05/11/2021 - Laserfiche WebLink

Home Browse Search

tri-Netivarock 325 Copayment S15 Copayment Out-of-Ne.'wcir k DED + 40% DED + 3D% Outpatien Flospitat Faci l'ry Premier Sih. er PE�n 053fl2 Premier Gold Plan -03559 (per visr} (Surgicsl M -Neff mirk Option '1: DED + 30% Option 1: DED + 20% Out-of-Nelwork DED + 4D% DED + 3D% En -Network, (Copayment Waived if Admitted) (Copayment Waived if Admitted) S500 Copayment + DED + 30% $250 Copayment + DED + 20% Out-of-Nedrxirk 5500 Copayment + lNN DED + 30?b $250 Copayment + INN DED + 20% tri -Network 5401 Copayment S30 Copayment Out-of-Nedrmak S40 Copayment S30 Copayment In-Nelwrmrk IDED + 30% DED + 20% Out-of-Ne€vmak INN DED + 30% INN. DED + 20% In -Network Family Physiician orSpecaallst 3D% $200 Copayment Out-of-Nefiarovk IDED +4D% DED + 30% - M&gx= - . tn-Network 3D% $200 Copayment Out-of-Netww k DED + 40% DED + 30% w En -Network DED + 305 DED + 20% Out -o1 -Network DED +4Dl% DED + 30% fn -Ne k $50D PAD + DED + 3+0S'S PAD $200 +DED + 2096 Out-of-Nef lurk S ..000 IPA'D + DED + 40% PAD $400 +IDED + 30% En -Network SEID Copayment $45 Copayment Out -of -Network DED +4D % DED + 3D% 1X Calendar Year Deductible Per Person $1M (manse be rnetbefore NIA Capayments ap;pfltr) Generic 55 Copayment $10 Copay Preferred Brand Name $ 5 Copayment S50 Copay Non -Preferred Brand Name $95 Copayment $75 Copay Mad Order Dnrg (GO -Day Supply) Express :Script 2x Retail Capay Express Script 2x IRetail Copay Maintenance MedIncalfan 2X Copayment at Covered! 2X C©payment at Covered Pharmacies Pharmacies pian RE;eren:E-, rtlt-4f- :-Max 82n" ce,EjHliF For rrr crmaia E]Ihg that may be charged by an a"-nehwk pmvlaer, pime resat kr tie tiuta.`-tfetmvrk `EMeM recticn em tow StmrrmMy at C ovsmge document IkagttosuM rs Fim = Eaw_ VM-= r ushg a lab other elate chest, p!aasR be sure to corarm ttt°tr are contracted viva Flo rMaBlue%Bin Oprkrrro I--M=prsarto reoem. goserebe-s.