$0
$25
$0
$3,900
$3,900
$5,500
No Medical or Rx Deductible
No Medical or Rx Deductible
No Medical or Rx Deductible
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$35 Copay
$30 Copay
$35 Copay
$60 Copay
$60 Copay
$55 Copay
$140 Copay
$140 Copay
$125 Copay
$0 Copay
$0 Copay
$0 Copay
100% Coverage
100% Coverage
100% Coverage
$20 Copay
$20 Copay
$20 Copay
$175 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
$175 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
$350 Per Day for Days 1-5,
$0 Per Day for Day 6 and Beyond
$150 Copay
$150 Copay
$200 Copay
$100 Copay
$100 Copay
$150 Copay
$200 allowance per year
$400 allowance per year
$200 allowance per year
Preventive and Comprehensive services combined annual allowance $1,000
Preventive and Comprehensive services combined annual allowance $2,000
Preventive and Comprehensive services combined annual allowance $1,500
$85 Per Quarter
$120 Per Quarter
$105 Per Quarter
$1,000 allowance for up to 2 hearing aids every 2 years (both ears combined)
$1,500 allowance for up to 2 hearing aids every 2 years (both ears combined)
$1,000 allowance for up to 2 hearing aids every 2 years (both ears combined)
$0 copay for 20 one-way trips to approved locations per year
$0 copay for 30 one-way trips to approved locations per year
$0 copay for 20 one-way trips to approved locations per year
Included at no additional cost
Included at no additional cost
Included at no additional cost
Emergency or urgent care coverage if you are making a trip out of state or country
Emergency or urgent care coverage if you are making a trip out of state or country
Emergency or urgent care coverage if you are making a trip out of state or country
No Deductible
No Deductible
No Deductible
$0 copay†
$0 copay†
$0 copay†
$10 copay†
$10 copay†
$10 copay†
$45 copay†
$45 copay†
$47 copay†
$95 copay†
$95 copay†
$100 copay†
33% Co-insurance
33% Co-insurance
33% Co-insurance
Tier 1: $0 copay
Tier 2: $0 copay
Tier 3: $135 copay
Tier 4: $285 copay
Tier 1: $0 copay
Tier 2: $0 copay
Tier 3: $135 copay
Tier 4: $285 copay
Tier 1: $0 copay
Tier 2: $0 copay
Tier 3: $141 copay
Tier 4: $300 copay
$0
$25
$0
$3,900
$3,900
$5,500
No Medical or Rx Deductible
No Medical or Rx Deductible
No Medical or Rx Deductible
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$0 Copay
$35 Copay
$30 Copay
$35 Copay
$60 Copay
$60 Copay
$55 Copay
$140 Copay
$140 Copay
$125 Copay
$0 Copay
$0 Copay
$0 Copay
100% Coverage
100% Coverage
100% Coverage
$20 Copay
$20 Copay
$20 Copay
$200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
$200 Per Day for Days 1-7,
$0 Per Day for Day 8 and Beyond
$350 Per Day for Days 1-5,
$0 Per Day for Day 6 and Beyond
$150 Copay
$150 Copay
$200 Copay
$100 Copay
$100 Copay
$150 Copay
$200 allowance per year
$400 allowance per year
$200 allowance per year
Preventive and Comprehensive services combined annual allowance $1,000
Preventive and Comprehensive services combined annual allowance $2,000
Preventive and Comprehensive services combined annual allowance $1,500
$85 Per Quarter
$115 Per Quarter
$105 Per Quarter
$1,000 allowance for up to 2 hearing aids every 2 years (both ears combined)
$1,500 allowance for up to 2 hearing aids every 2 years (both ears combined)
$1,000 allowance for up to 2 hearing aids every 2 years (both ears combined)
$0 copay for 20 one-way trips to approved locations per year
$0 copay for 30 one-way trips to approved locations per year
$0 copay for 20 one-way trips to approved locations per year
Included at no additional cost
Included at no additional cost
Included at no additional cost
Emergency or urgent care coverage if you are making a trip out of state or country
Emergency or urgent care coverage if you are making a trip out of state or country
Emergency or urgent care coverage if you are making a trip out of state or country
No Deductible
No Deductible
No Deductible
$0 copay†
$0 copay†
$0 copay†
$10 copay†
$10 copay†
$10 copay†
$45 copay†
$45 copay†
$47 copay†
$95 copay†
$95 copay†
$100 copay†
33% Co-insurance
33% Co-insurance
33% Co-insurance
Tier 1: $0 copay
Tier 2: $0 copay
Tier 3: $135 copay
Tier 4: $285 copay
Tier 1: $0 copay
Tier 2: $0 copay
Tier 3: $135 copay
Tier 4: $285 copay
Tier 1: $0 copay
Tier 2: $0 copay
Tier 3: $141 copay
Tier 4: $300 copay
