BestChoice PPO
| Health Plan # | Ded In/Out Comb | Office Copay | Add’l Ded Per Admit | Out Patient Surgery Copay | Urgent Care Copay | ER Copay | Coins % In/Out | Coins Stoploss In/Out | Pharmacy* |
|---|---|---|---|---|---|---|---|---|---|
| RSA1 | $1500 | $30/$100 | $500 | $250 | $75 | $250 | 90% / 70% | $3500/$7000 | $15/45/75 |
| RSA2 | $3000 | $30/$100 | $500 | $250 | $75 | $250 | 90% / 70% | $4000/$8000 | $15/45/75 |
* $300 deductible on brand name drugs
| Health Plan # | In Patient Ded | Cal Yr Ded | Office Copay | OV Limit | Urgent Care Copay | ER Copay | Coins % In/Out | Coins Stoploss In/Out | Pharmacy* |
|---|---|---|---|---|---|---|---|---|---|
| RSS1 | $2500 | $1500 | $30/$100 | N/A | $75 | $250 | 100% / 70% | $0/$10000 | $15/45/75 |
| RSS2 | $1500 | $2000 | $30/$100 | $5 | $75 | $250 | 80% / 60% | $5000/$10000 | $15/45/75 |
* $300 deductible on brand name drugs
| Health Plan # | Ded In/Out Combined | Office Copay | Coins % In/Out | Coins Stoploss In/Out | Pharmacy |
|---|---|---|---|---|---|
| RSE1 | $3000 | $30 | 100% / 70% | $0/$10000 | $10/40/60 |
