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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

Primary Care/Mental Health:
$25 copayment
Specialist:
$40 copayment
Chiropractor:
$20 copayment or 50% of total cost of service, whichever is less
Medicare: 20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

A visit with a health care or mental health care provider in an office, clinic or ambulatory care facility is covered based on the service, procedure or related treatment plan.

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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