| PLUS BENEFIT PLANS WITH CHIRO, WITHOUT DEDUCTIBLES | |||||||
| BPL# | BPL W/VISION | MEDICAL DEDUCTIBLE | PHYSICIAN OFFICE VISIT | IN & OUT PATIENT HOSPITALIZATION |
EMBERGENCY ROOM | URGENT CARE | OUT-OF-POCKET MAXIMUM |
| 95540 / 41000-12211 / JPL00200 | 95560 / 41020-12211 / JPL02600 | N/A | $10 | NONE | $50 | $25 | $1000/$2000 |
| 95541 / 41001-12211 / JPL00400 | 95561 / 41021-12211 / JPL02800 | N/A | $10 | 10% | $60 | $30 | $1000/$2000 |
| 95542 / 41002-21211 / JPL00600 | 95562 / 41022-21211 / JPL03000 | N/A | $15 | 10% | $60 | $30 | $1000/$2000 |
| 95543 / 41003-41411 / JPL00800 | 95563 / 41023-41411 / JPL03200 | N/A | $20 | 20% | $60 | $30 | $1500/$3000 |
| 95544 / 41004-51411 / JPL01000 | 95564 / 41024-51411 / JPL03400 | N/A | $20 | 20% | $100 | $50 | $2500/$5000 |
| 95546 / 41006-70511 / JPL01200 | 95566 / 41026-70511 / JPL03600 | N/A | $25 | 30% | $100 | $50 | $3000/$6000 |
| PLUS BENEFIT PLANS WITH CHIRO, WITH MEDICAL DEDUCTIBLES | |||||||
| BPL# | BPL W/VISION | MEDICAL DEDUCTIBLE | PHYSICIAN OFFICE VISIT | IN & OUT PATIENT HOSPITALIZATION |
EMBERGENCY ROOM | URGENT CARE | OUT-OF-POCKET MAXIMUM |
| 95551 / 41011-12211 / JPL01400 | 95571 / 41031-12211 / JPL03800 | $100/$200 | $10 | 10% | $60 | $30 | $1000/$2000 |
| 95552 / 41012-21211 / JPL01600 | 95572 / 41032-21211 / JPL04000 | $250/$500 | $15 | 10% | $60 | $30 | $1000/$2000 |
| 95553 / 41013-41411 / JPL01800 | 95573 / 41033-41411 / JPL04200 | $500/$1000 | $20 | 20% | $60 | $30 | $1500/$3000 |
| 95554 / 41014-51411 / JPL02000 | 95574 / 41034-51411 / JPL04400 | $750/$1500 | $20 | 20% | $100 | $50 | $2500/$5000 |
| 95555 / 41015-60411 / JPL02200 | 95575 / 41035-60411 / JPL04600 | $1000/$2000 | $20 | 20% | $100 | $50 | $2500/$5000 |
| 95556 / 41016-70511 / JPL02400 | 95576 / 41036-70511 / JPL04800 | $1500/$3000 | $25 | 30% | $100 | $50 | $3000/$6000 |