Greatest Plan Benefits – Option 1

FAMILY PLAN
Red PPO 85 Opt 1
100/100*/80/50/50 – $50/$150
PLAN ID: 80251UT0020022

CHILD ONLY ENHANCED PLAN
Red PPO 85 Opt 1
100/80/50/50 – $50/$150
PLAN ID: 80251UT0020020

CHILD ONLY PLAN
Red PPO 85 Opt 1
100/0/0/0 – $50/$150
PLAN ID: 80251UT0020018

FAMILY PLAN
Red PPO 70 Opt 1
100/100*/80/50/50 – $100/$300
PLAN ID: 80251UT0020021

CHILD ONLY ENHANCED PLAN
Red PPO 70 Opt 1
100/80/50/50 – $100/$300
PLAN ID: 80251UT0020019

CHILD ONLY PLAN
Red PPO 70 Opt 1
100/0/0/0 – $100/$300
PLAN ID: 80251UT0020017

FAMILY PLAN
Blue Co-Pay 85
Fixed Co-Pays – $25/$75
PLAN ID: 80251UT0020002

CHILD ONLY ENHANCED PLAN
Blue Co-Pay 85
Fixed Co-Pays – $25/$75
PLAN ID: 80251UT0020004

CHILD ONLY PLAN
Blue Co-Pay 85
Fixed Co-Pay/0/0/0 – $0/$0
PLAN ID: 80251UT0020006

Mid-Level Plan Benefits – Option 2

FAMILY PLAN
Red PPO 85 Opt 2
85/100*/80/50/50 – $50/$150
PLAN ID: 80251UT0020014

CHILD ONLY ENHANCED PLAN
Red PPO 85 Opt 2
85/80/50/50 – $50/$150
PLAN ID: 80251UT0020011

CHILD ONLY PLAN
Not Applicable

FAMILY PLAN
Red PPO 70 Opt 2
70/100*/80/50/50 – $50/$150
PLAN ID: 80251UT0020013

CHILD ONLY ENHANCED PLAN
Red PPO 70 Opt 2
70/80/50/50 – $50/$150
PLAN ID: 80251UT0020012

CHILD ONLY PLAN
Not Applicable

Essential Plan Benefits – Option 3

FAMILY PLAN
Red PPO 85 Opt 3
85/90*/70/50/50 – $75/$225
PLAN ID: 80251UT0020016

CHILD ONLY ENHANCED PLAN
Red PPO 85 Opt 3
85/70/50/50 – $75/$225
PLAN ID: 80251UT0020009

CHILD ONLY PLAN
Red PPO 85 Opt 3
85/0/0/0 – $0/$0
PLAN ID: 80251UT0020007

FAMILY PLAN
Red PPO 70 Opt 3
70/90*/70/50/50 – $75/$225
PLAN ID: 80251UT0020015

CHILD ONLY ENHANCED PLAN
Red PPO 70 Opt 3
70/70/50/50 – $75/$225
PLAN ID: 80251UT0020010

CHILD ONLY PLAN
Red PPO 70 Opt 3
70/0/0/0 – $0/$0
PLAN ID: 80251UT0020008

FAMILY PLAN
Blue Co-Pay 70
Fixed Co-Pays – $25/$750
PLAN ID: 80251UT0020001

CHILD ONLY ENHANCED PLAN
Blue Co-Pay 70
Fixed Co-Pays – $25/$75
PLAN ID: 80251UT0020003

CHILD ONLY PLAN
Blue Co-Pay 70
Fixed Co-Pay/0/0/0 – $0/$0
PLAN ID: 80251UT0020005

*Preventive Age 19+
All 2016 Out-of-Pocket Maximum Amounts are $350/$700