Aetna Small Business Health Plan Options

Transcription

1 Aetna Small Business Health Options NYC Community SM Manhattan, Bronx, Queens, Staten Island and Brooklyn RATES EECTIVE 01/01/01 through 0/1/01 Options NYC Community SM 1-1 NYC Community SM Referred Specialist Office $0 / $40 copay $0 / $50 copay Referred Inpatient Hospital / Outpatient $750 copay per admission / $150 copay $00 copay per day up to days per admission / $150 copay Referred Deductible Referred Referred Pharmacy $150 copay N/A N/A N/A Retail: $15 / $45 / $70 Mail Order: $0 / $90 / $140 $150 copay N/A N/A N/A Retail: $15 / 50% Mail Order: $0 / 50% S: E/S: Monthly Premium $8 $81 $715 $1,16 $77 $1,00 $6 $77 $679 $1,106 $701 $1,141 Self-Referred Deductible is $5,000 / $15,000 Self-Referred is Self-Referred Out of Pocket is $0,000 / $60,000 Deductible does not apply towards ; Referred and Self-Referred accumulate separately. Certain services may not apply toward the Deductible or. The NYC Community is an "in-network only plan (Referred and Self-Referred). Benefits for emergency services only are available from health care providers who do not participate in the Aetna network. conditions as set forth in the Aetna Group Policy or official renewal letters. Any changes in benefits level, conditions stated or other terms of the Policy may s/rates are effective as of 1/01/1 and could change at any time due to legislative or filing actions. This list of benefits isn't inclusive of all the benefits these plans offer. Please refer to the Aetna Avenue brochure for more information on our products. NYC Community (7/11) NYQ

2 Aetna Small Business Health Options GENESEE, LIVINGSTON, MONROE, ONTARIO, ORLEANS, WAYNE, WYOMING, YATES RATES EECTIVE 01/01/01 through /1/01 Options 1-1 $1,000 / $,000 $,000 / $9,000 N/A N/A N/A Pharmacy $15/$5/$70 S: E/S: $49 $1,180 $1,07 $1,605 $1,070 $1,656 $,000 / $6,000 $1,500 / $4,500 $,500 / $7,500 $,500 / $7,500 $,000 / $9,000 $1,500 / $4,500 $,000 / $9,000 $,000 / $9,000 $44 $1,061 $9 $1,44 $96 $1,488 $451 $1,078 $948 $1,466 $978 $1,51 $404 $966 $849 $1,1 $876 $1,55 $8 $916 $805 $1,45 $81 $1,85 $70 $884 $777 $1,0 $80 $1,41 $54 $1,76 $1,1 $1,75 $1,157 $1, $0 / $0 copay; 0% after 0% after 0% after $,000 / $9,000 $,500 / $5,000 $,500 / $7,000 $5,000 / $10,000 $,000 / $6,000 $10,000 / $0,000 $471 $1,17 $990 $1,5 $1,0 $1,581 $74 $894 $786 $1,16 $811 $1,54 $19 $76 $670 $1,07 $69 $1,070 $99 $716 $69 $97 $649 $1,004 $14 $751 $660 $1,0 $681 $1,054 $97 $949 $84 $1,91 $861 $1, 1 Deductible applies toward Limit; and accumulate separately. Certain services may not apply toward the Deductible or Limit. Deductible, and all payments for RX and all covered expenses, unless indicated otherwise, count towards the Limit. s/rates are effective as of 1/1/1 and could change at any time due to legislative or filing actions. RA-01

