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HSA Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 750 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 1250 Plan

Network

Specialist:
$40 copayment*
Medicare: 20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

One exam per covered person per calendar year.

*Copayment covers office visit only. Lab, X-ray or other services associated with the visit apply to deductible and out-of-pocket maximum.


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