Page 5 - Williams Gun Sight Benefits Booklet
P. 5
Williams Gunsight Major Medical Plans
BCN-BCBS
BCN HMO $2,500 BCBS PPO $3,000
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Service Benefit Service Benefit
$2,500 Single / $5,000 $3,000 Single / $6,000
Deductible Deductible
Family Family
Coinsurance 20% 20% - $2,500 embeded
Coinsurance
maximum
$6,350 Single / $12,700
Out of Pocket Maximum $6,850 Single / $13,700
Family Out of Pocket Maximum
Family
Primary Care Visit Copay $30
Primary Care Visit $30
Emergency Room Visit Deductible, then $250
Emergency Room $250
Urgent Care Copay $60
Urgent Care $60
Please note: These are brief descriptions. Read plan certificates for limitation, exclusions,
5
and plan specifics.
