the View buttons below your Summary of Benefits and Coverage (SBC) will pull up in PDF format.
| Plan Number | Network | Maternity | In-Network Deductible Amount | Primary Care Practitioner/Specialist Copay | Coinsurance Percent | Out-of-Pocket Maximum | RX Coverage* | |
|---|---|---|---|---|---|---|---|---|
| View | K01 | P | No | $1000 Individual / $3000 Family | $35/$50 | 20% | $4000 Individual / $9000 Family | $8/$35/$60 Copay |
| View | K01 | P | Yes | $1000 Individual / $3000 Family | $35/$50 | 20% | $4000 Individual / $9000 Family | $8/$35/$60 Copay |
| View | K01 | S | No | $1000 Individual / $3000 Family | $35/$50 | 20% | $4000 Individual / $9000 Family | $8/$35/$60 Copay |
| View | K01 | S | Yes | $1000 Individual / $3000 Family | $35/$50 | 20% | $4000 Individual / $9000 Family | $8/$35/$60 Copay |
| View | K04 | P | No | $1500 Individual / $4500 Family | $35/$50 | 20% | $4500 Individual / $10500 Family | $8/$35/$60 Copay |
| View | K04 | P | Yes | $1500 Individual / $4500 Family | $35/$50 | 20% | $4500 Individual / $10500 Family | $8/$35/$60 Copay |
| View | K04 | S | No | $1500 Individual / $4500 Family | $35/$50 | 20% | $4500 Individual / $10500 Family | $8/$35/$60 Copay |
| View | K04 | S | Yes | $1500 Individual / $4500 Family | $35/$50 | 20% | $4500 Individual / $10500 Family | $8/$35/$60 Copay |
| View | K07 | P | No | $2500 Individual / $7500 Family | $35/$50 | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay |
| View | K07 | P | Yes | $2500 Individual / $7500 Family | $35/$50 | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay |
| View | K07 | S | No | $2500 Individual / $7500 Family | $35/$50 | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay |
| View | K07 | S | Yes | $2500 Individual / $7500 Family | $35/$50 | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay |
| View | K08 | P | No | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay |
| View | K08 | P | Yes | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay |
| View | K08 | S | No | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay |
| View | K08 | S | Yes | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay |
| View | K09 | P | No | $2500 Individual / $7500 Family | Deductible/Coinsurance | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay |
| View | K09 | P | Yes | $2500 Individual / $7500 Family | Deductible/Coinsurance | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay |
| View | K09 | S | No | $2500 Individual / $7500 Family | Deductible/Coinsurance | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay |
| View | K09 | S | Yes | $2500 Individual / $7500 Family | Deductible/Coinsurance | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay |
| View | K10 | P | No | $2500 Individual / $7500 Family | $35/$50 | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay |
| View | K10 | P | Yes | $2500 Individual / $7500 Family | $35/$50 | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay |
| View | K10 | S | No | $2500 Individual / $7500 Family | $35/$50 | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay |
| View | K10 | S | Yes | $2500 Individual / $7500 Family | $35/$50 | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay |
| View | K11 | P | No | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay |
| View | K11 | P | Yes | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay |
| View | K11 | S | No | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay |
| View | K11 | S | Yes | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay |
| View | K12 | P | No | $2500 Individual / $7500 Family | Deductible/Coinsurance | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay |
| View | K12 | P | Yes | $2500 Individual / $7500 Family | Deductible/Coinsurance | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay |
| View | K12 | S | No | $2500 Individual / $7500 Family | Deductible/Coinsurance | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay |
| View | K12 | S | Yes | $2500 Individual / $7500 Family | Deductible/Coinsurance | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay |
| View | K13 | P | No | $3500 Individual / $10500 Family | $35/$50 | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay |
| View | K13 | P | Yes | $3500 Individual / $10500 Family | $35/$50 | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay |
| View | K13 | S | No | $3500 Individual / $10500 Family | $35/$50 | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay |
| View | K13 | S | Yes | $3500 Individual / $10500 Family | $35/$50 | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay |
| View | K14 | P | No | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay |
| View | K14 | P | Yes | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay |
| View | K14 | S | No | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay |
| View | K14 | S | Yes | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay |
| View | K15 | P | No | $3500 Individual / $10500 Family | Deductible/Coinsurance | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay |
| View | K15 | P | Yes | $3500 Individual / $10500 Family | Deductible/Coinsurance | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay |
| View | K15 | S | No | $3500 Individual / $10500 Family | Deductible/Coinsurance | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay |
| View | K15 | S | Yes | $3500 Individual / $10500 Family | Deductible/Coinsurance | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay |
| View | K16 | P | No | $3500 Individual / $10500 Family | $35/$50 | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay |
| View | K16 | P | Yes | $3500 Individual / $10500 Family | $35/$50 | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay |
| View | K16 | S | No | $3500 Individual / $10500 Family | $35/$50 | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay |
| View | K16 | S | Yes | $3500 Individual / $10500 Family | $35/$50 | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay |
| View | K17 | P | No | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay |
| View | K17 | P | Yes | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay |
| View | K17 | S | No | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay |
| View | K17 | S | Yes | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay |
| View | K18 | P | No | $3500 Individual / $10500 Family | Deductible/Coinsurance | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay |
| View | K18 | P | Yes | $3500 Individual / $10500 Family | Deductible/Coinsurance | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay |
| View | K18 | S | No | $3500 Individual / $10500 Family | Deductible/Coinsurance | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay |
| View | K18 | S | Yes | $3500 Individual / $10500 Family | Deductible/Coinsurance | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay |
| View | K19 | P | No | $5000 Individual / $15000 Family | $35/$50 | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay |
| View | K19 | P | Yes | $5000 Individual / $15000 Family | $35/$50 | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay |
| View | K19 | S | No | $5000 Individual / $15000 Family | $35/$50 | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay |
| View | K19 | S | Yes | $5000 Individual / $15000 Family | $35/$50 | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay |
| View | K20 | P | No | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay |
| View | K20 | P | Yes | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay |
| View | K20 | S | No | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay |
| View | K20 | S | Yes | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay |
| View | K21 | P | No | $5000 Individual / $15000 Family | Deductible/Coinsurance | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay |
| View | K21 | P | Yes | $5000 Individual / $15000 Family | Deductible/Coinsurance | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay |
| View | K21 | S | No | $5000 Individual / $15000 Family | Deductible/Coinsurance | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay |
| View | K21 | S | Yes | $5000 Individual / $15000 Family | Deductible/Coinsurance | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay |
| View | K22 | P | No | $5000 Individual / $15000 Family | $35/$50 | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay |
| View | K22 | P | Yes | $5000 Individual / $15000 Family | $35/$50 | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay |
| View | K22 | S | No | $5000 Individual / $15000 Family | $35/$50 | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay |
| View | K22 | S | Yes | $5000 Individual / $15000 Family | $35/$50 | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay |
| View | K23 | P | No | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay |
| View | K23 | P | Yes | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay |
| View | K23 | S | No | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay |
| View | K23 | S | Yes | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay |
| View | K24 | P | No | $5000 Individual / $15000 Family | Deductible/Coinsurance | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay |
| View | K24 | P | Yes | $5000 Individual / $15000 Family | Deductible/Coinsurance | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay |
| View | K24 | S | No | $5000 Individual / $15000 Family | Deductible/Coinsurance | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay |
| View | K24 | S | Yes | $5000 Individual / $15000 Family | Deductible/Coinsurance | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay |
| View | L01 | P | No | $1000 Individual / $3000 Family | $35/$50 | 20% | $4000 Individual / $9000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L01 | P | Yes | $1000 Individual / $3000 Family | $35/$50 | 20% | $4000 Individual / $9000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L01 | S | No | $1000 Individual / $3000 Family | $35/$50 | 20% | $4000 Individual / $9000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L01 | S | Yes | $1000 Individual / $3000 Family | $35/$50 | 20% | $4000 Individual / $9000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L04 | P | No | $1500 Individual / $4500 Family | $35/$50 | 20% | $4500 Individual / $10500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L04 | P | Yes | $1500 Individual / $4500 Family | $35/$50 | 20% | $4500 Individual / $10500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L04 | S | No | $1500 Individual / $4500 Family | $35/$50 | 20% | $4500 Individual / $10500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L04 | S | Yes | $1500 Individual / $4500 Family | $35/$50 | 20% | $4500 Individual / $10500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L07 | P | No | $2500 Individual / $7500 Family | $35/$50 | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L07 | P | Yes | $2500 Individual / $7500 Family | $35/$50 | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L07 | S | No | $2500 Individual / $7500 Family | $35/$50 | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L07 | S | Yes | $2500 Individual / $7500 Family | $35/$50 | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L08 | P | No | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L08 | P | Yes | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L08 | S | No | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L08 | S | Yes | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L09 | P | No | $2500 Individual / $7500 Family | Deductible/Coinsurance | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L09 | P | Yes | $2500 Individual / $7500 Family | Deductible/Coinsurance | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L09 | S | No | $2500 Individual / $7500 Family | Deductible/Coinsurance | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L09 | S | Yes | $2500 Individual / $7500 Family | Deductible/Coinsurance | 20% | $5500 Individual / $13500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L10 | P | No | $2500 Individual / $7500 Family | $35/$50 | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L10 | P | Yes | $2500 Individual / $7500 Family | $35/$50 | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L10 | S | No | $2500 Individual / $7500 Family | $35/$50 | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L10 | S | Yes | $2500 Individual / $7500 Family | $35/$50 | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L11 | P | No | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L11 | P | Yes | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L11 | S | No | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L11 | S | Yes | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L12 | P | No | $2500 Individual / $7500 Family | Deductible/Coinsurance | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L12 | P | Yes | $2500 Individual / $7500 Family | Deductible/Coinsurance | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L12 | S | No | $2500 Individual / $7500 Family | Deductible/Coinsurance | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L12 | S | Yes | $2500 Individual / $7500 Family | Deductible/Coinsurance | 0% | $2500 Individual / $7500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L13 | P | No | $3500 Individual / $10500 Family | $35/$50 | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L13 | P | Yes | $3500 Individual / $10500 Family | $35/$50 | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L13 | S | No | $3500 Individual / $10500 Family | $35/$50 | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L13 | S | Yes | $3500 Individual / $10500 Family | $35/$50 | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L14 | P | No | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L14 | P | Yes | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L14 | S | No | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L14 | S | Yes | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L15 | P | No | $3500 Individual / $10500 Family | Deductible/Coinsurance | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L15 | P | Yes | $3500 Individual / $10500 Family | Deductible/Coinsurance | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L15 | S | No | $3500 Individual / $10500 Family | Deductible/Coinsurance | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L15 | S | Yes | $3500 Individual / $10500 Family | Deductible/Coinsurance | 20% | $6500 Individual / $16500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L16 | P | No | $3500 Individual / $10500 Family | $35/$50 | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L16 | P | Yes | $3500 Individual / $10500 Family | $35/$50 | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L16 | S | No | $3500 Individual / $10500 Family | $35/$50 | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L16 | S | Yes | $3500 Individual / $10500 Family | $35/$50 | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L17 | P | No | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L17 | P | Yes | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L17 | S | No | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L17 | S | Yes | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L18 | P | No | $3500 Individual / $10500 Family | Deductible/Coinsurance | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L18 | P | Yes | $3500 Individual / $10500 Family | Deductible/Coinsurance | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L18 | S | No | $3500 Individual / $10500 Family | Deductible/Coinsurance | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L18 | S | Yes | $3500 Individual / $10500 Family | Deductible/Coinsurance | 0% | $3500 Individual / $10500 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L19 | P | No | $5000 Individual / $15000 Family | $35/$50 | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L19 | P | Yes | $5000 Individual / $15000 Family | $35/$50 | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L19 | S | No | $5000 Individual / $15000 Family | $35/$50 | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L19 | S | Yes | $5000 Individual / $15000 Family | $35/$50 | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L20 | P | No | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L20 | P | Yes | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L20 | S | No | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L20 | S | Yes | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L21 | P | No | $5000 Individual / $15000 Family | Deductible/Coinsurance | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L21 | P | Yes | $5000 Individual / $15000 Family | Deductible/Coinsurance | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L21 | S | No | $5000 Individual / $15000 Family | Deductible/Coinsurance | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L21 | S | Yes | $5000 Individual / $15000 Family | Deductible/Coinsurance | 20% | $8000 Individual / $21000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L22 | P | No | $5000 Individual / $15000 Family | $35/$50 | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L22 | P | Yes | $5000 Individual / $15000 Family | $35/$50 | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L22 | S | No | $5000 Individual / $15000 Family | $35/$50 | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L22 | S | Yes | $5000 Individual / $15000 Family | $35/$50 | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L23 | P | No | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L23 | P | Yes | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L23 | S | No | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L23 | S | Yes | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L24 | P | No | $5000 Individual / $15000 Family | Deductible/Coinsurance | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L24 | P | Yes | $5000 Individual / $15000 Family | Deductible/Coinsurance | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L24 | S | No | $5000 Individual / $15000 Family | Deductible/Coinsurance | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | L24 | S | Yes | $5000 Individual / $15000 Family | Deductible/Coinsurance | 0% | $5000 Individual / $15000 Family | $8/$35/$60 Copay after $500 Brand Deductible |