3 Aetna Small Business Health Options CAYUGA, ONONDAGA, OSWEGO RATES EECTIVE 01/01/01 through 0/1/01 Options 1-1 $1,000 / $,000 $,000 / $9,000 N/A N/A N/A Pharmacy $15/$5/$70 S: E/S: $55 $1,1 $1,161 $1,796 $1,198 $1,85 $,000 / $6,000 $1,500 / $4,500 $,500 / $7,500 $,500 / $7,500 $,000 / $9,000 $1,500 / $4,500 $,000 / $9,000 $,000 / $9,000 $496 $1,187 $1,04 $1,614 $1,076 $1,665 $504 $1,07 $1,060 $1,641 $1,094 $1,69 $45 $1,081 $950 $1,470 $980 $1,517 $48 $1,05 $901 $1,9 $99 $1,48 $414 $989 $869 $1,45 $897 $1,88 $597 $1,48 $1,55 $1,94 $1,95 $, $0 / $0 copay; 0% after 0% after 0% after $,000 / $9,000 $,500 / $5,000 $,500 / $7,000 $5,000 / $10,000 $,000 / $6,000 $10,000 / $0,000 $57 $1,61 $1,108 $1,715 $1,144 $1,770 $418 $1,000 $879 $1,60 $907 $1,404 $57 $85 $750 $1,160 $774 $1,198 $5 $801 $704 $1,089 $76 $1,14 $51 $841 $79 $1,14 $76 $1,180 $444 $1,06 $94 $1,444 $96 $1,491 1 Deductible applies toward Limit; and accumulate separately. Certain services may not apply toward the Deductible or Limit. Deductible, and all payments for RX and all covered expenses, unless indicated otherwise, count towards the Limit. s/rates are effective as of 1/1/1 and could change at any time due to legislative or filing actions. RA-0

4 Aetna Small Business Health Options CORTLAND, MADISON, SENECA, TOMPKINS RATES EECTIVE 01/01/01 through 0/1/01 Options 1-1 $1,000 / $,000 $,000 / $9,000 N/A N/A N/A Pharmacy $15/$5/$70 S: E/S: $55 $1,1 $1,161 $1,796 $1,198 $1,85 $,000 / $6,000 $1,500 / $4,500 $,500 / $7,500 $,500 / $7,500 $,000 / $9,000 $1,500 / $4,500 $,000 / $9,000 $,000 / $9,000 $496 $1,187 $1,04 $1,614 $1,076 $1,665 $504 $1,07 $1,060 $1,641 $1,094 $1,69 $45 $1,081 $950 $1,470 $980 $1,517 $48 $1,05 $901 $1,9 $99 $1,48 $414 $989 $869 $1,45 $897 $1,88 $597 $1,48 $1,55 $1,94 $1,95 $, $0 / $0 copay; 0% after 0% after 0% after $,000 / $9,000 $,500 / $5,000 $,500 / $7,000 $5,000 / $10,000 $,000 / $6,000 $10,000 / $0,000 $57 $1,61 $1,108 $1,715 $1,144 $1,770 $418 $1,000 $879 $1,60 $907 $1,404 $57 $85 $750 $1,160 $774 $1,198 $5 $801 $704 $1,089 $76 $1,14 $51 $841 $79 $1,14 $76 $1,180 $444 $1,06 $94 $1,444 $96 $1,491 1 Deductible applies toward Limit; and accumulate separately. Certain services may not apply toward the Deductible or Limit. Deductible, and all payments for RX and all covered expenses, unless indicated otherwise, count towards the Limit. s/rates are effective as of 1/1/1 and could change at any time due to legislative or filing actions. RA-0

