Personal Choice — Groups 2–50IBC Forms Online — Benefit Summaries

These summaries include medical benefits only, but have been named so that you can reference the appropriate corresponding drug and vision benefit summaries.

PDF icon Forms are in pdf format.

Option PCP Copay Last Updated
PPO 1.1 Rx $10/$40/$70 Vision $100 $10 2012-03
PPO 2.1 Rx $10/$40/$70 Vision $100 $15 2012-03
PPO 3.1 Rx $10/$40/$70 Vision $100 $20 2012-03
PPO 4.1 Rx $10/$45/$75 Vision $100 $30 2012-03
PPO 5.1 Rx $10/$45/$75 Vision $100 $30 2012-03
PPO 6 Rx $7/50%/$125 Vision $100 - HCR $40 2012-03
PPO 7.1 Rx $250/$10/$45/$75 Vision $100 $20 2012-03
PPO 7 Rx $10/$45/$75 Vision $100 $20 2012-03
PPO 8.1 Rx $250/$10/$45/$75 Vision $100 $80 2012-03
PPO 8 Rx $10/$45/$75 Vision $100 $30 2012-03
Personal Choice HDHP 1 Rx $20/$40/$60 Vision $100 Contract yr. - HCR 100%* 2012-03
Personal Choice HDHP 2 Rx $20/$40/$60 Vision $100 Contract yr. - HCR 100%* 2012-03
Personal Choice HDHP 3 Rx $20/$40/$60 Vision $100 Contract yr. - HCR 100%* 2012-03
Personal Choice HDHP 4 Rx $20/$40/$60 Vision $100 Contract yr. - HCR 100%* 2012-03
Personal Choice HDHP 5 Rx $20/$40/$60 Vision $100 Contract yr. - HCR 100%* 2012-03
PPO 1 Rx $10/$20/$35 Vision $100 - HCR $10 2012-03
PPO 2 Rx $10/$20/$35 Vision $100 - HCR $15 2012-03
PPO 3 Rx $10/$20/$35 Vision $100 - HCR $20 2012-03
PPO 4 Rx $7/$50/$125 Vision $100 - HCR $30 2012-03
PPO 5 Rx $10/$20/$35 Vision $100 - HCR $30 2012-03
PPO 6 Rx $10/$20/$35 Vision $100 - HCR $40 2012-03
*after deductible