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October 23, 2017

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HEALTH INSURANCE: PLATINUM
Print-friendly PDF of all plans (525k)
Major Medical BenefitsNetworkNon-Network
Individual
Family
$100
$200
$200
$400
Co-Insurance 90% / 10% 70% / 30%
Out-of-Pocket (including deductable)
Individual
Family

$600
$1,200

$1,700
$3,400
Inpatient Hospital Care 90% / 10%
after deductable
70% / 30%
after deductable
Emergency Room Treatment
(Limited to severe medical condition)
$50 co-pay 70% / 30%
after deductable
Outpatient Hospital Care 90% / 10%
after deductable
70% / 30%
after deductable
Office Visits 100%
after $10 co-pay
70% / 30%
after deductable
Inpatient Maternity Care 90% / 10%
after deductable
70% / 30%
after deductable
Lab and X-Ray 90% / 10%
after deductable
70% / 30%
after deductable
Therapy Services
(limited to 10 visits per year)
90% / 10%
after deductable
70% / 30%
after deductable
Life Insurance $10,000 Term
Urgent Care $25 co-pay
Lifetime Maximum $2,500,000
Retail Prescription Drugs ($3,000 annual limit)
(30-day supply)
$5 generic / $15 name brand formulary
$30 name brand non-formulary
Mail Order Prescription Drugs
(Mandatory for prescriptions in excess of a 90-day supply)
$10 generic / $30 name brand formulary
$60 name brand non-formulary
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This summary is intended to highlight your healthcare benefits and is not a contract of insurance. Please refer to your Summary Plan Description for a complete explanation of covered services, limitations, exclusions and a description of all terms and conditions of coverage.