5 Aetna Small Business Health Options BROOME, TIOGA RATES EECTIVE 01/01/01 through 0/1/01 Options 1-1 $1,000 / $,000 $,000 / $9,000 N/A N/A N/A Pharmacy $15/$5/$70 S: E/S: $55 $1,1 $1,161 $1,796 $1,198 $1,85 $,000 / $6,000 $1,500 / $4,500 $,500 / $7,500 $,500 / $7,500 $,000 / $9,000 $1,500 / $4,500 $,000 / $9,000 $,000 / $9,000 $496 $1,187 $1,04 $1,614 $1,076 $1,665 $504 $1,07 $1,060 $1,641 $1,094 $1,69 $45 $1,081 $950 $1,470 $980 $1,517 $48 $1,05 $901 $1,9 $99 $1,48 $414 $989 $869 $1,45 $897 $1,88 $597 $1,48 $1,55 $1,94 $1,95 $, $0 / $0 copay; 0% after 0% after 0% after $,000 / $9,000 $,500 / $5,000 $,500 / $7,000 $5,000 / $10,000 $,000 / $6,000 $10,000 / $0,000 $57 $1,61 $1,108 $1,715 $1,144 $1,770 $418 $1,000 $879 $1,60 $907 $1,404 $57 $85 $750 $1,160 $774 $1,198 $5 $801 $704 $1,089 $76 $1,14 $51 $841 $79 $1,14 $76 $1,180 $444 $1,06 $94 $1,444 $96 $1,491 1 Deductible applies toward Limit; and accumulate separately. Certain services may not apply toward the Deductible or Limit. Deductible, and all payments for RX and all covered expenses, unless indicated otherwise, count towards the Limit. s/rates are effective as of 1/1/1 and could change at any time due to legislative or filing actions. RA-04

6 Aetna Small Business Health Options CHEMUNG, DELAWARE, STEUBEN RATES EECTIVE 01/01/01 through 0/1/01 Options 1-1 $1,000 / $,000 $,000 / $9,000 N/A N/A N/A Pharmacy $15/$5/$70 S: E/S: $55 $1,1 $1,161 $1,796 $1,198 $1,85 $,000 / $6,000 $1,500 / $4,500 $,500 / $7,500 $,500 / $7,500 $,000 / $9,000 $1,500 / $4,500 $,000 / $9,000 $,000 / $9,000 $496 $1,187 $1,04 $1,614 $1,076 $1,665 $504 $1,07 $1,060 $1,641 $1,094 $1,69 $45 $1,081 $950 $1,470 $980 $1,517 $48 $1,05 $901 $1,9 $99 $1,48 $414 $989 $869 $1,45 $897 $1,88 $597 $1,48 $1,55 $1,94 $1,95 $, $0 / $0 copay; 0% after 0% after 0% after $,000 / $9,000 $,500 / $5,000 $,500 / $7,000 $5,000 / $10,000 $,000 / $6,000 $10,000 / $0,000 $57 $1,61 $1,108 $1,715 $1,144 $1,770 $418 $1,000 $879 $1,60 $907 $1,404 $57 $85 $750 $1,160 $774 $1,198 $5 $801 $704 $1,089 $76 $1,14 $51 $841 $79 $1,14 $76 $1,180 $444 $1,06 $94 $1,444 $96 $1,491 1 Deductible applies toward Limit; and accumulate separately. Certain services may not apply toward the Deductible or Limit. Deductible, and all payments for RX and all covered expenses, unless indicated otherwise, count towards the Limit. s/rates are effective as of 1/1/1 and could change at any time due to legislative or filing actions. RA-05

7 Aetna Small Business Health Options HERKIMER, ONEIDA RATES EECTIVE 01/01/01 through 0/1/01 Options 1-1 $1,000 / $,000 $,000 / $9,000 N/A N/A N/A Pharmacy $15/$5/$70 S: E/S: $55 $1,1 $1,161 $1,796 $1,198 $1,85 $,000 / $6,000 $1,500 / $4,500 $,500 / $7,500 $,500 / $7,500 $,000 / $9,000 $1,500 / $4,500 $,000 / $9,000 $,000 / $9,000 $496 $1,187 $1,04 $1,614 $1,076 $1,665 $504 $1,07 $1,060 $1,641 $1,094 $1,69 $45 $1,081 $950 $1,470 $980 $1,517 $48 $1,05 $901 $1,9 $99 $1,48 $414 $989 $869 $1,45 $897 $1,88 $597 $1,48 $1,55 $1,94 $1,95 $, $0 / $0 copay; 0% after 0% after 0% after $,000 / $9,000 $,500 / $5,000 $,500 / $7,000 $5,000 / $10,000 $,000 / $6,000 $10,000 / $0,000 $57 $1,61 $1,108 $1,715 $1,144 $1,770 $418 $1,000 $879 $1,60 $907 $1,404 $57 $85 $750 $1,160 $774 $1,198 $5 $801 $704 $1,089 $76 $1,14 $51 $841 $79 $1,14 $76 $1,180 $444 $1,06 $94 $1,444 $96 $1,491 1 Deductible applies toward Limit; and accumulate separately. Certain services may not apply toward the Deductible or Limit. Deductible, and all payments for RX and all covered expenses, unless indicated otherwise, count towards the Limit. s/rates are effective as of 1/1/1 and could change at any time due to legislative or filing actions. RA-06

