Common use of MEDICAL PLAN SELECTION Clause in Contracts

MEDICAL PLAN SELECTION. PPO and HMO Network Plans: Select PPO and Select HMO Network Plans: PPO 10/0/10% PPO 20/500/20% PPO HRA 45/5000/10% Select PPO 10/0/10% Select PPO 20/500/20% Select PPO 25/500/30% Select PPO 25/500/30% RxV Select PPO 35/1000/40% Select PPO 40/1800/40% Select PPO 40/1800/40% RxV Select PPO 45/1500/50% Select PPO 45/5000/10% Saver Select PPO HRA 45/5000/10% PPO HSA 1350/50% PPO HSA 1750/30%RxC PPO HSA 2700/20%/RxC PPO HSA 3500/30%/RxC PPO HSA 4500/20%/RxC PPO HSA 5500/0%/RxC HMO 10/0% HMO 35/20% Select PPO HSA 1350/50% Select PPO HSA 1750/30%/RxC Select PPO HSA 2700/20%/RxC Select PPO HSA 3500/30%/RxC Select PPO HSA 4500/20%/RxC Select PPO HSA 5500/0%/RxC Select HMO 10/0% Select HMO 35/20% PPO 25/500/30% PPO 25/500/30% RxV PPO 35/1000/40% PPO 40/1800/40% PPO 40/1800/40% RxV PPO 45/1500/50% PPO 45/5000/10% Saver Were Employees of the employer covered by any other group health plan during the last 60 days? □ No □ Yes - Name of Provider (Carrier, HMO, MEWA, etc.): Policy #: Date of Termination:

MEDICAL PLAN SELECTION. PPO and HMO Network Plans: Select PPO and Select HMO Network Plans: PPO 10/0/10% PPO 20/500/2010/250/10% PPO HRA 45/5000/1045/1000/10% Select PPO 10/0/1010/250/10% Select PPO 20/500/20HRA 45/1000/10% PPO 15/500/20% PPO HSA 1700/30%RxC Select PPO 15/500/20% Select PPO HSA 1700/30%/RxC PPO 25/500/30% PPO HSA 2600/20%/RxC Select PPO 25/500/30% Select PPO HSA 2600/20%/RxC PPO 25/500/30% RxV PPO HSA 3500/30%/RxC Select PPO 25/500/30% RxV Select PPO HSA 3500/30%/RxC PPO 35/1000/40% PPO HSA 4500/20%/RxC Select PPO 35/1000/40% Select PPO 40/1800/40HSA 4500/20%/RxC PPO 40/1500/40% PPO HSA 5500/0%/RxC Select PPO 40/1500/40% Select PPO 40/1800/40HSA 5500/0%/RxC PPO 40/1500/40% RxV HMO 10/0% Select PPO 40/1500/40% RxV Select HMO 10/0% PPO 45/1500/50% Select PPO 45/5000/10% Saver Select PPO HRA 45/5000/10% PPO HSA 1350/50% PPO HSA 1750/30%RxC PPO HSA 2700/20%/RxC PPO HSA 3500/30%/RxC PPO HSA 4500/20%/RxC PPO HSA 5500/0%/RxC HMO 10/0% HMO 35/20% Select PPO HSA 1350/50% Select PPO HSA 1750/30%/RxC Select PPO HSA 2700/20%/RxC Select PPO HSA 3500/30%/RxC Select PPO HSA 4500/20%/RxC Select PPO HSA 5500/0%/RxC Select HMO 10/045/1500/50% Select HMO 35/20% PPO 25/500/3045/5000/10% PPO 25/500/30% RxV PPO 35/1000/40% PPO 40/1800/40% PPO 40/1800/40% RxV PPO 45/1500/50% Saver Select PPO 45/5000/10% Saver Were Employees of the employer covered by any other group health plan during the last 60 days? □ No □ Yes - Name of Provider (Carrier, HMO, MEWA, etc.): Policy #: Date of Termination:

MEDICAL PLAN SELECTION. PPO and HMO Network Plans: Select PPO and Select HMO Network Plans: PPO 10/0/10% PPO 20/500/20% PPO HRA 45/5000/1045/1000/10% Select PPO 10/0/10% Select PPO 20/500/20HRA 45/1000/10% PPO 20/500/25% PPO HSA 1300/50% Select PPO 20/500/25% Select PPO HSA 1300/50% PPO 25/500/30% PPO HSA 1700/30%RxC Select PPO 25/500/30% Select PPO HSA 1700/30%/RxC PPO 25/500/30% RxV PPO HSA 2600/20%/RxC Select PPO 25/500/30% RxV Select PPO HSA 2600/20%/RxC PPO 35/1000/40% PPO HSA 3500/30%/RxC Select PPO 35/1000/40% Select PPO 40/1800/40HSA 3500/30%/RxC PPO 40/1500/40% PPO HSA 4500/20%/RxC Select PPO 40/1500/40% Select PPO 40/1800/40HSA 4500/20%/RxC PPO 40/1500/40% RxV PPO HSA 5500/0%/RxC Select PPO 40/1500/40% RxV Select PPO HSA 5500/0%/RxC PPO 45/1500/50% HMO 10/0% Select PPO 45/1500/50% Select HMO 10/0% PPO 45/5000/10% Saver HMO 35/20% Select PPO 45/5000/10% Saver Select PPO HRA 45/5000/10% PPO HSA 1350/50% PPO HSA 1750/30%RxC PPO HSA 2700/20%/RxC PPO HSA 3500/30%/RxC PPO HSA 4500/20%/RxC PPO HSA 5500/0%/RxC HMO 10/0% HMO 35/20% Select PPO HSA 1350/50% Select PPO HSA 1750/30%/RxC Select PPO HSA 2700/20%/RxC Select PPO HSA 3500/30%/RxC Select PPO HSA 4500/20%/RxC Select PPO HSA 5500/0%/RxC Select HMO 10/0% Select HMO 35/20% PPO 25/500/30% PPO 25/500/30% RxV PPO 35/1000/40% PPO 40/1800/40% PPO 40/1800/40% RxV PPO 45/1500/50% PPO 45/5000/10% Saver Were Employees of the employer covered by any other group health plan during the last 60 days? □ No □ Yes - Name of Provider (Carrier, HMO, MEWA, etc.): Policy #: Date of Termination: