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Insurance Plan Summary
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$1500 Deductible
Plan
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Apply
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HMO
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$200.00
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Online Physician Directory
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Yes
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No
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No
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No
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Optional Benefits (Example: Dental,
Maternity, Life, etc.)
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In-Network Coverage
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Family:$3,000($1,500 per
person)
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None
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Family:$7,000($3,500 per
person)
Does not include deductible
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Primary Doctor
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$30 Copay after
deductible
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Specialist
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$30 Copay after
deductible
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Periodic Health Exam
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$30 Copay (deductible
waived)
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Periodic OB-GYN Exam
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$30 Copay (deductible
waived)
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Well Baby Care
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$30 Copay (deductible
waived)
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Chiropractic
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$15 Copay
Limitations
20 Visits Per Year
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Mental Health
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$30 Copay after
deductible
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Generic
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$10 Copay
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Brand
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$35 Copay
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Non-Formulary
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Not Covered
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Rx Deductible
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$250 Individual
applies to
Brand
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Mail Order
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Not Available
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$10 Copay after
deductible
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$100 Copay after
deductible (waived if admitted)
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$250 Copay after
deductible
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$500 Copay per day after
deductible
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Pre & Postnatal Office Visit
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$30 Copay (deductible
waived)
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Labor & Delivery Hospital Stay
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$500 Copay per day after
deductible
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None
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Additional
Information
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N/A
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eSign
(electronic signature)
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Yes
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More Insurance Plan Details
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Exclusions and Limitations
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Actions
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$1500 Deductible
Plan
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Apply
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Get online recommendations using online
Plan Advisor
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Get live professional advice about this
insurance plan
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