{"text_format":"1","workbook":"xlsx","n_sheets":16,"sheets":["Cover Page","HIPAA Notice","Page 1","Pg 2 - Grp Size & Participa","Page 3 - Plan Info","Plan Info Lookups","Page 4 - Rates Insured","Page 4 - Rates ASO","Page 4 - Rates Minimum Premium","Page 5 - Agent-Signature pg","Page 6 - Reports (Internal)","Page 7 - ESA Agreement ","Nondiscrimination_Taglines","Page 8 - Acct Structure ","RX_ELIGIBILITY_LG_DROPDOWN (2)","Checklist"],"not_rendered":{"charts":0,"images":7,"macros":1,"external_links":1,"defined_names":47,"comments":6,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Cover Page","index":0,"n_rows":39,"n_cols":8,"rows_kept":39,"cut":false,"hidden":false,"merged":[[2,0,2,9],[3,0,3,9],[38,7,38,8],[38,0,38,6]]}
[]
[]
["Welcome"]
["Thank you for choosing Moda Health and Delta Dental."]
[]
[]
["New Group Enrollment Checklist for Employers and Agents"]
[]
["Please forward the following to Moda Health and Delta Dental, Attn Sales and Account Services Department:"]
[]
[]
[null,"(include hire dates on all enrollment forms)"]
[]
[]
[]
[]
[]
[]
["Enrollment Process Timeline:"]
["All new group information must be received by Moda to initiate the enrollment process.  Submission of"]
["paperwork should be completed by the 20th of the month, prior to the effective date, in order for members to"]
["receive ID cards in a timely manner.  For new group information received after the 20th, Moda Health may"]
["require up to 10 business days to complete the enrollment process.  Member handbooks and ID cards are"]
["mailed from Portland, Oregon.  Variation in mailing schedules can affect the arrival of these materials."]
[]
["Sending Paperwork to Moda:"]
["All new group information should be sent to the Moda Alaska Sales and Account Services Team:"]
[]
[null,null,null,null,"Moda Health and Delta Dental"]
[null,null,null,null,"Attn: Sales and Account Services"]
[null,null,null,null,"510 L St. Suite 270"]
[null,null,null,null,"Anchorage, AK 99501"]
[null,null,null,null,"907-278-2626 or toll free 1-888-374-8910"]
[null,null,null,null,"907-278-2900 fax"]
[]
["Member Handbooks"]
["We encourage our members to view their handbooks from their myModa account at www.modahealth.com",null,null,null,null,null,null,"www.modahealth.com/mymoda"]
[]
["How many printed Moda member handbooks would you like?"]

{"sheet":"HIPAA Notice","index":1,"n_rows":0,"n_cols":0,"rows_kept":0,"cut":false,"hidden":true,"merged":[]}

{"sheet":"Page 1","index":2,"n_rows":56,"n_cols":29,"rows_kept":56,"cut":false,"hidden":false,"merged":[[10,0,10,2],[16,11,16,13],[30,1,30,13],[19,11,19,13],[19,3,19,8],[13,3,13,8],[14,3,14,8],[17,11,17,13],[14,9,14,10],[13,9,13,10],[17,9,17,10],[17,3,17,8],[45,16,45,17],[39,8,39,13],[20,3,20,8],[40,9,40,10],[40,11,40,13],[40,5,40,7],[20,11,20,13],[4,3,4,4],[6,3,6,6],[55,4,55,13],[48,12,48,13],[52,12,52,13],[48,8,48,9],[18,3,18,8],[36,4,36,5],[9,3,9,12],[10,3,10,12],[33,6,33,13],[18,11,18,13],[31,1,31,11],[9,0,9,2],[16,3,16,8],[32,1,32,11]]}
[null,null,null,null,null,null,null,"ALASKA Large Employer Group Application (51+)",null,null,null,null,null,null,null,null,null,null,null,null,null,30,2]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,60,3]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,90,4]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,120,5]
[null,null,"EFFECTIVE DATE:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,150,6]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,180,7]
[null,null,"TYPE:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,210,8]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,240,9]
["GROUP INFORMATION:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,270,10]
["Legal Name:"]
["Billing Name:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,30,60,90,120,150,180,210,240,270]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2014-01-01","2013-12-01","2013-11-01","2013-10-01","2013-09-01","2013-08-01","2013-07-01","2013-06-01","2013-05-01","2013-04-01"]
[null,null,"Street Address:",null,null,null,null,null,null,"City_________",null,"State__________","Zip",null,null,null,null,{"$f":"LEFT(N14,3)","v":""},null,"2014-02-01","2014-01-01","2013-12-01","2013-11-01","2013-10-01","2013-09-01","2013-08-01","2013-07-01","2013-06-01","2013-05-01"]
[null,null,"Billing Address:",null,null,null,null,null,null,"City_________",null,"State__________","Zip",null,null,null,null,{"$f":"LEFT(N15,3)","v":""},null,"2014-03-01","2014-02-01","2014-01-01","2013-12-01","2013-11-01","2013-10-01","2013-09-01","2013-08-01","2013-07-01","2013-06-01"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2014-04-01","2014-03-01","2014-02-01","2014-01-01","2013-12-01","2013-11-01","2013-10-01","2013-09-01","2013-08-01","2013-07-01"]
[null,null,"Group Administrator:",null,null,null,null,null,null,null,"Billing Contact:",null,null,null,null,null,null,null,null,"2014-05-01","2014-04-01","2014-03-01","2014-02-01","2014-01-01","2013-12-01","2013-11-01","2013-10-01","2013-09-01","2013-08-01"]
[null,null,"Phone #:",null,null,null,null,null,null,"Phone #:",null,null,null,null,null,null,null,null,null,"2014-06-01","2014-05-01","2014-04-01","2014-03-01","2014-02-01","2014-01-01","2013-12-01","2013-11-01","2013-10-01","2013-09-01"]
[null,null,"Fax #:",null,null,null,null,null,null,null,"Fax #:",null,null,null,null,null,null,null,null,"2014-07-01","2014-06-01","2014-05-01","2014-04-01","2014-03-01","2014-02-01","2014-01-01","2013-12-01","2013-11-01","2013-10-01"]
[null,null,"E-mail Address:",null,null,null,null,null,null,null,"E-mail Address:",null,null,null,null,null,null,null,null,"2014-08-01","2014-07-01","2014-06-01","2014-05-01","2014-04-01","2014-03-01","2014-02-01","2014-01-01","2013-12-01","2013-11-01"]
[null,null,"Tax ID #:",null,null,null,null,null,null,null,"ERISA Plan #:",null,null,null,null,null,null,null,null,"2014-09-01","2014-08-01","2014-07-01","2014-06-01","2014-05-01","2014-04-01","2014-03-01","2014-02-01","2014-01-01","2013-12-01"]
