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Options
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Calendar Year Deductibles
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Copayment Amounts
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Calendar Year Out-of-Pocket Maximum/Security Provisions
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*Coinsurance
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Individual
(in-network/ out-of-network) |
Family
(in-network/ out-of-network) |
Office Visit
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Emergency Room
|
Individual (in-network/
out-of-network) |
Family
(in-network/ out-of-network) |
In-Network | Out-of-Network | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Plan Pays |
You Pay |
Plan Pays |
You Pay |
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| Plan I |
$5,000/$10,000
|
$15,000/$30,000
|
None | 80% after $200 copay (waived if admitted and calendar year deductible) |
$5,000/
$10,000 |
$15,000/ $30,000 |
80%
|
20% | 60% | 40% | ||