| View | M07 | P | No | $2500 Individual / $7500 Family | $35/$50 | 20% | $5500 Individual / $13500 Family | 50% Coinsurance after deductible |
| View | M07 | P | Yes | $2500 Individual / $7500 Family | $35/$50 | 20% | $5500 Individual / $13500 Family | 50% Coinsurance after deductible |
| View | M07 | S | No | $2500 Individual / $7500 Family | $35/$50 | 20% | $5500 Individual / $13500 Family | 50% Coinsurance after deductible |
| View | M07 | S | Yes | $2500 Individual / $7500 Family | $35/$50 | 20% | $5500 Individual / $13500 Family | 50% Coinsurance after deductible |
| View | M08 | P | No | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $5500 Individual / $13500 Family | 50% Coinsurance after deductible |
| View | M08 | P | Yes | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $5500 Individual / $13500 Family | 50% Coinsurance after deductible |
| View | M08 | S | No | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $5500 Individual / $13500 Family | 50% Coinsurance after deductible |
| View | M08 | S | Yes | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $5500 Individual / $13500 Family | 50% Coinsurance after deductible |
| View | M09 | P | No | $2500 Individual / $7500 Family | Deductible/Coinsurance | 20% | $5500 Individual / $13500 Family | 50% Coinsurance after deductible |
| View | M09 | P | Yes | $2500 Individual / $7500 Family | Deductible/Coinsurance | 20% | $5500 Individual / $13500 Family | 50% Coinsurance after deductible |
| View | M09 | S | No | $2500 Individual / $7500 Family | Deductible/Coinsurance | 20% | $5500 Individual / $13500 Family | 50% Coinsurance after deductible |
| View | M09 | S | Yes | $2500 Individual / $7500 Family | Deductible/Coinsurance | 20% | $5500 Individual / $13500 Family | 50% Coinsurance after deductible |
| View | M10 | P | No | $2500 Individual / $7500 Family | $35/$50 | 0% | $2500 Individual / $7500 Family | 50% Coinsurance after deductible |
| View | M10 | P | Yes | $2500 Individual / $7500 Family | $35/$50 | 0% | $2500 Individual / $7500 Family | 50% Coinsurance after deductible |
| View | M10 | S | No | $2500 Individual / $7500 Family | $35/$50 | 0% | $2500 Individual / $7500 Family | 50% Coinsurance after deductible |
| View | M10 | S | Yes | $2500 Individual / $7500 Family | $35/$50 | 0% | $2500 Individual / $7500 Family | 50% Coinsurance after deductible |
| View | M11 | P | No | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $2500 Individual / $7500 Family | 50% Coinsurance after deductible |
| View | M11 | P | Yes | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $2500 Individual / $7500 Family | 50% Coinsurance after deductible |
| View | M11 | S | No | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $2500 Individual / $7500 Family | 50% Coinsurance after deductible |
| View | M11 | S | Yes | $2500 Individual / $7500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $2500 Individual / $7500 Family | 50% Coinsurance after deductible |
| View | M12 | P | No | $2500 Individual / $7500 Family | Deductible/Coinsurance | 0% | $2500 Individual / $7500 Family | 50% Coinsurance after deductible |
| View | M12 | P | Yes | $2500 Individual / $7500 Family | Deductible/Coinsurance | 0% | $2500 Individual / $7500 Family | 50% Coinsurance after deductible |
| View | M12 | S | No | $2500 Individual / $7500 Family | Deductible/Coinsurance | 0% | $2500 Individual / $7500 Family | 50% Coinsurance after deductible |
| View | M12 | S | Yes | $2500 Individual / $7500 Family | Deductible/Coinsurance | 0% | $2500 Individual / $7500 Family | 50% Coinsurance after deductible |
| View | M13 | P | No | $3500 Individual / $10500 Family | $35/$50 | 20% | $6500 Individual / $16500 Family | 50% Coinsurance after deductible |
| View | M13 | P | Yes | $3500 Individual / $10500 Family | $35/$50 | 20% | $6500 Individual / $16500 Family | 50% Coinsurance after deductible |
| View | M13 | S | No | $3500 Individual / $10500 Family | $35/$50 | 20% | $6500 Individual / $16500 Family | 50% Coinsurance after deductible |
| View | M13 | S | Yes | $3500 Individual / $10500 Family | $35/$50 | 20% | $6500 Individual / $16500 Family | 50% Coinsurance after deductible |
| View | M14 | P | No | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $6500 Individual / $16500 Family | 50% Coinsurance after deductible |
| View | M14 | P | Yes | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $6500 Individual / $16500 Family | 50% Coinsurance after deductible |