[null,null,"Renewal Date:",null,null,null,null,null,null,null,"Advance Renewal Notice (days):",null,null,null,null,null,null,null,null,"2014-10-01","2014-09-01","2014-08-01","2014-07-01","2014-06-01","2014-05-01","2014-04-01","2014-03-01","2014-02-01","2014-01-01"]
[null,null,"NotificationMonth/Year:",{"$f":"IF(D22=\"\",\"\",IF(L22=\"\",\"\",((DATE(YEAR(D22),MONTH(D22),DAY(D22))-L22))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2014-11-01","2014-10-01","2014-09-01","2014-08-01","2014-07-01","2014-06-01","2014-05-01","2014-04-01","2014-03-01","2014-02-01"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2014-12-01","2014-11-01","2014-10-01","2014-09-01","2014-08-01","2014-07-01","2014-06-01","2014-05-01","2014-04-01","2014-03-01"]
["ELIGIBILITY:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2015-01-01","2014-12-01","2014-11-01","2014-10-01","2014-09-01","2014-08-01","2014-07-01","2014-06-01","2014-05-01","2014-04-01"]
["1.","What percentage of the medical premium is to be contributed by the employer?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2015-02-01","2015-01-01","2014-12-01","2014-11-01","2014-10-01","2014-09-01","2014-08-01","2014-07-01","2014-06-01","2014-05-01"]
[null,null,null,null,null,null,null,null,null,"For employees:",null,null,"For dependents:",null,null,null,null,null,null,"2015-03-01","2015-02-01","2015-01-01","2014-12-01","2014-11-01","2014-10-01","2014-09-01","2014-08-01","2014-07-01","2014-06-01"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2015-04-01","2015-03-01","2015-02-01","2015-01-01","2014-12-01","2014-11-01","2014-10-01","2014-09-01","2014-08-01","2014-07-01"]
["2.","What percentage of the dental premium is to be contributed by the employer?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2015-05-01","2015-04-01","2015-03-01","2015-02-01","2015-01-01","2014-12-01","2014-11-01","2014-10-01","2014-09-01","2014-08-01"]
[null,null,null,null,null,null,null,null,null,"For employees (minimum 50%):",null,null,"For dependents:",null,null,null,null,null,null,"2015-06-01","2015-05-01","2015-04-01","2015-03-01","2015-02-01","2015-01-01","2014-12-01","2014-11-01","2014-10-01","2014-09-01"]
["3.","Will the plan be integrated or standalone – specifically – Integrated is when all plans are purchased/bundled together and an employee and their family cannot waive. ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2015-07-01","2015-06-01","2015-05-01","2015-04-01","2015-03-01","2015-02-01","2015-01-01","2014-12-01","2014-11-01","2014-10-01"]
["3a.","For the dental plan – is this integrated with the medical plan? Y/N (regardless if Moda is the medical carrier)",null,null,null,null,null,null,null,null,null,null,"(Y/N):",null,null,null,null,null,null,"2015-08-01","2015-07-01","2015-06-01","2015-05-01","2015-04-01","2015-03-01","2015-02-01","2015-01-01","2014-12-01","2014-11-01"]
["3b.","For the vision plan – is the vision plan integrated with the medical plan? Y/N (regardless if Moda is the medical carrier)",null,null,null,null,null,null,null,null,null,null,"(Y/N):",null,null,null,null,null,null,"2015-09-01","2015-08-01","2015-07-01","2015-06-01","2015-05-01","2015-04-01","2015-03-01","2015-02-01","2015-01-01","2014-12-01"]
[null,null,null,null,null,null,"(Yes = Integrated; No = Standalone)",null,null,null,null,null,null,null,null,null,null,null,null,"2015-10-01","2015-09-01","2015-08-01","2015-07-01","2015-06-01","2015-05-01","2015-04-01","2015-03-01","2015-02-01","2015-01-01"]
["4.","How many hours per week must an employee work to be eligible for benefits? ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2015-11-01","2015-10-01","2015-09-01","2015-08-01","2015-07-01","2015-06-01","2015-05-01","2015-04-01","2015-03-01","2015-02-01"]
[null,null,null,null,null,null,null,null,null,null,null,null,"(minimum 20 per week):",null,null,null,null,null,null,"2015-12-01","2015-11-01","2015-10-01","2015-09-01","2015-08-01","2015-07-01","2015-06-01","2015-05-01","2015-04-01","2015-03-01"]
["5.","Dependent age maximum:",null,null,null,null,null,null,null,"Student age maximum:",null,null,"Verified by:"]
[]
["6.","What is the eligibility period an employee must complete before becoming eligible for benefits?   "]
[null,null,null,null,null,null,null,"The first of the month following:"]
[null,null,null,"Apply to all employees?","(Y/N):",null,null,null,null,"  If no, describe:"]
["6b.","Will the group elect a one month orientation period in addition to their probationary period?",null,null,null,null,null,null,null,null,null,null,"(Y/N):"]
["7.","When do changes made during open enrollment become effective?",null,null,null,null,null,null,null,null,"At renewal?",null,"or date:"]
[]
["8.","Is the group subject to ERISA (Employee Retirement Income Security Act of 1974)? ",null,null,null,null,null,null,null,null,null,null,"(Y/N):"]
["9.     Is Domestic Partner coverage available?  ",null,null,null,null,null,null,null,null,null,null,null,"(Y/N):"]
[]
["10.","Does the group have a bargaining agreement (Union) in force?",null,null,null,null,null,null,null,null,null,null,"(Y/N):"]
[null,null,null,null,null,null,null,"If yes, effective date:",null,null,null,"Expiration date:"]
[]
["11.","Does the group represent or belong to an association or trust?   ",null,null,null,null,null,null,null,null,null,null,"(Y/N):"]
[null,"If yes, provide the date filed with the State as a group policyholder and the approval number:"]
[null,null,null,null,null,null,null,null,"Date:",null,null,"Approval #:"]
["12.","Will out of state employees be covered by Moda Health/Delta Dental?:",null,null,null,null,null,null,null,null,null,null,"(Y/N):"]
[null,"Employees who reside in the state of Hawaii are not eligible to enroll for medical coverage."]
