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MEDICAL_INSURANCE

VIEWS: 23 PAGES: 3

									Prescription          15 (Generic)
Card                  35 (Brand)
                      60/OC/N/A/2x 90/day excl V (d


Major Medical

Deductible            Member pays
Ind/Fam               $1000/$2000

Co-Insurance                                80%

Maximum               $1500/$3000
Out-of-Pocket

Office Co-pay         $20 copay/No ded

DXL/Lab Fees          $30 copay/No ded

Specialist Co-pay     $30 copay/No ded

Lifetime Maximum      Unlimited

Hospital Benefits

Hospital In-Patient   80% after ded

Hospital              80% after ded
Out-Patient

Emergency Room        $50 copay/No ded

Private Nursing       Not Covered, except
                      under HHC


Surgical Benefits

Surgical In-Patient   Incl. Hosp Co-pay

Surgical              80% after ded
Out-Patient


Mental Health

Mental Nervous        a) 80% after ded
In-Patient            30d Cal Yr

Substance Abuse       a) 80% after ded
In-Patient            30d/Cal
                      Yr/90d/lifetime


Mental Nervous        a) $30 copay/No ded
Out-Patient           20 visits/Cal Yr


Substance Abuse       a) $30 copay/No ded
Out-Patient           20 visits/Cal Yr


Other

Well Care(Up to 19)   $20 copay/No ded

Routine Adult Care    $20 copay/No ded

Chiropractic Care     $30 copay; 30
                      vistis/Cal Yr

Home Health Care      No copay; 60 visits
                      per cal yr


Non-Authorization     Refer to Carrier Plan
                      Information




Single                                        232

EE with Spouse                                486

EE with Child(ren)                            410

Family                                        684

Medicare                                       0

Monthly Cost

Annual Cost
 The rates and benefits in this report are for discussion and estimation purposes only and
 are not valid without approval from the insurance carriers. Final rates must be based on
                    insurance carrier confirmation and final enrollment.


 (d) Non-Formulary / Oral Contraceptive / Deductible / Mail Order (Wellchoice includes Mail
                     Order Generic, Brand, and Non-Formulary costs)
(a) Biological based Mental Nervous & Alcohol Abuse/Treated same way as any other illness.

								
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