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Empire BCBS Prism - (EPO)
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Click here for the detailed
plan summary.
Option #:4
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| This policy is an EPO
(Exclusive Provider Organization) with no out of network
coverage & no referrals needed. With this plan there is
a primary & specialist office visit of $35. The Hospital
co-pay for this plan is $500 & a $100 co-pay for an
emergency room visits. The prescription coverage is
10/35/70 with a $100 deductible. |
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Monthly |
Monthly |
Quarterly |
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Small
Group |
Sole Proprietor |
Sole Proprietor |
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Employee |
$482.87 |
N/A |
N/A |
| Employee
+ One |
$965.74 |
N/A |
N/A |
| Employee + Child(ren) |
$869.16 |
N/A |
N/A |
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Family |
$1,448.61 |
N/A |
N/A |
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Plan Selection |
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Instructions |
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Application |
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Student Verification Form |
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