[null,null,null,"If yes, which state(s)?:"]

{"sheet":"Pg 2 - Grp Size & Participa","index":3,"n_rows":67,"n_cols":15,"rows_kept":67,"cut":false,"hidden":false,"merged":[[40,0,40,9],[41,0,41,9],[54,0,54,11],[56,10,57,10],[56,11,57,11],[52,11,53,11],[63,0,63,11],[42,0,42,9],[43,0,45,9],[43,10,45,10],[52,0,52,9],[52,10,53,10],[60,0,60,11],[18,0,18,9],[18,10,21,10],[19,0,19,9],[20,0,20,9],[38,11,39,11],[39,0,39,9],[38,0,38,9],[32,11,33,11],[34,0,35,9],[34,10,37,10],[34,11,37,11],[36,0,36,9],[37,0,37,9],[38,10,39,10],[32,0,33,9],[32,10,33,10],[21,0,21,9],[27,11,31,11],[28,0,28,9],[29,0,29,9],[30,0,30,9],[27,10,31,10],[22,10,24,10],[23,0,23,9],[24,0,24,9],[16,0,16,9],[16,10,17,10],[17,0,17,9],[10,0,10,9],[2,0,2,11],[5,0,5,11],[7,0,7,9],[8,0,8,9],[9,0,9,9],[3,0,3,11],[4,0,4,9],[4,10,4,11],[11,0,11,9],[11,10,12,10],[12,0,12,9]]}
[]
["ALASKA STANDARDIZED GROUP PROFILE FORM"]
["This form must be completed for all new and renewing groups to determine whether a group qualifies as a large employer. Moda Health must treat an employer as a large employer if the employer has a least 51 employees on average during the preceding calendar year and has at least one employee enrolled on the first day of the plan year."]
["Controlled and Affiliated Groups:"]
["Are you a Controlled Group?"]
["If you are a controlled or affiliated group of employers as described under subsection (b), (c), (m) or (o) of section 414 of the Internal Revenue Code of 1986, Moda Health must treat all employees within the affiliated group as a single group for purposes of determining group size. You must fill out one group profile form for the entire controlled group. If a controlled group is determined as a large employer, each affiliated employer is part of the large employer even if separately the employer would not meet the definition of a large employer. Therefore, each affiliated employer is considered a large group for the purposes of group determination.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"."]
["SECTION A"]
["Is this an employee only plan?"]
[]
["1.   On average, how many employees did the employer employ during the preceding calendar year?\nIf less than 1 enrolled, no Alaska large group exists, If 1 to 50, the group is a small group and not eligible as an Alaska large group. If more than 50, the group is a large group."]
[]
["2.   If an employer was not in existence through the preceding calendar year, what is the average number of employees the employer reasonably expects to employ on business days in the current calendar year?  \nIf less than 1 enrolled, no Alaska large group exists, If 1 to 50, the group is a small group and not eligible as an Alaska large group. If more than 50, the group is a large group."]
[]
[]
[]
[]
[]
["   \n                                                                                                                                                                                                               "]
["3.   How many employees will be employed on the date that coverage is to take effect? \nThe employer must have at least one employee enrolled on the date coverage will take effect in order to be issued large group coverage."]
["   \n   "]
[]
[]
[]
["4.   Out of the number of eligible employees indicated in question #3, indicate the number of employees not eligible for coverage due to group's eligibility rules: "]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"Medical","Dental"]
[null,null,null,null,null,null,null,null,null,null,{"$f":"K19-K23","v":0},{"$f":"K19-K23","v":0}]
["5.   Total number of group eligible employees (#3 - #4):\nTo be an eligible employee, an independent contractor must have federal taxes deducted from income related to the Group's business."]
[]
[]
[]
["6.   Out of the number of employees indicated in question #5, indicate the number of employees waiving due to other group or individual coverage: "]
[]
["7.   Total employee count (for participation requirement)  (#5 - #6):",null,null,null,null,null,null,null,null,null,{"$f":"K28-K33","v":0},{"$f":"L28-L33","v":0}]
[]
[]
[]
["8.   Out of the number of employees indicated in question #7, indicate the number of employees opting out of coverage: \nCount employees choosing not to take coverage here."]
