Level
| Office Visit Copay
| ER Copay
| Hospital Copay
| Spinal Manipulation Coverage
| Pediatric Dental Coverage
| Product Sheet
|
|---|---|---|---|---|---|---|
$10 |
$50 |
None |
Yes |
No |
||
$15 |
$50 |
$250 |
Yes |
No |
||
$20 |
$75 |
$500 |
Yes |
No |
||
$25 |
$75 |
$600 |
Yes |
No |
||
$35 |
$100 |
$1,000 |
Yes |
No |
||
$50 |
$200 |
$1,000 |
Yes |
No |
||
$20 |
$100 |
Covered in full after $1,000 deductible |
Yes |
No |
||
$20 |
$100 |
Covered in full after $1,500 deductible |
Yes |
No |
||
$20 |
$100 |
Covered in full after $2,000 deductible |
Yes |
No |
||
$20 |
Covered in full after $1,500 deductible |
Covered in full after $1,500 deductible |
Yes |
No |
||
$25 |
Covered in full after $2,000 deductible |
Covered in full after $2,000 deductible |
Yes |
No |