8 Aetna Small Business Health Options ALBANY, RENSSELAER, SARATOGA, SCHENECTADY, WARREN, WASHINGTON RATES EECTIVE 01/01/01 through 0/1/01 Options 1-1 $1,000 / $,000 $,000 / $9,000 N/A N/A N/A Pharmacy $15/$5/$70 S: E/S: $55 $1,1 $1,161 $1,796 $1,198 $1,85 $,000 / $6,000 $1,500 / $4,500 $,500 / $7,500 $,500 / $7,500 $,000 / $9,000 $1,500 / $4,500 $,000 / $9,000 $,000 / $9,000 $496 $1,187 $1,04 $1,614 $1,076 $1,665 $504 $1,07 $1,060 $1,641 $1,094 $1,69 $45 $1,081 $950 $1,470 $980 $1,517 $48 $1,05 $901 $1,9 $99 $1,48 $414 $989 $869 $1,45 $897 $1,88 $597 $1,48 $1,55 $1,94 $1,95 $, $0 / $0 copay; 0% after 0% after 0% after $,000 / $9,000 $,500 / $5,000 $,500 / $7,000 $5,000 / $10,000 $,000 / $6,000 $10,000 / $0,000 $57 $1,61 $1,108 $1,715 $1,144 $1,770 $418 $1,000 $879 $1,60 $907 $1,404 $57 $85 $750 $1,160 $774 $1,198 $5 $801 $704 $1,089 $76 $1,14 $51 $841 $79 $1,14 $76 $1,180 $444 $1,06 $94 $1,444 $96 $1,491 1 Deductible applies toward Limit; and accumulate separately. Certain services may not apply toward the Deductible or Limit. Deductible, and all payments for RX and all covered expenses, unless indicated otherwise, count towards the Limit. s/rates are effective as of 1/1/1 and could change at any time due to legislative or filing actions. RA-07

9 Aetna Small Business Health Options ALLEGANY, CATTARAUGUS, CHAUTAUQUA, ERIE, NIAGARA RATES EECTIVE 01/01/01 through 0/1/01 Options 1-1 $1,000 / $,000 $,000 / $9,000 N/A N/A N/A Pharmacy $15/$5/$70 S: E/S: $681 $1,60 $1,4 $,16 $1,478 $,87 $,000 / $6,000 $1,500 / $4,500 $,500 / $7,500 $,500 / $7,500 $,000 / $9,000 $1,500 / $4,500 $,000 / $9,000 $,000 / $9,000 $61 $1,465 $1,87 $1,991 $1,8 $,055 $6 $1,489 $1,09 $,05 $1,51 $,090 $558 $1,4 $1,17 $1,814 $1,10 $1,87 $59 $1,65 $1,111 $1,70 $1,147 $1,775 $510 $1,1 $1,07 $1,660 $1,107 $1,71 $77 $1,76 $1,549 $,97 $1,598 $, $0 / $0 copay; 0% after 0% after 0% after $,000 / $9,000 $,500 / $5,000 $,500 / $7,000 $5,000 / $10,000 $,000 / $6,000 $10,000 / $0,000 $651 $1,556 $1,68 $,116 $1,411 $,184 $516 $1,4 $1,085 $1,679 $1,10 $1,7 $440 $1,05 $95 $1,4 $955 $1,478 $41 $988 $868 $1,44 $896 $1,87 $44 $1,07 $91 $1,411 $941 $1,456 $548 $1,11 $1,15 $1,78 $1,189 $1,840 1 Deductible applies toward Limit; and accumulate separately. Certain services may not apply toward the Deductible or Limit. Deductible, and all payments for RX and all covered expenses, unless indicated otherwise, count towards the Limit. s/rates are effective as of 1/1/1 and could change at any time due to legislative or filing actions. RA-08

