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Rx Deductible
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Generic
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Preferred Brand
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Preferred Brand
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Non-Preferred Brand
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Non-Preferred Brand
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1
Carrier Name
Carrier Plan Type
PPO
PPOc
POS
POSc
HMO
HMOc
Indemnity
HSA
HRA
MSA
Referral Required?
Yes
No
Copay
PCP
$
Specialist
$
Coinsurance
In-Network
%
Out-of-Network
%
Rx Card
Yes?
Yes
No
Rx Deductible
$
Seperate Hospital Copay
Yes
No
Deductible
In-Network
$
Out-of-Network
$
Max Out of Pocket including Deductible
In-Network
$
Out-of-Network
$
RX Copay
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%
Generic
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Generic
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Preferred Brand
$
Preferred Brand
%
Non-Preferred Brand
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Non-Preferred Brand
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