
Tier 1 Cash Card 100% to $4,000
Tier 2 Virtual Primary Care 100%
Tier 3 * Deductible $8,000
Tier 4 Plan Pays 100%
□ Plan Allowed Amount is based on Reference Based Pricing metrics.
□ Rx limited to $640 for a 30-day supply.
□ All specialty & facility care must be pre-certified
□ Plan is excess coverage to IRC501r
□ Plan members participate in year-end plan surplus
□ * Compassionate Care Plan™ option for those plan members who qualify
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