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2024 Benefit Summary Comparison Chart
RF Self-Service
Description | RF Traditional PPO (Empire BlueCross Blue Shield) |
RF Deductible PPO |
---|---|---|
Co-Pay | $20.00 | $30 |
In-Network Deductible | None | $500 Individual / $1,250 Family |
In-Network Co-Insurance | None | 90/10 coinsurance |
Out of Network Deductible | Yes ($1000 Individual/ $2500 Family deductible) |
Yes ($1500 Individual/ $3750 Family deductible) |
Out of Network Co-Insurance | 80/20 coinsurance | 40/60 coinsurance |
Preventive Care | $0 (up to $300 gym reimbursement) |
$0 (up to $300 gym reimbursement) |
Hospital | $100 | Deductible and Coinsurance |
ER Visit | $50 | $50 |
Lab or X-rays | $20 | Deductible and Coinsurance |
Prescriptions | $10/$25/$45 | $10/$25/$45 |
Annual Out of Pocket Limit
COVERAGE TYPE |
RF Traditional PPO (Empire BlueCross Blue Shield) |
RF Deductible PPO |
|
In Network |
Individual Coverage | $4,224 | $1,500 |
Family Coverage | $10,560 | $3,750 | |
Out of Network |
Individual Coverage | $4,000 | $5,500 |
Family Coverage | $10,000 | $13,750 |
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