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| | Click here or scroll down to respond to this candidateTiWvNDeductibleCandidate's Name
InpatientOutpatientEmergency RoomRxLab & X-RayOut-of-NetworkOut-of-Pocket MaximumPage 1TiWvNChoice Plus HSA BC-OD RX 0I "Bronze","Choice Plus Premier AX-PG RX 0I "Silver","Choice Plus Premier BC-OP RX 0I "Go"Per Pay Period (Weekly)$3,500 Single / $7,000 FamilyPCP: Ded. then $25 Copay; SP: Ded. then $50 CopayDed. then 0%Ded. then 0%UC: Ded. then $75 Copay; ER: Ded. then $250 CopayRetail: Ded. then $10/$35/$70; Mail Order: Ded. then $25/$87.50/$175Ded. then 0%See SBC$6,650 Single / $13,300 FamilyPage 2TiWvN$29.81$3,000 Single / $6,000 FamilyPCP: $15 Copay / Tier 1SP: $50 Copay / SP: $100 CopayDed. then 20%Ded. then 20%UC: $25 Copay; ER: $300 Copay, Ded. then 20%Retail: $10/$35/$70; Mail Order: $25/$87.50/$175Ded. then 20%See SBC$7,150 Single / $14,300 FamilyPage 3TiWvN$31.61 $78.36$1,500 Single / $3,000 FamilyPCP: $25 Copay / Tier 1SP: $25 Copay / SP: $50 CopayDed. then 0%Ded. then 0%$300 CopayRetail: $10/$35/$70; Mail Order: $25/$87.50/$175Covered in fullSee SBC$3,000 Single / $6,000 FamilyPage 4 |