| PLUS BENEFIT PLANS, WITHOUT DEDUCTIBLES | |||||||
| BPL# | BPL W/VISION | MEDICAL DEDUCTIBLE | PHYSICIAN OFFICE VISIT | IN & OUT PATIENT HOSPITALIZATION |
EMBERGENCY ROOM | URGENT CARE | OUT-OF-POCKET MAXIMUM |
| 95500 / 41000-12210 / JPL00100 | 95520 / 41020-12210 / JPL02500 | N/A | $10 | NONE | $50 | $25 | $1000/$2000 |
| 95501 / 41001-12210 / JPL00300 | 95521 / 41021-12210 / JPL02700 | N/A | $10 | 10% | $60 | $30 | $1000/$2000 |
| 95502 / 41002-21210 / JPL00500 | 95522 / 41022-21210 / JPL02900 | N/A | $15 | 10% | $60 | $30 | $1000/$2000 |
| 95503 / 41003-41410 / JPL00700 | 95523 / 41023-41410 / JPL03100 | N/A | $20 | 20% | $60 | $30 | $1500/$3000 |
| 95504 / 41004-51410 / JPL00900 | 95524 / 41024-51410 / JPL03300 | N/A | $20 | 20% | $100 | $50 | $2500/$5000 |
| 95506 / 41006-70510 / JPL01100 | 95526 / 41026-70510 / JPL03500 | 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 |
| 95511 / 41011-12210 / JPL01300 | 95531 / 41031-12210 / JPL03700 | $100/$200 | $10 | 10% | $60 | $30 | $1000/$2000 |
| 95512 / 41012-21210 / JPL01500 | 95532 / 41032-21210 / JPL03900 | $250/$500 | $15 | 10% | $60 | $30 | $1000/$2000 |
| 95513 / 41013-41410 / JPL01700 | 95533 / 41033-41410 / JPL04100 | $500/$1000 | $20 | 20% | $60 | $30 | $1500/$3000 |
| 95514 / 41014-51410 / JPL01900 | 95534 / 41034-51410 / JPL04300 | $750/$1500 | $20 | 20% | $100 | $50 | $2500/$5000 |
| 95515 / 41015-60410 / JPL02100 | 95535 / 41035-60410 / JPL04500 | $1000/$2000 | $20 | 20% | $100 | $50 | $2500/$5000 |
| 95516 / 41016-70510 / JPL02300 | 95536 / 41036-70510 / JPL04700 | $1500/$3000 | $25 | 30% | $100 | $50 | $3000/$6000 |