|
Plans: |
Rates: |
No
1: $10
Office Visit Copay, $500 Hospital Copay, $50 ER Copay
Prescriptions in Hospital Only |
Single:
$189.00;
Two-party: $341.00;
Family: $496.00
|
No 2:
$10 Office Visit Copay, $500 Hospital Copay, $50 ER Copay
$10/15
Prescriptions Drug Copay |
Single:
$202.00;
Two-party: $365.00;
Family: $532.00 |
No 3:
No Office Visit Copay, No Hospital Copay, No ER Copay
Prescriptions in Hospital Only |
Single:
$216.00;
Two-party: $380.00;
Family: $554.00 |
No 4:
No Office Visit Copay, No Hospital Copay, No ER Copay
Prescriptions in Hospital Only |
Single:
$231.00;
Two-party: $419.00;
Family: $611.00 |
No 5:
No Office Visit Copay, No Hospital Copay, No ER Copay
$10/15
Prescription Drug Copay, Optical: 1 pair glasses/year
DME:
$50 deductible 80/20 |
Single:
$243.00;
Two-party: $443.00;
Family: $646.00 |