[]
["9.   Total number of employees enrolling (#7 - #8):",null,null,null,null,null,null,null,null,null,{"$f":"K35-K39","v":0},{"$f":"L35-L39","v":0}]
["10. Total number COBRA Enrollees (include primary insured's only):"]
["11. Total number of employees and COBRA enrollees (#9 + #10):",null,null,null,null,null,null,null,null,null,{"$f":"K41+K42","v":0},{"$f":"L41+L42","v":0}]
["12. What type of employees are you offering coverage to:\n       a.  All employees working 20 hours or more per week\n       b.  All employees working the minimum hours required by your specific company in\n            order to qualify for benefits (i.e. 40 hours per week)\n"]
[]
[]
["Comments:"]
[]
[]
[]
[]
["EMPLOYEE PARTICIPATION",null,null,null,null,null,null,null,null,null,"Medical","Dental"]
["13.  What percentage of employees participate in the plan(s)? ((#6 + #9) / #5) \nFor Voluntary Dental Plans, a minimum of 25% of eligible employees must participate with a minimum of 10 enrolling.\n",null,null,null,null,null,null,null,null,null,{"$f":"IF(K43=\"\",\"\",IF(K35=0,0,(K33+K41)/K28))","v":0},{"$f":"IF(L43=\"\",\"\",IF(L35=0,0,(L33+L41)/L28))","v":0}]
[]
["DEPENDENT PARTICIPATION \nIf you checked \"yes\" to EMPLOYEE ONLY PLAN on page 1, please mark \"N/A\" for dependent participation in question #14 below.  Please note that under an employee only contract, Moda will not allow any future dependents to be covered on this plan. \nIf you checked \"no\" to EMPLOYEE ONLY PLAN on page 1, but currently have no eligible dependents to enroll, please indicate 0% for dependent participation in question #14 below.  Please note that under an employee + dependent contract, Moda will allow any future dependents to be covered on this plan.                                                                                                                                  If you checked\"no\" to EMPLOYEE ONLY PLAN on page 1, and currently have eligible dependents to enroll, please calculate your current dependent participation and indicate this percentage in question #14 below.  Please note that under an employee + dependent contract, Moda will allow any future dependents to be covered on this plan. "]
["DEPENDENT PARTICIPATION",null,null,null,null,null,null,null,null,null,"Medical","Dental"]
["14.  What percentage of dependents participate in the plan(s)?",null,null,null,null,null,null,null,null,null,"% ","%"]
[]
["SECTION B"]
["Disclosure Notice for Employers"]
["If an employer has an average of more than 50 employees during the preceding calendar year, the carrier may provide the employer a health insurance quote as a large group.  However, the carrier must treat an employer as a small employer and must provide a quote only on that basis if both of the following conditions apply:\n     (1) The employer’s workforce consists of at least two but not more than 50 eligible employees as of the date coverage is to take effect; and\n     (2) Coverage is limited to eligible employees."]
[]
[]
["To the best of my knowledge, I certify that all the information contained herein is correct.  I understand that the final rates will be based on actual enrollment and may be different than the rates originally quoted and that additional information may be required to verify eligibility of the group."]
["I am the:"]
[]
["Name (printed please)",null,null,null,null,"Signature",null,null,null,null,"Date:"]

{"sheet":"Page 3 - Plan Info","index":4,"n_rows":404,"n_cols":112,"rows_kept":404,"cut":false,"hidden":false,"merged":[[27,1,27,2],[12,1,12,3],[13,0,13,1],[42,7,42,11],[42,2,42,5],[26,10,26,11],[28,9,28,11],[27,10,27,11],[25,8,25,11],[19,7,19,9],[22,1,22,3],[23,1,23,3],[25,5,25,7],[26,1,26,2],[15,1,15,4],[23,7,23,9],[52,8,52,10],[48,0,48,10],[50,9,50,11],[33,1,33,5],[49,9,49,11],[46,2,46,5],[44,2,44,5],[44,7,44,11],[46,7,46,11],[51,9,51,11],[47,0,47,9],[34,9,34,11],[2,8,2,11],[13,4,13,6],[13,9,13,11],[2,3,2,7],[6,9,6,11],[9,10,9,12],[11,11,11,12],[10,11,10,12],[5,8,5,9],[9,6,9,9],[7,1,7,4],[32,7,32,11],[3,10,3,11],[31,7,31,11],[14,9,14,11],[31,1,31,5],[9,2,9,5],[5,0,5,3],[5,4,5,6],[32,1,32,5],[18,1,18,3],[19,1,19,3],[4,10,4,11],[11,0,11,1],[4,0,4,1],[3,0,3,1],[10,0,10,1]]}
["Types of Coverage: "]
[]
["Medical:",null,null,"In-Network",null,null,null,null,"Out-of-Network",null,null,null,"Group Size"]
["Plan Design #",null,"Plan Type","Deductible","Co-ins.    %","Co-pay","Hospital Co-pay","Out-of-Pocket","Ded","Co-ins.    %","Out-of-Pocket",null,"Large"]
[null,null,{"$f":"IFERROR(VLOOKUP(LEFT(A5,1),'Plan Info Lookups'!$B$56:$C$63,2,FALSE),\"\")","v":""},{"$f":"IFERROR(VLOOKUP(MID(A5,5,1),'Plan Info Lookups'!$M$56:$N$76,2,FALSE),\"\")","v":""},{"$f":"IFERROR(VLOOKUP(MID(A5,6,1),'Plan Info Lookups'!$S$56:$T$63,2,FALSE),\"\")","v":""},{"$f":"IFERROR(VLOOKUP(MID(A5,3,2),'Plan Info Lookups'!$G$56:$H$65,2,FALSE),\"\")","v":""},{"$f":"IFERROR(VLOOKUP(MID(A5,6,1),'Plan Info Lookups'!$S$56:$T$63,2,FALSE),\"\")","v":""},{"$f":"IF(A5=\"\",\"\",IFERROR(VLOOKUP(MID(A5,7,2),'Plan Info Lookups'!$Z$56:$AA$92,2,FALSE),\"Error\"))","v":""},{"$f":"IFERROR(VLOOKUP(MID(A5,10,1),'Plan Info Lookups'!$M$56:$N$87,2,FALSE),\"\")","v":""},{"$f":"IFERROR(VLOOKUP(MID(A5,11,1),'Plan Info Lookups'!$S$56:$T$63,2,FALSE),\"\")","v":""},{"$f":"IFERROR(VLOOKUP(MID(A5,12,2),'Plan Info Lookups'!$Z$56:$AA$114,2,FALSE),\"\")","v":""},{"$f":"IF($A$5=\"\",\"\",IF(VLOOKUP($A$5,$EC$7:$EK$29880,1)=$A$5,VLOOKUP($A$5,$EC$7:$EK$29880,2),\"\"))","v":""}]
["Group will utilize the following Network:",null,null,null,null,null,null,null,"No",null,"Maximum Cost Share Wrap (in-net)"]
[null,"Modified Plan.  Please note changes in ITALICS & BOLD.  ",null,null,null,null,null,null,"Modified from Plan #:"]
[null,"GRANDFATHERED BENEFITS"]
[]
["Pharmacy:",null,"Retail",null,null,null,"Mail Order",null,null,null,"Retail & Mail Order - (Specify):",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"","Add New Class",null,"Renewal",1]
["Plan #",null,"Value Co-pay","Select                 Co-pay","Preferred Co-pay","Brand Co-pay","Value Co-pay","Select              Co-pay","Preferred Co-pay","Brand Co-pay","Ded","Out-of-Pocket",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Add New Subgroup",null,"Renewal",1]
[null,null,{"$f":"IF($A$12=\"\",\"\",(IF(VLOOKUP($A$12,$AI$310:$AX$329,1,FALSE)=$A$12,VLOOKUP($A$12,$AI$310:$AX$329,14,FALSE),\"\")))","v":""},{"$f":"IF($A$12=\"\",\"\",(IF(VLOOKUP($A$12,$AI$310:$AX$329,1,FALSE)=$A$12,VLOOKUP($A$12,$AI$310:$AX$329,5,FALSE),\"\")))","v":""},{"$f":"IF($A$12=\"\",\"\",IF(VLOOKUP($A$12,$AI$310:$AX$329,1,FALSE)=$A$12,VLOOKUP($A$12,$AI$310:$AX$329,9,FALSE),\"\"))","v":""},{"$f":"IF($A$12=\"\",\"\",IF(VLOOKUP($A$12,$AI$310:$AX$329,1,FALSE)=$A$12,VLOOKUP($A$12,$AI$310:$AX$329,10,FALSE),\"\"))","v":""},{"$f":"IF($A$12=\"\",\"\",IF(VLOOKUP($A$12,$AI$310:$AX$329,1,FALSE)=$A$12,VLOOKUP($A$12,$AI$310:$AX$329,15,FALSE),\"\"))","v":""},{"$f":"IF($A$12=\"\",\"\",IF(VLOOKUP($A$12,$AI$310:$AX$329,1,FALSE)=$A$12,VLOOKUP($A$12,$AI$310:$AX$329,7,FALSE),\"\"))","v":""},{"$f":"IF($A$12=\"\",\"\",IF(VLOOKUP($A$12,$AI$310:$AX$329,1,FALSE)=$A$12,VLOOKUP($A$12,$AI$310:$AX$329,11,FALSE),\"\"))","v":""},{"$f":"IF($A$12=\"\",\"\",IF(VLOOKUP($A$12,$AI$310:$AX$329,1,FALSE)=$A$12,VLOOKUP($A$12,$AI$310:$AX$329,12,FALSE),\"\"))","v":""},{"$f":"IF($A$12=\"\",\"\",IF(VLOOKUP($A$12,$AI$310:$AX$329,1,FALSE)=$A$12,VLOOKUP($A$12,$AI$310:$AX$329,16,FALSE),\"\"))","v":""},{"$f":"IF($A$12=\"\",\"\",IF(I6=\"Yes- $6850/$13700\",\"See Max Cost Share\",IF(VLOOKUP($A$12,$AI$310:$AX$329,1,FALSE)=$A$12,VLOOKUP($A$12,$AI$310:$AX$329,13,FALSE),\"\")))","v":""},null,null,null,null,null,null,null,null,null,null,null,false,null,null,null,"Change",null,"Renewal",1]
[null,{"$f":"IF(A5=\"\",\"\",IF(LEFT(A5,1)=\"H\",\"HSA Plan Rx:\",\"\"))","v":""},null,null,{"$f":"IF(A5=\"\",\"\",IF(LEFT(A5,1)=\"H\",\"Deductible Applies, then \"&(E5),\"\"))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Renewal",null,"Renewal",1]
["Contraceptive Coverage:",null,null,"Type of Coverage:",null,null,null,null,"Diabetic Supplies:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NEW",null,"NEW",0]
[null,"Modified Plan.  Please note changes in ITALICS & BOLD.  ",null,null,null,null,null,null,"Modified from Plan #:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Reinstate (include diary & renewal)",null,"Renewal",1]
[null,"GRANDFATHERED BENEFITS"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Renewal",null,"Renewal",1]
["Hearing Aid Rider:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Revised Renewal",null,"Renewal",1]
["Plan #","Plan Type"]
[null,{"$f":"IF($A$20=\"\",\"\",VLOOKUP($A$20,$AJ$290:$AK$296,2,FALSE))","v":""},"","",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1,"New Pool",12]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"Renewal Pool",30]
["Vision:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Revised Renewal",null,"Renewal",1]
["Plan #","Plan Type",null,null,null,"Modified Plan.  Please note changes in ITALICS & BOLD.  "]
[null,{"$f":"IF($A$24=\"\",\"\",IF(VLOOKUP($A$24,$AJ$290:$AK$295,1,FALSE)=$A$24,VLOOKUP($A$24,$AJ$290:$AK$295,2,FALSE),\"\"))","v":""},"","",null,null,"Modified from Plan #:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1,"New Pool",12]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"Renewal Pool",30]
["Dental:","Group Size:",null,null,null,"In-Network",null,null,"Out-of-Network",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(C26=\"\",\"\",IF(C26=\"51-99\",1,IF(C26=\"100+\",3,0)))","v":""},51,99,"Pool",1,null,null,null,3,"New Experience",60]
["Plan #","Plan Type",null,"Deductible","Maximum","Preventive","Basic","Major","Preventive","Basic","Major",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,100,50000,"Experience",3,null,null,null,4,"Renewal Experience",60]
[null,{"$f":"IF($A$28=\"\",\"\",VLOOKUP(A28,$AI$342:$AS$390,3,FALSE))","v":""},"",{"$f":"IF($A$28=\"\",\"\",VLOOKUP($A$28,$AI$342:$AS$390,4,FALSE))","v":""},{"$f":"IF($A$28=\"\",\"\",VLOOKUP($A$28,$AI$342:$AS$390,8,FALSE))","v":""},{"$f":"IF($A$28=\"\",\"\",VLOOKUP($A$28,$AI$342:$AS$390,5,FALSE))","v":""},{"$f":"IF($A$28=\"\",\"\",VLOOKUP($A$28,$AI$342:$AS$390,6,FALSE))","v":""},{"$f":"IF($A$28=\"\",\"\",VLOOKUP($A$28,$AI$342:$AS$390,7,FALSE))","v":""},{"$f":"IF($A$28=\"\",\"\",VLOOKUP($A$28,$AI$342:$AS$390,9,FALSE))","v":""},{"$f":"IF($A$28=\"\",\"\",VLOOKUP($A$28,$AI$342:$AS$390,10,FALSE))","v":""},{"$f":"IF($A$28=\"\",\"\",VLOOKUP($A$28,$AI$342:$AS$390,11,FALSE))","v":""},{"$f":"IF($A$28=\"\",\"\",VLOOKUP($A$28,$AI$334:$AS$348,10,FALSE))","v":""},null,null,null,null,null,null,{"$f":"+A28","v":0},null,null,null,null,null,null,null,{"$f":"IF(OR(AA10=\"\",AA26=\"\"),\"\",SUM(AA9:AA26))","v":""},null,null,null,{"$f":"SUM(AE10:AE27)","v":12}]