10 Aetna Small Business Health Options CHENANGO, CLINTON, COLUMBIA, ESSEX, RANKLIN, ULTON, GREENE, HAMILTON, JEERSON, LEWIS, MONTGOMERY, OTSEGO, SAINT LAWRENCE, SCHOHARIE, SCHUYLER RATES EECTIVE 01/01/01 through 0/1/01 Options 1-1 $1,000 / $,000 $,000 / $9,000 N/A N/A N/A Pharmacy $15/$5/$70 S: E/S: $605 $1,447 $1,7 $1,968 $1,1 $,01 $,000 / $6,000 $1,500 / $4,500 $,500 / $7,500 $,500 / $7,500 $,000 / $9,000 $1,500 / $4,500 $,000 / $9,000 $,000 / $9,000 $544 $1,00 $1,14 $1,768 $1,179 $1,85 $55 $1, $1,16 $1,798 $1,199 $1,856 $495 $1,184 $1,041 $1,610 $1,074 $1,66 $469 $1,1 $987 $1,57 $1,018 $1,576 $45 $1,084 $95 $1,474 $98 $1,51 $654 $1,565 $1,75 $,18 $1,419 $, $0 / $0 copay; 0% after 0% after 0% after $,000 / $9,000 $,500 / $5,000 $,500 / $7,000 $5,000 / $10,000 $,000 / $6,000 $10,000 / $0,000 $578 $1,8 $1,14 $1,879 $1,5 $1,99 $458 $1,096 $96 $1,490 $994 $1,58 $91 $95 $8 $1,71 $848 $1,1 $67 $877 $771 $1,19 $796 $1,1 $85 $91 $810 $1,5 $85 $1,9 $487 $1,164 $1,0 $1,58 $1,056 $1,6 1 Deductible applies toward Limit; and accumulate separately. Certain services may not apply toward the Deductible or Limit. Deductible, and all payments for RX and all covered expenses, unless indicated otherwise, count towards the Limit. s/rates are effective as of 1/1/1 and could change at any time due to legislative or filing actions. RA-09

11 Aetna Small Business Health Options DUTCHESS, ORANGE, PUTNAM, SULLIVAN, ULSTER RATES EECTIVE 01/01/01 through 0/1/01 Options 1-1 $1,000 / $,000 $,000 / $9,000 N/A N/A N/A Pharmacy $15/$5/$70 S: E/S: $498 $1,191 $1,047 $1,60 $1,080 $1,67 $,000 / $6,000 $1,500 / $4,500 $,500 / $7,500 $,500 / $7,500 $,000 / $9,000 $1,500 / $4,500 $,000 / $9,000 $,000 / $9,000 $448 $1,071 $941 $1,456 $971 $1,50 $455 $1,089 $957 $1,480 $987 $1,58 $408 $975 $857 $1,6 $884 $1,68 $86 $94 $81 $1,57 $88 $1,97 $7 $89 $784 $1,14 $809 $1,5 $59 $1,88 $1,1 $1,75 $1,169 $1, $0 / $0 copay; 0% after 0% after 0% after $,000 / $9,000 $,500 / $5,000 $,500 / $7,000 $5,000 / $10,000 $,000 / $6,000 $10,000 / $0,000 $476 $1,18 $1,000 $1,547 $1,0 $1,596 $77 $90 $79 $1,7 $818 $1,66 $ $770 $677 $1,047 $698 $1,080 $0 $7 $65 $98 $655 $1,014 $17 $758 $667 $1,01 $688 $1,064 $401 $958 $84 $1,0 $869 $1,45 1 Deductible applies toward Limit; and accumulate separately. Certain services may not apply toward the Deductible or Limit. Deductible, and all payments for RX and all covered expenses, unless indicated otherwise, count towards the Limit. s/rates are effective as of 1/1/1 and could change at any time due to legislative or filing actions. RA-10

