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    This document outlines the copays, deductibles, and coinsurance amounts for three different health insurance plans (Plans 1, 2, and 3). Plan 1 has in-network copays of $35 and out-of-network of deductible plus 40% coinsurance for most services. Plan 2 has lower in-network copays of $15 or $100 and out-of-network of deductible plus 50% coinsurance. Generic prescription drug copays are $10 for 90-day supplies. Plan 3 has higher in-network copays of $45 and out-of-network of deductible plus 50% coinsurance for most services.

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    This document outlines the copays, deductibles, and coinsurance amounts for three different health insurance plans (Plans 1, 2, and 3). Plan 1 has in-network copays of $35 and out-of-network of deductible plus 40% coinsurance for most services. Plan 2 has lower in-network copays of $15 or $100 and out-of-network of deductible plus 50% coinsurance. Generic prescription drug copays are $10 for 90-day supplies. Plan 3 has higher in-network copays of $45 and out-of-network of deductible plus 50% coinsurance for most services.

    Copyright:

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    Download as XLS, PDF, TXT or read online from Scribd
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    Download as xls, pdf, or txt
    120 views2 pages

    Rinuado Medical

    Uploaded by

    res6250
    This document outlines the copays, deductibles, and coinsurance amounts for three different health insurance plans (Plans 1, 2, and 3). Plan 1 has in-network copays of $35 and out-of-network of deductible plus 40% coinsurance for most services. Plan 2 has lower in-network copays of $15 or $100 and out-of-network of deductible plus 50% coinsurance. Generic prescription drug copays are $10 for 90-day supplies. Plan 3 has higher in-network copays of $45 and out-of-network of deductible plus 50% coinsurance for most services.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as XLS, PDF, TXT or read online from Scribd
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    Download as xls, pdf, or txt
    of 2

    Plan

    Copay:

    Plan 5260 (Plan 1)


    In-Network: $35 Out-of-Network: DED + 40% In-Network: DED + 20% Co-Ins Out-of-Network: DED + 40% Co-Ins In-Network: 20% after deductible Out-of-Network: DED + 40% Co-Ins In-Network: $30 Copay Out-of-Network: 40% Co-Ins In-Network: $35 CoPay Out-of-Network: 40% Co-Ins In-Network: DED + 20% Co-Ins Out-of-Network: DED + 40% Co-Ins

    Plan 5462 (Plan 2)


    In-Network: $15 CoPay Out-of-Network: DED + 50% Co-Ins In-Network: $100 Copayment Out-of-Network: Same as In-Network In-Network: (1)$600/(2)$1000 CoPay Out-of-Network: DED + 50% Co-Ins In-Network: $0 Out-of-Network: 50% Co-Ins In-Network: $0 Out-of-Network: 50% Co-Ins In-Network: (1)$250 / (2)$350 Co-Pay Out-of-Network: DED + 50% Co-Ins

    Emergency Room:

    Inpatient Care:

    Child Wellness:

    Adult Routine Physicals:

    Outpatient Surgery:

    Prescription Drug
    90 day suply (retail) Generic: Select: Non-Select $10 $30 $50 90 day suply (retail) $10 $30 $50

    Annual Deductibles
    Individual:
    In-Network: $1,500 Out-of-Network: $3,000 In-Network: $4,500 Out-of-Network: $6,000 In-Network: $500 Out-of-Network: $1,000 In-Network: $1,500 Out-of-Network: $3,000

    Family:

    Annual Out-of-Pocket Maximum


    Individual:
    In-Network: $4,000 Out-of-Network: $5,000 In-Network: $8,000 Out-of-Network: $10,000 In-Network: 20% Out-of-Network: 40% In-Network: $2,500 Out-of-Network: $5,000 In-Network: $5,000 Out-of-Network: $10,000 In-Network: 20% Out-of-Network: 50%

    Family:

    Co-Insurance:

    Plan
    Copay:

    Plan 5803 (Plan 3)


    In-Network: $45 Out-of-Network: DED + 50% Co-Ins In-Network: DED + 50% Co-Ins Out-of-Network: Same as In-Network In-Network: DED + 50% Co-Ins Out-of-Network: DED + 50% Co-Ins In-Network: $0 Out-of-Network: 50% Coinsurance In-Network: $0 Out-of-Network: 50% Coinsurance In-Network:(1)$400 / (2)$500 Co-Pay Out-of-Network: DED + 50% Co-Ins

    Emergency Room:

    Inpatient Care:

    Child Wellness:

    Adult Routine Physicals:

    Outpatient Surgery:

    Prescription Drug
    90 day suply (retail) Generic: Select: Non-Select $10 $30 $50

    Annual Deductibles
    Individual:
    In-Network: $2,000 Out-of-Network: $6,000 In-Network: N/A Out-of-Network: N/A

    Family:

    Annual Out-of-Pocket Maximum


    Individual:
    In-Network: $15,000 Out-of-Network: $30,000 In-Network: $15,000 Out-of-Network: $30,000 In-Network: 50% Out-of-Network: 50%

    Family:

    Co-Insurance:

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