Option |
Copay |
Integrated Rx |
PPO 520/80/50
|
$20 |
|
PPO 1020/80/50
|
$20 |
|
PPO 2020/80/50
|
$20 |
|
PPO 2520/80/50
|
$20 |
|
PPO C201 — $1,000 Deductible
|
$20 |
x |
PPO D201 — $1,000 Deductible
|
$20 |
x |
PPO D201 — $1,000 Deductible w/ Rx Card
|
$20 |
|
PPO C201 — $500 Deductible
|
$20 |
x |
PPO D201 — $500 Deductible
|
$20 |
x |
PPO C20 — $1,000 Deductible w/ Rx Card
|
$20 |
|
PPO D20 — $1,000 Deductible w/ Rx Card
|
$20 |
|
PPO C20 — $1,000 Deductible
|
$20 |
x |
PPO D20 — $1,000 Deductible
|
$20 |
x |
PPO C20 — $500 Deductible w/ Rx Card
|
$20 |
|
PPO D20 — $500 Deductible
|
$20 |
x |
PPO D20 — $500 Deductible w/ Rx Card
|
$20 |
|
PPO C301 — $1,000 Deductible w/ Rx Card
|
$30 |
|
PPO C301 — $1,000 Deductible
|
$30 |
x |
PPO C301 — $2,500 Deductible w/ Rx Card
|
$30 |
|
PPO C301 — $2,500 Deductible
|
$30 |
x |
PPO C30 — $1,000 Deductible w/ Rx Card
|
$30 |
|
PPO C30 — $1,000 Deductible
|
$30 |
x |
PPO C30 — $2,500 Deductible w/ Rx Card
|
$30 |
|
PPO C30 — $2,500 Deductible
|
$30 |
x |