Choice Plus Medical/Rx Plan

Network: International Network
Group/Policy #: 929343

*Plan design shown below are for services received through the International Provider Network.

• Deductible | $0
• Maximum Out of Pocket | $2,000 Individual ($6,000 Family)
• Primary Care Doctor | $0
• Specialist | $0
• Telemedicine | $0
• Urgent Care | $0
• Hospital | 10%
• X-Ray and Labs | $0
• Emergency Room | $0
• Prescription Drugs | Retail up to 31-day supply / Mail Order up to a 90-day supply
• Tier 1 | $20 Copay (Retail) / $50 Copay (Mail Order)
• Tier 2 | $40 Copay (Retail) / $100 (Mail Order)
• Tier 3 | $75 Copay (Retail) / $187.50 (Mail Order)

Dental PPO Plan

Network: International Network
Group/Policy #: 929343

*Plan design shown below are for services received through the International Provider Network.

• Deductible | $0 Single ($0 Family)
• Annual Maximum | $2,000 Per Person Per Calendar Year
• Preventive Care | 100%
• Basic Services | 80%
• Major Services | 80%
• Orthodontics | 50% – $2,000 Lifetime Benefit Per Person Per LIfetime

Vision PPO Plan

Network: International Network
Group/Policy #: 929343

*Plan design shown below are for services received through the International Provider Network.

• Vision Exam | $0 Copay
• Frames | $0 Copay; 30% Off balance over $130 allowance
• Lenses (Single, Bifocal, Trifocal, Lenticular) | $0 copay
• Contact Lenses (Formulary) | If you choose disposable contacts, up to 6 boxes are inlcuded when obtained from an in-network provider
• Contact Lenses (Non-Formulary) | $150 Copay
• Contact Lenses (Medically Necessary) | Paid-In-Full
• Frequency (Exams / Lenses / Frames) | 10%
• Orthodontics | 12 / 12 / 12 Months