12 Aetna Small Business Health Options NASSAU, SUOLK RATES EECTIVE 01/01/01 through 0/1/01 Options 1-1 $1,000 / $,000 $,000 / $9,000 N/A N/A N/A Pharmacy $15/$5/$70 S: E/S: $580 $1,87 $1,19 $1,886 $1,58 $1,947 $,000 / $6,000 $1,500 / $4,500 $,500 / $7,500 $,500 / $7,500 $,000 / $9,000 $1,500 / $4,500 $,000 / $9,000 $,000 / $9,000 $51 $1,47 $1,096 $1,695 $1,11 $1,750 $50 $1,68 $1,114 $1,74 $1,150 $1,779 $475 $1,15 $998 $1,544 $1,00 $1,59 $450 $1,077 $946 $1,464 $976 $1,511 $45 $1,09 $91 $1,41 $94 $1,459 $67 $1,500 $1,19 $,040 $1,61 $, $0 / $0 copay; 0% after 0% after 0% after $,000 / $9,000 $,500 / $5,000 $,500 / $7,000 $5,000 / $10,000 $,000 / $6,000 $10,000 / $0,000 $554 $1,5 $1,164 $1,801 $1,01 $1,859 $49 $1,051 $9 $1,49 $95 $1,475 $75 $897 $788 $1,19 $81 $1,58 $5 $841 $79 $1,144 $76 $1,180 $69 $88 $776 $1,01 $801 $1,9 $467 $1,116 $981 $1,517 $1,01 $1,566 1 Deductible applies toward Limit; and accumulate separately. Certain services may not apply toward the Deductible or Limit. Deductible, and all payments for RX and all covered expenses, unless indicated otherwise, count towards the Limit. s/rates are effective as of 11/1/1 and could change at any time due to legislative or filing actions. RA-11

13 Aetna Small Business Health Options BRONX, KINGS, NEW YORK, QUEENS, RICHMOND RATES EECTIVE 01/01/01 through 0/1/01 Options 1-1 $1,000 / $,000 $,000 / $9,000 N/A N/A N/A Pharmacy $15/$5/$70 S: E/S: $56 $1,45 $1,18 $1,89 $1,0 $1,888 $,000 / $6,000 $1,500 / $4,500 $,500 / $7,500 $,500 / $7,500 $,000 / $9,000 $1,500 / $4,500 $,000 / $9,000 $,000 / $9,000 $505 $1,09 $1,06 $1,644 $1,096 $1,697 $514 $1,9 $1,080 $1,67 $1,115 $1,75 $460 $1,101 $968 $1,497 $999 $1,545 $46 $1,044 $917 $1,40 $947 $1,465 $41 $1,008 $886 $1,71 $914 $1,414 $608 $1,455 $1,79 $1,978 $1,0 $, $0 / $0 copay; 0% after 0% after 0% after $,000 / $9,000 $,500 / $5,000 $,500 / $7,000 $5,000 / $10,000 $,000 / $6,000 $10,000 / $0,000 $57 $1,85 $1,19 $1,747 $1,165 $1,80 $46 $1,019 $896 $1,86 $94 $1,40 $6 $869 $764 $1,18 $788 $1,0 $41 $816 $717 $1,109 $740 $1,145 $58 $856 $75 $1,165 $777 $1,0 $45 $1,08 $951 $1,47 $981 $1,519 1 Deductible applies toward Limit; and accumulate separately. Certain services may not apply toward the Deductible or Limit. Deductible, and all payments for RX and all covered expenses, unless indicated otherwise, count towards the Limit. s/rates are effective as of 1/1/1 and could change at any time due to legislative or filing actions. RA-1

