Personal ChoiceGroups 100+

Forms are in pdf format.

Option	PCP Copay
Personal Choice 5	$5
Personal Choice 5-15-70	$5
Personal Choice 10	$10
Personal Choice 210	$10
Personal Choice 310	$10
Personal Choice 10-20-70	$10
Personal Choice 15	$15
Personal Choice 15-25-70	$15
Personal Choice 20	$20
Personal Choice 320	$20
Personal Choice 20-30-70	$20
Flex PPO C1-F1-O1	$10
Flex PPO C1-F1-O2	$10
Flex PPO C1-F2-O1	$10
Flex PPO C1-F2-O2	$10
Flex PPO C1-F3-O1	$10
Flex PPO C1-F3-O2	$10
Flex PPO C1-F4-O1	$10
Flex PPO C1-F4-O2	$10
Flex PPO C2-F1-O1	$15
Flex PPO C2-F1-O2	$15
Flex PPO C2-F2-O1	$15
Flex PPO C2-F2-O2	$15
Flex PPO C2-F3-O1	$15
Flex PPO C2-F3-O2	$15
Flex PPO C2-F4-O1	$15
Flex PPO C2-F4-O2	$15
Flex PPO C3-F1-O1	$20
Flex PPO C3-F1-O2	$20
Flex PPO C3-F2-O1	$20
Flex PPO C3-F3-O2	$20
Flex PPO C3-F4-O1	$20
Flex PPO C3-F5-O2	$20
Flex PPO C4-F3-O1	$30
Flex PPO C4-F3-O2	$30
Flex PPO C4-F4-O1	$30
Flex PPO C4-F4-O2	$30
Flex PPO C4-F5-O2	$30
Personal Choice D1-N1	$20
Personal Choice D1-N2	$20
Personal Choice D2-N1	$20
Personal Choice D2-N2	$20
Personal Choice D3-N1	$20
Personal Choice D3-N2	$20
Personal Choice D4-N1	$20
Personal Choice D4-N2	$20
Personal Choice HDHP HD1-HC1 — Calendar Year	100%*
Personal Choice HDHP HD1-HC1 — Contract Year	100%*
Personal Choice HDHP HD1-HC2 — Calendar Year	80%*
Personal Choice HDHP HD1-HC2 — Contract Year	80%*
Personal Choice HDHP HD2-HC1 — Calendar Year	100%*
Personal Choice HDHP HD2-HC1 — Contract Year	100%*
Personal Choice HDHP HD2-HC2 — Calendar Year	80%*
Personal Choice HDHP HD2-HC2 — Contract Year	80%*
Personal Choice HDHP HD3-HC1 — Calendar Year	100%*
Personal Choice HDHP HD3-HC1 — Contract Year	100%*
Personal Choice HDHP HD3-HC2 — Calendar Year	80%*
Personal Choice HDHP HD3-HC2 — Contract Year	80%*
Personal Choice HDHP HD4-HC1 — Calendar Year	100%*
Personal Choice HDHP HD4-HC1 — Contract Year	100%*
Personal Choice HDHP HD4-HC2 — Calendar Year	80%*
Personal Choice HDHP HD4-HC2 — Contract Year	80%*

*after deductible