| View | M14 | S | No | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $6500 Individual / $16500 Family | 50% Coinsurance after deductible |
| View | M14 | S | Yes | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $6500 Individual / $16500 Family | 50% Coinsurance after deductible |
| View | M15 | P | No | $3500 Individual / $10500 Family | Deductible/Coinsurance | 20% | $6500 Individual / $16500 Family | 50% Coinsurance after deductible |
| View | M15 | P | Yes | $3500 Individual / $10500 Family | Deductible/Coinsurance | 20% | $6500 Individual / $16500 Family | 50% Coinsurance after deductible |
| View | M15 | S | No | $3500 Individual / $10500 Family | Deductible/Coinsurance | 20% | $6500 Individual / $16500 Family | 50% Coinsurance after deductible |
| View | M15 | S | Yes | $3500 Individual / $10500 Family | Deductible/Coinsurance | 20% | $6500 Individual / $16500 Family | 50% Coinsurance after deductible |
| View | M16 | P | No | $3500 Individual / $10500 Family | $35/$50 | 0% | $3500 Individual / $10500 Family | 50% Coinsurance after deductible |
| View | M16 | P | Yes | $3500 Individual / $10500 Family | $35/$50 | 0% | $3500 Individual / $10500 Family | 50% Coinsurance after deductible |
| View | M16 | S | No | $3500 Individual / $10500 Family | $35/$50 | 0% | $3500 Individual / $10500 Family | 50% Coinsurance after deductible |
| View | M16 | S | Yes | $3500 Individual / $10500 Family | $35/$50 | 0% | $3500 Individual / $10500 Family | 50% Coinsurance after deductible |
| View | M17 | P | No | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $3500 Individual / $10500 Family | 50% Coinsurance after deductible |
| View | M17 | P | Yes | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $3500 Individual / $10500 Family | 50% Coinsurance after deductible |
| View | M17 | S | No | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $3500 Individual / $10500 Family | 50% Coinsurance after deductible |
| View | M17 | S | Yes | $3500 Individual / $10500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $3500 Individual / $10500 Family | 50% Coinsurance after deductible |
| View | M18 | P | No | $3500 Individual / $10500 Family | Deductible/Coinsurance | 0% | $3500 Individual / $10500 Family | 50% Coinsurance after deductible |
| View | M18 | P | Yes | $3500 Individual / $10500 Family | Deductible/Coinsurance | 0% | $3500 Individual / $10500 Family | 50% Coinsurance after deductible |
| View | M18 | S | No | $3500 Individual / $10500 Family | Deductible/Coinsurance | 0% | $3500 Individual / $10500 Family | 50% Coinsurance after deductible |
| View | M18 | S | Yes | $3500 Individual / $10500 Family | Deductible/Coinsurance | 0% | $3500 Individual / $10500 Family | 50% Coinsurance after deductible |
| View | M19 | P | No | $5000 Individual / $15000 Family | $35/$50 | 20% | $8000 Individual / $21000 Family | 50% Coinsurance after deductible |
| View | M19 | P | Yes | $5000 Individual / $15000 Family | $35/$50 | 20% | $8000 Individual / $21000 Family | 50% Coinsurance after deductible |
| View | M19 | S | No | $5000 Individual / $15000 Family | $35/$50 | 20% | $8000 Individual / $21000 Family | 50% Coinsurance after deductible |
| View | M19 | S | Yes | $5000 Individual / $15000 Family | $35/$50 | 20% | $8000 Individual / $21000 Family | 50% Coinsurance after deductible |
| View | M20 | P | No | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $8000 Individual / $21000 Family | 50% Coinsurance after deductible |
| View | M20 | P | Yes | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $8000 Individual / $21000 Family | 50% Coinsurance after deductible |
| View | M20 | S | No | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $8000 Individual / $21000 Family | 50% Coinsurance after deductible |
| View | M20 | S | Yes | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $8000 Individual / $21000 Family | 50% Coinsurance after deductible |
| View | M21 | P | No | $5000 Individual / $15000 Family | Deductible/Coinsurance | 20% | $8000 Individual / $21000 Family | 50% Coinsurance after deductible |
| View | M21 | P | Yes | $5000 Individual / $15000 Family | Deductible/Coinsurance | 20% | $8000 Individual / $21000 Family | 50% Coinsurance after deductible |
| View | M21 | S | No | $5000 Individual / $15000 Family | Deductible/Coinsurance | 20% | $8000 Individual / $21000 Family | 50% Coinsurance after deductible |
| View | M21 | S | Yes | $5000 Individual / $15000 Family | Deductible/Coinsurance | 20% | $8000 Individual / $21000 Family | 50% Coinsurance after deductible |