14 Aetna Small Business Health Options WESTCHESTER RATES EECTIVE 01/01/01 through 0/1/01 Options 1-1 $1,000 / $,000 $,000 / $9,000 N/A N/A N/A Pharmacy $15/$5/$70 S: E/S: $596 $1,46 $1,5 $1,99 $1,9 $,001 $,000 / $6,000 $1,500 / $4,500 $,500 / $7,500 $,500 / $7,500 $,000 / $9,000 $1,500 / $4,500 $,000 / $9,000 $,000 / $9,000 $56 $1,8 $1,16 $1,74 $1,16 $1,798 $545 $1,0 $1,145 $1,77 $1,18 $1,89 $488 $1,167 $1,06 $1,587 $1,059 $1,68 $46 $1,107 $97 $1,505 $1,004 $1,55 $447 $1,068 $99 $1,45 $969 $1,499 $645 $1,54 $1,55 $,097 $1,99 $, $0 / $0 copay; 0% after 0% after 0% after $,000 / $9,000 $,500 / $5,000 $,500 / $7,000 $5,000 / $10,000 $,000 / $6,000 $10,000 / $0,000 $569 $1,6 $1,197 $1,85 $1,5 $1,911 $45 $1,080 $949 $1,469 $980 $1,516 $85 $9 $810 $1,5 $86 $1,9 $61 $865 $760 $1,176 $784 $1,1 $80 $908 $798 $1,5 $8 $1,74 $480 $1,147 $1,008 $1,560 $1,040 $1,610 1 Deductible applies toward Limit; and accumulate separately. Certain services may not apply toward the Deductible or Limit. Deductible, and all payments for RX and all covered expenses, unless indicated otherwise, count towards the Limit. s/rates are effective as of 1/1/1 and could change at any time due to legislative or filing actions. RA-14

15 Aetna Small Business Health Options ROCKLAND RATES EECTIVE 01/01/01 through 0/1/01 Options 1-1 $1,000 / $,000 $,000 / $9,000 N/A N/A N/A Pharmacy $15/$5/$70 S: E/S: $56 $1,44 $1,181 $1,87 $1,19 $1,886 $,000 / $6,000 $1,500 / $4,500 $,500 / $7,500 $,500 / $7,500 $,000 / $9,000 $1,500 / $4,500 $,000 / $9,000 $,000 / $9,000 $505 $1,08 $1,061 $1,64 $1,095 $1,695 $51 $1,8 $1,079 $1,670 $1,114 $1,7 $460 $1,100 $967 $1,496 $998 $1,544 $46 $1,04 $916 $1,418 $946 $1,46 $41 $1,007 $885 $1,69 $91 $1,41 $608 $1,45 $1,77 $1,976 $1,18 $, $0 / $0 copay; 0% after 0% after 0% after $,000 / $9,000 $,500 / $5,000 $,500 / $7,000 $5,000 / $10,000 $,000 / $6,000 $10,000 / $0,000 $56 $1,8 $1,18 $1,745 $1,164 $1,801 $46 $1,018 $895 $1,84 $9 $1,49 $6 $868 $76 $1,181 $788 $1,19 $41 $815 $716 $1,108 $79 $1,14 $58 $856 $75 $1,16 $776 $1,01 $45 $1,081 $950 $1,470 $980 $1,517 1 Deductible applies toward Limit; and accumulate separately. Certain services may not apply toward the Deductible or Limit. Deductible, and all payments for RX and all covered expenses, unless indicated otherwise, count towards the Limit. s/rates are effective as of 1/1/1 and could change at any time due to legislative or filing actions. RA-15