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NetworkNetworkNetwork <br />$3,000/$9,000/ <br />$27,000 <br />$9,000 <br />Coinsurance20%50%20%50%20%50%(PCP/Spec)$25/$4050%20%50%20%50%Care$4050%20%50%20%50%waived50%waived50%20%50%20%50%waived20%20%20%20%20%50%20%50% <br />NetworkNonNetworkNonNetworkNon <br />1500 <br />(Individual/Family)N/AN/A$500/$1,000$500/$1,000 <br />FUND <br />1000HEALTH <br />$1,500/$4,200/ <br />$12,600 <br />$4,500 <br />waived50%100%,dedwaived50%100%,ded <br />NetworkInNetworkInNetworkIn <br />$2,000/$6,000/ <br />$18,000 <br />$6,000 <br />NetworkNonNetworkNonNetworkNon <br />FUND <br />Plan <br />500HEALTH <br />$1,000/$3,000/ <br />$3,000$9,000 <br />100%,ded$050%100%,ded <br />NetworkInNetworkInNetworkIn <br />Medical <br />deductible <br />$1,000/$7,000/ <br />$21,000 <br />$3,000 <br />$050%Ambulance20%50% <br />50% <br />copay; <br />NetworkNonNetworkNonNetworkNon <br />waived$150 <br />PPO <br />deductible <br />$3,500/ <br />$10,500 <br />$1,500 <br />$500/ <br />ray20% <br />copay; <br />InInPROCEDURESIn <br />Room*$150 <br />Current <br />(Individual/Family) <br />Woman <br />Immunizations <br />Well <br />(Individual/Family) <br />Exams/ <br />Exams/ <br />CARE <br />Maximum <br />Exams <br />Physical <br />FEATURES <br />Amount <br />X <br />and <br />Child <br />PREVENTIVE <br />Hearingmo's <br />Lab <br />Adult <br />Pocket <br />Well <br />DIAGNOSTIC <br />FundVisits <br />Emergency <br />Deductible <br />exam/24Diagnostic <br />Member <br />RoutineRoutine <br />Exams/ <br />Urgent <br />of <br />Health <br />PLAN <br />Office <br />Out <br />1 <br /> <br />