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Enter between one and three network tiers per benefit plan, one at a time. Start by entering the details of your benefit design here:

Basic Information

Your Email Address

Client Name

Plan Name

Network Tier Name

Average Claims PMPM

Best guess of the plan's metal level

% Enrolled in Employee Only

$450

75%

Enter a valid name

Employer-Funded Accounts

Is there an HRA, an HSA, or neither?

What is the value of the EE Only account?

How much does the employee have to spend until the HRA begins?

$500

$0

Enter a valid email

Deductible

Are medical and Rx separate or integrated?

Is the deductible embedded or non-embedded?

Out-of-Pocket Maximum (OOPM)

Employee Only

Integrated

Medical

$1,000

$500

Rx

$1,000

$2,000

$3,000

$2,000

Rx

Medical

Family

$2,000

Coverage by Type of Service

Subject to deductible?

Set All To:

Subject to coinsurance?

Plan Coinsurance

(Enter % as Whole Number)

%

Copay, if separate

Medical

%

$

Emergency Room Services

All IP Hospital Services (incl. MH/SUD)

PCP Visit (excl. Preventive and X-rays)

Specialist Visit

MH/SUD Outpatient Services

Imaging (CT/PET Scans, MRIs)

Occupational and Physical Therapy

Laboratory Services

X-rays and Diagnostic Imaging

Outpatient Facility Fees

Outpatient Surgery

Prescription Drugs

%

$

Generics

Preferred Brand

Non-Preferred Brand

Specialty Drugs

Actuarial Value:

AV

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