|
with the standard network (Accord)
|
|
Tobacco free — including substance abuse coverage
|
|
Coinsurance
|
80/20%
|
100/0%
|
|
Deductible
| $1,300
| $2,000
| $2,500
| $3,500
| $4,500
| $5,800
|
| Individual
| $510.00
| $416.00
| $471.50
| $387.50
| $351.50
| $316.00
|
|
Tobacco free — without substance abuse coverage
|
|
Coinsurance
|
80/20%
|
100/0%
|
|
Deductible
| $1,300
| $2,000
| $2,500
| $3,500
| $4,500
| $5,800
|
| Individual
| $495.00
| $403.50
| $458.00
| $376.50
| $341.50
| $306.50
|
|
Tobacco user — including substance abuse coverage
|
|
Coinsurance
|
80/20%
|
100/0%
|
|
Deductible
| $1,300
| $2,000
| $2,500
| $3,500
| $4,500
| $5,800
|
| Individual
| $663.00
| $540.50
| $613.00
| $504.00
| $457.00
| $410.50
|
|
Tobacco user — without substance abuse coverage
|
|
Coinsurance
|
80/20%
|
100/0%
|
|
Deductible
| $1,300
| $2,000
| $2,500
| $3,500
| $4,500
| $5,800
|
| Individual
| $643.50
| $524.50
| $595.00
| $489.00
| $444.00
| $398.50
|
|
|
|
with the expanded network (Aware)
|
|
Tobacco free — including substance abuse coverage
|
|
Coinsurance
|
80/20%
|
100/0%
|
|
Deductible
| $1,300
| $2,000
| $2,500
| $3,500
| $4,500
| $5,800
|
| Individual
| $545.50
| $445.00
| $504.50
| $414.50
| $376.50
| $338.00
|
|
Tobacco free — without substance abuse coverage
|
|
Coinsurance
|
80/20%
|
100/0%
|
|
Deductible
| $1,300
| $2,000
| $2,500
| $3,500
| $4,500
| $5,800
|
| Individual
| $663.00
| $540.50
| $613.00
| $504.00
| $457.00
| $410.50
|
|
Tobacco user — including substance abuse coverage
|
|
Coinsurance
|
80/20%
|
100/0%
|
|
Deductible
| $1,300
| $2,000
| $2,500
| $3,500
| $4,500
| $5,800
|
| Individual
| $709.50
| $578.50
| $656.00
| $539.00
| $489.00
| $439.50
|
|
Tobacco user — without substance abuse coverage
|
|
Coinsurance
|
80/20%
|
100/0%
|
|
Deductible
| $1,300
| $2,000
| $2,500
| $3,500
| $4,500
| $5,800
|
| Individual
| $688.50
| $561.50
| $636.50
| $523.50
| $475.00
| $426.50
|
|