| View | M22 | P | No | $5000 Individual / $15000 Family | $35/$50 | 0% | $5000 Individual / $15000 Family | 50% Coinsurance after deductible |
| View | M22 | P | Yes | $5000 Individual / $15000 Family | $35/$50 | 0% | $5000 Individual / $15000 Family | 50% Coinsurance after deductible |
| View | M22 | S | No | $5000 Individual / $15000 Family | $35/$50 | 0% | $5000 Individual / $15000 Family | 50% Coinsurance after deductible |
| View | M22 | S | Yes | $5000 Individual / $15000 Family | $35/$50 | 0% | $5000 Individual / $15000 Family | 50% Coinsurance after deductible |
| View | M23 | P | No | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $5000 Individual / $15000 Family | 50% Coinsurance after deductible |
| View | M23 | P | Yes | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $5000 Individual / $15000 Family | 50% Coinsurance after deductible |
| View | M23 | S | No | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $5000 Individual / $15000 Family | 50% Coinsurance after deductible |
| View | M23 | S | Yes | $5000 Individual / $15000 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $5000 Individual / $15000 Family | 50% Coinsurance after deductible |
| View | M24 | P | No | $5000 Individual / $15000 Family | Deductible/Coinsurance | 0% | $5000 Individual / $15000 Family | 50% Coinsurance after deductible |
| View | M24 | P | Yes | $5000 Individual / $15000 Family | Deductible/Coinsurance | 0% | $5000 Individual / $15000 Family | 50% Coinsurance after deductible |
| View | M24 | S | No | $5000 Individual / $15000 Family | Deductible/Coinsurance | 0% | $5000 Individual / $15000 Family | 50% Coinsurance after deductible |
| View | M24 | S | Yes | $5000 Individual / $15000 Family | Deductible/Coinsurance | 0% | $5000 Individual / $15000 Family | 50% Coinsurance after deductible |
| View | M26 | P | No | $7500 Individual / $22500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $10500 Individual / $28500 Family | 50% Coinsurance after deductible |
| View | M26 | P | Yes | $7500 Individual / $22500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $10500 Individual / $28500 Family | 50% Coinsurance after deductible |
| View | M26 | S | No | $7500 Individual / $22500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $10500 Individual / $28500 Family | 50% Coinsurance after deductible |
| View | M26 | S | Yes | $7500 Individual / $22500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 20% | $10500 Individual / $28500 Family | 50% Coinsurance after deductible |
| View | M27 | P | No | $7500 Individual / $22500 Family | Deductible/Coinsurance | 20% | $10500 Individual / $28500 Family | 50% Coinsurance after deductible |
| View | M27 | P | Yes | $7500 Individual / $22500 Family | Deductible/Coinsurance | 20% | $10500 Individual / $28500 Family | 50% Coinsurance after deductible |
| View | M27 | S | No | $7500 Individual / $22500 Family | Deductible/Coinsurance | 20% | $10500 Individual / $28500 Family | 50% Coinsurance after deductible |
| View | M27 | S | Yes | $7500 Individual / $22500 Family | Deductible/Coinsurance | 20% | $10500 Individual / $28500 Family | 50% Coinsurance after deductible |
| View | M29 | P | No | $7500 Individual / $22500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $7500 Individual / $22500 Family | 50% Coinsurance after deductible |
| View | M29 | P | Yes | $7500 Individual / $22500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $7500 Individual / $22500 Family | 50% Coinsurance after deductible |
| View | M29 | S | No | $7500 Individual / $22500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $7500 Individual / $22500 Family | 50% Coinsurance after deductible |
| View | M29 | S | Yes | $7500 Individual / $22500 Family | $35/$50 Copay for First 4 Visits Total(PCP-Specialist Combined)/All others 20% Coinsurance After Deductible | 0% | $7500 Individual / $22500 Family | 50% Coinsurance after deductible |
| View | M30 | P | No | $7500 Individual / $22500 Family | Deductible/Coinsurance | 0% | $7500 Individual / $22500 Family | 50% Coinsurance after deductible |
| View | M30 | P | Yes | $7500 Individual / $22500 Family | Deductible/Coinsurance | 0% | $7500 Individual / $22500 Family | 50% Coinsurance after deductible |
| View | M30 | S | No | $7500 Individual / $22500 Family | Deductible/Coinsurance | 0% | $7500 Individual / $22500 Family | 50% Coinsurance after deductible |
| View | M30 | S | Yes | $7500 Individual / $22500 Family | Deductible/Coinsurance | 0% | $7500 Individual / $22500 Family | 50% Coinsurance after deductible |
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