BestChoice PPO
| Health Plan # | Ded In/Out Comb | Office Copay | Urgent Care Copay | ER Copay | Coins % In/Out | Coins Stoploss In/Out | Pharmacy |
|---|---|---|---|---|---|---|---|
| RS33 | $7500 | $40 | $65 | $100 | 75% / 50% | $5000/$10000 | $20/40/60 |
| RS34 | $10000 | $40 | $65 | $100 | 75% / 50% | $5000/$10000 | $20/40/60 |
| RS35 | $1000 | Ded & Coins | Ded & Coins | $100 | 100% / 70% | $0/$8000 | 80% / 50%/ 50% after cal yr ded |
| RS36 | $2000 | $30 | $55 | $100 | 100% / 80% | $0/$8000 | $20/35/50 |
| RS37 | $4000 | $30 | $55 | $100 | 100% / 70% | $0/$10000 | $20/40/60 |
| RS38 | $2500 | $25 | $50 | $100 | 100% / 70% | $0/$10000 | $15/30/45 |
| RS39 | $300 | $20 | $45 | $100 | 85% / 70% | $5000/$7000 | 80% / 70% / 55% |
| RS40 | $7500 | $25 | $50 | $100 | 100% / 70% | $0/$10000 | $15/40/60 |
| RS41 | $10000 | $25 | $50 | $100 | 100% / 70% | $0/$10000 | $15/40/60 |
| RSB1 * | $1000 | $20 | $45 | $100 | 80% / 60% | $3000/$6000 | $15/40/55 |
| RSB2 * | $2500 | $30 | $55 | $100 | 80% / 60% | $4000/$8000 | $20/40/60 |
| RSB3 ** | $3000 | $30 | $55 | $100 | 80% / 60% | $3000/$6000 | $10/40/60 |
| RSB4 ** | $5000 | $40 | $65 | $100 | 70% / 50% | $5000/$10000 | $20/40/60 |
* Copay applies to the Physician Office Visit Only and Lab & X-Ray paid after coinsurance
** Copay applies to the Physician Office Visit Only and Lab & X-Ray paid after deductible and coinsurance
