Prepared for CBT FinancialZip code 62660Eff date 1/2021


Plan
Metal
Network
Deductible
Coinsurance
Out of Pocket Mzx
Ambulance
Chiropractor
Durable Med Equip
Emergency Room
Hospital
Infertility
Lab & X-Ray
Office Visit
Specialist
Outpatient Surgery
Physical Therapy
Inpatient Psych
Outpatient Psych
Rx Tier 1
Rx Tier 2
Rx Tier 3
Rx Tier 4
Links
Chris
Christine
Denise
Kristie
Total