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MANUAL ENTRY INSTRUCTIONS |
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Switch to: |
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Fill in the coverage details for one plan in the orange cells using numbers only. |
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If the category is not covered or included in the plan, leave the cell blank. |
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Click the 'Run the Calculator' button to compute the cost sharing for the scenarios. |
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Selection |
$ OR % |
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COST SHARING |
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Durable Medical Equipment |
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No Cost Sharing
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Generic Prescriptions |
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Copayment
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$10 |
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Hospital Care, Inpatient & Anesthesia |
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Coinsurance
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30% |
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Laboratory |
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No Cost Sharing
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Radiology (Ultrasound) |
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Coinsurance
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30% |
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Routine Obstetric Care (Bundled) |
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Copayment
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$40 |
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Vaccine & Preventive |
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No Cost Sharing
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Visits & Procedures |
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Copayment
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$40 |
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Individual Out-of-Pocket (OOP) Limit |
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DEDUCTIBLES |
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Overall Plan Deductible |
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$1,000 |
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Durable Medical Equipment |
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Generic RX |
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$100 |
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Hospital Care, Inpatient & Anesthesia |
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Routine Obstetric Care (Bundled) |
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Vaccine & Preventive |
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LIMITS |
MATERNITY |
Generic Prescriptions # Limit Per Month |
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Generic Prescriptions # Limit Per Year |
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DIABETES |
Generic Prescriptions # Limit Per Month |
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Generic Prescriptions # Limit Per Year |
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Durable Medical Equipment # Limit Per Month |
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Durable Medical Equipment # Limit Per Year |
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Visits & Procedures # Limit Per Year |
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