2010 General Exclusions and Limitations HMO Plans 0HY201YY: Copay $20, Coins 20% 0HYB2051: Copay $20, $500D 0HYB2052: Copay $20, $500D, Coins 20% 0HYB2053: Copay $20, $1,000D, Coins 20% 0HYB3551: Copay $35, $500D, Coins 20% 0HYB3581: Copay $35, $1,500D, Coins 20% HMO Two-Tier Plans 0H20HY5C: Copay $20/$40, $500D 0H20HY1C: Copay $20/$40, $1,000D 0H35HY5C: Copay $35/$70, $500D 0H35HY1C: Copay $35/$70, $1,000D
HMO Plans
0HY201YY: Copay $20, Coins 20%
0HYB2051: Copay $20, $500D
0HYB2052: Copay $20, $500D, Coins 20%
0HYB2053: Copay $20, $1,000D, Coins 20%
0HYB3551: Copay $35, $500D, Coins 20%
0HYB3581: Copay $35, $1,500D, Coins 20%
HMO Two-Tier Plans
0H20HY5C: Copay $20/$40, $500D
0H20HY1C: Copay $20/$40, $1,000D
0H35HY5C: Copay $35/$70, $500D
0H35HY1C: Copay $35/$70, $1,000D
The schedules of benefits are in PDF format and require Adobe Acrobat Reader to view and print.
2010 Dependent Eligibility Q & A
Other Dependent Eligibility Info
