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Family monthly premium Co-payment Family Deductible ln-network discount Out-of-network discount Individual coinsurance Out-of-pocket maxim um* Preventative services In I Out Network? individuai Family Plan 1

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Family monthly premium Co-payment Family Deductible" ln-network discount Out-of-network discount Individual coinsurance Out-of-pocket maxim um* Preventative services In I Out Network? individuai Family Plan 1 $250 $20 $4,000 15% 0% 20% $ 4,000 $ 8 .000 No cost to insured No copayment Network Discount Copayment 696999686969696969999991969696969699 Claim PostNetwork mammwwwmmmmmmmmaammm Discount Adult 1 Adult 2

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