Find claims for: John Doe Select a date range of no more than 3 months and click "Search". History is available for the past 24 months. From: JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember01020304050607080910111213141516171819202122232425262728293031200320022001 To: JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember01020304050607080910111213141516171819202122232425262728293031200320022001
Below are benefit plan highlights for: John Doe Please review your plan documents for full details, including exclusions, limitations and state mandates that might affect the benefits described below. DeductiblesIn-Network Out-of-Network Individual $2,000.00 $2,500.00 Family $4,000.00 $5,000.00 Member's Coinsurance Percents In-Network Out-of-Network Office Visit 20% 40% Specialist Office Visit 20% 40% Pharmacy ServicesGenericPreferred BrandNon-PreferredBrand Retail Copay (30 Day Supply)$10.00$30.00$ 50.00 Mail Order Copay (90 Day Supply)$20.00$60.00$100.00 Additional Benefits VisionView View medical benefit details.