[null,"Modified Plan.  Please note changes in ITALICS & BOLD.  ",null,null,null,null,null,null,"Modified from Plan #:"]
[null,{"$f":"IF(LEFT(A28,2)=\"BP\",\"*** Group must be located in Anchorage to have a PPO Dental Plan! ***\",\"\")","v":""}]
["Orthodontia:"]
["Plan #","Plan Type",null,null,null,null,"Other:"]
[null,{"$f":"IF($A$33=\"\",\"\",VLOOKUP($A$33,$AI$391:$AJ$404,2,FALSE))","v":""},"","",""]
[null,{"$f":"IF(A33=\"\",\"\",IF(LEFT(A33,2)=\"VC\",\"                (\"&DH81&\")                   \",\"\"))","v":""}]
[null,"Modified Plan.  Please note changes in ITALICS & BOLD.  ",null,null,null,null,null,null,"Modified from Plan #:"]
[]
[]
[]
[]
[]
["EXISTING COVERAGE:"]
["1.  Please provide the previous carrier(s) name and contact phone number:"]
[null,"Medical:",null,null,null,null,"Dental:"]
["2.  Please provide the name and contact phone number for the current insurance carrier(s), both medical and dental:"]
[null,"Medical:",null,null,null,null,"Dental:"]
["3. If dual coverage is available, please list the other carrier(s):"]
[null,"Medical:",null,null,null,null,"Dental:"]
["4. If this plan is replacing an existing plan, will members receive credit from the previous plan?",null,null,null,null,null,null,null,null,null,"(Y/N):"]
["If Yes, check the type(s) of report(s) below that will be available for applying credit:"]
[null,null,"Medical deductible:"]
[null,null,"Medical Out-of-pocket:"]
[null,null,"Dental deductible:"]
[null,null,"Accumulator Report:"]
["5. If enrolling in Dental Plan A (incentive plan), will benefits for members who were covered under the"]
["     group's prior plan begin at the first year benefit level?",null,null,null,null,null,null,null,"(Y/N):"]
["If No, check the benefit level that will apply to existing members:"]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1,2,3,4,5,6,7,8,9]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"OUT-CLASS1","OUT-CLASS2","OUT-CLASS3","OV","Crowns/Bridges/Pontics/Inlays/Onlays","Root Canals","Root Planing","Gingivectomy","Dentures Full","Dentures Partial","Surg Extractions","Nitrous Oxide"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"A0","PREMIER OPTION A ","$0","70%/80%/90%/100%","70%/80%/90%/100%","50%","$1,500","N/A","N/A","N/A","$10 Copay","$30 Copay","$20/$40/$60",20,20,20,20,"$20 Copay",10,"DO1","Direct Option 1","A1000","ADULT - 50% UP TO $1,000 LIFETIME MAXIMUM"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B3X25","PREMIER OPTION B","$25/$75 Deductible (waived on Preventive)","100%(Ded. wavied)","80%","50%","$1,500","N/A","N/A","N/A","$10 Copay","$30 Copay","$20/$40/$60",20,20,20,20,"$20 Copay",10,"DO1","Direct Option 1","A1500","ADULT - 50% UP TO $1,500 LIFETIME MAXIMUM"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B3X50","PREMIER OPTION B","$50/$150 Deductible (waived on Preventive)","100%(Ded. wavied)","80%","50%","$1,500","N/A","N/A","N/A","$10 Copay","$30 Copay","$20/$40/$60",20,20,20,20,"$20 Copay",10,"DO1","Direct Option 1","A2000","ADULT -  50% UP TO $2,000 LIFETIME MAXIMUM"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B3X501","PREMIER OPTION B","$50/$150 Deductible (waived on Preventive)","100%(Ded. wavied)","80%","50%","$1,000","N/A","N/A","N/A","$15 Copay","$150 Copay","$75/$150/$225",120,150,150,90,"$120 Copay",20,"DO3","Direct Option 3","A2500","ADULT -  50% UP TO $2,500 LIFETIME MAXIMUM"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X25","PPO OPTION B","$25/$75 Deductible (waived on Preventive)","100%(Ded. wavied)","80%","50%","$1,500","80%(Ded. wavied)","60%","50%","$15 Copay","$150 Copay","$75/$150/$225",120,150,150,90,"$120 Copay",20,"DO3","Direct Option 3","A500","ADULT - 50% UP TO $500 LIFETIME MAXIMUM"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X50","PPO OPTION B","$50/$150 Deductible (waived on Preventive)","100%(Ded. wavied)","80%","50%","$1,500","80%(Ded. wavied)","60%","50%","$15 Copay","$150 Copay","$75/$150/$225",120,150,150,90,"$120 Copay",20,"DO3","Direct Option 3","AC1000","ADULT & CHILD - 50% UP TO $1,000 LIFETIME MAXIMUM"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X501","PPO OPTION B","$50/$150 Deductible (waived on Preventive)","100%(Ded. wavied)","80%","50%","$1,000","80%(Ded. wavied)","60%","50%","$20 Copay","$150 Copay","$75/$150/$225",120,150,150,90,"$120 Copay",20,"DO4","Direct Option 4","AC1500","ADULT & CHILD - 50% UP TO $1,500 LIFETIME MAXIMUM"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C3X25","PREMIER OPTION C","$25/$75 Deductible","80%","80%","50%","$1,500","N/A","N/A","N/A","$10 Copay","$150 Copay","$75/$150/$225",120,150,150,90,"$120 Copay",20,"DO2","Direct Option 2","AC2000","ADULT & CHILD - 50% UP TO $2,000 LIFETIME MAXIMUM"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C3X50","PREMIER OPTION C","$50/$150 Deductible","80%","80%","50%","$1,500","N/A","N/A","N/A","$10 Copay","$150 Copay","$75/$150/$225",120,150,150,90,"$120 Copay",20,"DO2","Direct Option 2","AC2500","ADULT & CHILD - 50% UP TO $2,500 LIFETIME MAXIMUM"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C3X501","PREMIER OPTION C","$50/$150 Deductible","80%","80%","50%","$1,000","N/A","N/A","N/A","$20 Copay","$150 Copay","$75/$150/$225",120,150,150,90,"$120 Copay",20,"DO4","Direct Option 4","AC500","ADULT & CHILD - 50% UP TO $500 LIFETIME MAXIMUM"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"D3X501","PREMIER OPTION D","$50/$150 Deductible (waived on Preventive)","80%(Ded. wavied)","50%","50%","$1,000","N/A","N/A","N/A","$20 Copay","$200 Copay","$75/$150/$225",120,200,200,90,"$150 Copay",20,"DO5","Direct Option 5","C1000","CHILD ONLY - 50% UP TO $1,000 LIFETIME MAXIMUM"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-150101-2300",null,"2-150101-2300",null,"2-150102-2300","PPO","$15","$0","10%","10%","$2,000",250,"30%","None",null,"2-150102-2300",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B3X5025","PREMIER OPTION B FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$2,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-150101-5300",null,"2-150101-5300",null,"2-150102-5300","PPO","$15","$0","10%","10%","$2,000",500,"30%","None",null,"2-150102-5300",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B50","PREMIER OPTION B","$50","100%(Ded. wavied)","80%","50%","$1,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-150102-2300",null,"2-150102-2300",null,"2-150103-2300","PPO","$15","$0","10%","10%","$3,000",250,"30%","None",null,"2-150103-2300",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B501","PREMIER OPTION B","$50","100%(Ded. wavied)","80%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-150102-5300",null,"2-150102-5300",null,"2-150103-5300","PPO","$15","$0","10%","10%","$3,000",500,"30%","None",null,"2-150103-5300",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B502","PREMIER OPTION B","$50","100%(Ded. wavied)","80%","50%","$2,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-150103-2300",null,"2-150103-2300",null,"2-150202-2400","PPO","$15","$0","20%","20%","$2,000",250,"40%","None",null,"2-150202-2400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B5025","PREMIER OPTION B","$50","100%(Ded. wavied)","80%","50%","$2,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-150103-5300",null,"2-150103-5300",null,"2-150202-5400","PPO","$15","$0","20%","20%","$2,000",500,"40%","None",null,"2-150202-5400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP25","PPO OPTION B","$25","100%(Ded. wavied)","80%","50%","$1,500","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-150202-2400",null,"2-150202-2400",null,"2-152122-2300","PPO","$15",250,"10%","10%","$2,250",250,"30%","None",null,"2-152122-2300",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP251","PPO OPTION B","$25","100%(Ded. wavied)","80%","50%","$1,000","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-150202-5400",null,"2-150202-5400",null,"2-152132-2300","PPO","$15",250,"10%","10%","$3,250",250,"30%","None",null,"2-152132-2300",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP252","PPO OPTION B","$25","100%(Ded. wavied)","80%","50%","$2,000","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-150701-2300",null,"2-150701-2300",null,"2-152222-2400","PPO","$15",250,"20%","20%","$2,250",250,"40%","None",null,"2-152222-2400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP2525","PPO OPTION B","$25","100%(Ded. wavied)","80%","50%","$2,500","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-150701-5300",null,"2-150701-5300",null,"2-152232-2400","PPO","$15",250,"20%","20%","$3,250",250,"40%","None",null,"2-152232-2400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X25","PPO OPTION B FAMILY DEDUCTIBLE","$25/$75","100%(Ded. wavied)","80%","50%","$1,500","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-152122-2300",null,"2-152122-2300",null,"2-155225-5400","PPO","$15",500,"20%","20%","$2,500",500,"40%","None",null,"2-155225-5400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X251","PPO OPTION B FAMILY DEDUCTIBLE","$25/$75","100%(Ded. wavied)","80%","50%","$1,000","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-152132-2300",null,"2-152132-2300",null,"2-155235-5400","PPO","$15",500,"20%","20%","$3,500",500,"40%","None",null,"2-155235-5400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X252","PPO OPTION B FAMILY DEDUCTIBLE","$25/$75","100%(Ded. wavied)","80%","50%","$2,000","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-152222-2400",null,"2-152222-2400",null,"2-155255-5400","PPO","$15",500,"20%","20%","$5,500",500,"40%","None",null,"2-155255-5400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X2525","PPO OPTION B FAMILY DEDUCTIBLE","$25/$75","100%(Ded. wavied)","80%","50%","$2,500","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-152232-2400",null,"2-152232-2400",null,"2-155355-5500","PPO","$15",500,"30%","30%","$5,500",500,"50%","None",null,"2-155355-5500",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X50","PPO