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Plan Benefits
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Select HMO
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HMO Saver
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Individual HMO
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In-Select Network1
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In-Network
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In-Network
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Annual Deductible
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$0
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$1,500 per member
Inpatient / Outpatient Hospital Services
and Ambulatory Surgical Centers
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$0
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Annual Out-Of-Pocket Limit
(in addition to deductible, if any)
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Individual
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$3,000 per member
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$1,500 per member
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$3,000 per member
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Family
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Once 2 members each reach
the limit, the maximum is satisfied
for the entire family
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Once 2 members each reach
the limit, the maximum is satisfied
for the entire family
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Once 2 members each reach
the limit, the maximum is satisfied
for the entire family
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Lifetime Maximum
(the plan will pay up to this amount)
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unlimited
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unlimited
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unlimited
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Covered Services
The amounts shown are your share of costs after any deductible
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In-Select Network1
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In-Network
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In-Network
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Doctors’ Office Visits
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$25 copay
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$10 copay per visit
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$10 copay per visit
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Professional Services
(x-ray, lab, anesthesia, surgeon, etc.)
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No charge for
office visit-related services
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No charge for
office visit-related services
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No charge for office
visit-related services
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Hospital Inpatient
(overnight hospital stays)
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$250 copay per day
up to the first four days,
then 0% of negotiated fee
per admission
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20% of negotiated fee
(after deductible)
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20% of negotiated fee
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Hospital Outpatient
(if you don’t stay overnight)
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20% of negotiated fee
for services;
$250 per surgery
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20% of negotiated fee
(after deductible)
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20% of negotiated fee
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Emergency Room Services
($100 copay applies for each visit;
waived if admitted as inpatient)
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20% of negotiated fee
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20% of negotiated fee
(after deductible)
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20% of negotiated fee
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Maternity
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Office Visits: $25 copay
Hospital Inpatient: $250 copay
per day up to the first four days,
then 0% of negotiated
fee per admission
Outpatient Services:
20% of negotiated fee
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Office visits: $10 copay
Inpatient/Outpatient:
20% of negotiated fee
(after deductible)
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Office visits: $10 copay
Inpatient/Outpatient:
20% of negotiated fee
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Preventive Care
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$25 copay for specific
health maintenance services
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$10 copay for specific
health maintenance services
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$10 copay for specific
health maintenance services
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Ambulance
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$50 copay
(waived if admitted to hospital)
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$50 copay
(waived if admitted to hospital)
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$50 copay
(waived if admitted to hospital)
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Chiropractic Services
(up to 60 consecutive days
following an illness or injury; provided with medical group referral only)
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Inpatient
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$0
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20% of negotiated fee
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20% of negotiated fee
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Outpatient
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$25 copay per visit
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$10 copay per visit
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$10 copay per visit
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Prescription Drug Benefits
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Generic: $10 copay
Brand-name: $30 copay after
$250 Brand-name prescription drug
deductible2 (2 member maximum)
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Generic: $10 copay
Brand-name: $30 copay after
$250 Brand-name prescription drug
deductible2 (2 member maximum)
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Generic: $10 copay
Brand-name: $30 copay after
$250 Brand-name prescription drug
deductible2 (2 member maximum)
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