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Review our plans for:
ZIP code , County
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Plan Benefit In Network
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Monthly premium
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Physician office visits copay
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Specialty physician office visit copay
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Inpatient hospital admission daily copay for days 1-6
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Out-of-pocket maximum
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Prescription drug benefits
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Doctor services for inpatient hospital
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Outpatient hospital services copay per visit
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Emergency room copay per visit
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Skilled nursing facility
Days 1-20 daily copay
Days 21-100 daily copay
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Home health care
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Durable medical equipment coinsurance
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Emergency care during foreign travel
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Diagnostic hearing exam copay
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| Label | Label | Label |
| Label | Label | Label |
| Label | Label | Label |
| Label | Label | Label |
| Label | Label | Label |
| Label | Label | Label |
| Label | Label | Label |
| Label | $200 | $200 |
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$50
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$50
| $50 |
$0
Label |
$0
Label |
$0
Label |
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$0
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$0
| $0 |
| Label | Label | Label |
$250 deductible
then 20% up to
a $15,000
annual limit
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$250 deductible
then 20% up to
a $15,000
annual limit
| $250 deductible
then 20% up to
a $15,000
annual limit |
| Label | Label | Label |
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The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. This is an advertisement; for more information, contact a benefits specialist.
H4213_Adv 2011 Website Submission CMS Approved 10182010
Web Page Last Updated: 8/30/2011
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