OPTION B FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$1,500","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-155225-5400",null,"2-155225-5400",null,"2-159206-9400","PPO","$15",1000,"20%","20%","$6,000",1000,"40%","None",null,"2-159206-9400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X501","PPO OPTION B FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$1,000","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-155235-5400",null,"2-155235-5400",null,"2-200102-2300","PPO","$20","$0","10%","10%","$2,000",250,"30%","None",null,"2-200102-2300",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X502","PPO OPTION B FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$2,000","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-155255-5400",null,"2-155255-5400",null,"2-200102-5300","PPO","$20","$0","10%","10%","$2,000",500,"30%","None",null,"2-200102-5300",null,{"$f":"IF(AO124=AN124,\"\",\"here\")","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X5025","PPO OPTION B FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$2,500","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-155355-5500",null,"2-155355-5500",null,"2-200202-2400","PPO","$20","$0","20%","20%","$2,000",250,"40%","None",null,"2-200202-2400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP50","PPO OPTION B","$50","100%(Ded. wavied)","80%","50%","$1,500","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-159206-9400",null,"2-159206-9400",null,"2-200202-5400","PPO","$20","$0","20%","20%","$2,000",500,"40%","None",null,"2-200202-5400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP501","PPO OPTION B","$50","100%(Ded. wavied)","80%","50%","$1,000","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-200102-2300",null,"2-200102-2300",null,"2-202122-2300","PPO","$20",250,"10%","10%","$2,250",250,"30%","None",null,"2-202122-2300",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP502","PPO OPTION B","$50","100%(Ded. wavied)","80%","50%","$2,000","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-200102-5300",null,"2-200102-5300",null,"2-202132-2300","PPO","$20",250,"10%","10%","$3,250",250,"30%","None",null,"2-202132-2300",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP5025","PPO OPTION B","$50","100%(Ded. wavied)","80%","50%","$2,500","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-200202-2400",null,"2-200202-2400",null,"2-202217-2400","PPO","$20",250,"20%","20%","$1,750",250,"40%","None",null,"2-202217-2400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C25","PREMIER OPTION C ","$25","80%","80%","50%","$1,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-200202-5400",null,"2-200202-5400",null,"2-202222-2400","PPO","$20",250,"20%","20%","$2,250",250,"40%","None",null,"2-202222-2400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C251","PREMIER OPTION C ","$25","80%","80%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-202122-2300",null,"2-202122-2300",null,"2-202232-2400","PPO","$20",250,"20%","20%","$3,250",250,"40%","None",null,"2-202232-2400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C252","PREMIER OPTION C ","$25","80%","80%","50%","$2,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-202132-2300",null,"2-202132-2300",null,"2-205203-5400","PPO","$20",500,"20%","20%","$3,000",500,"40%","None",null,"2-205203-5400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C2525","PREMIER OPTION C ","$25","80%","80%","50%","$2,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-202217-2400",null,"2-202217-2400",null,"2-205204-5400","PPO","$20",500,"20%","20%","$4,000",500,"40%","None",null,"2-205204-5400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C3X25","PREMIER OPTION C FAMILY DEDUCTIBLE","$25/$75","80%","80%","50%","$1,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-202222-2400",null,"2-202222-2400",null,"2-205225-5400","PPO","$20",500,"20%","20%","$2,500",500,"40%","None",null,"2-205225-5400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C3X251","PREMIER OPTION C FAMILY DEDUCTIBLE","$25/$75","80%","80%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-202232-2400",null,"2-202232-2400",null,"2-205235-5400","PPO","$20",500,"20%","20%","$3,500",500,"40%","None",null,"2-205235-5400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C3X252","PREMIER OPTION C FAMILY DEDUCTIBLE","$25/$75","80%","80%","50%","$2,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-205203-5400",null,"2-205203-5400",null,"2-205255-5400","PPO","$20",500,"20%","20%","$5,500",500,"40%","None",null,"2-205255-5400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C3X2525","PREMIER OPTION C FAMILY DEDUCTIBLE","$25/$75","80%","80%","50%","$2,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-205204-5400",null,"2-205204-5400",null,"2-205305-5500","PPO","$20",500,"30%","30%","$5,000",500,"50%","None",null,"2-205305-5500",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C3X50","PREMIER OPTION C FAMILY DEDUCTIBLE","$50/$150","80%","80%","50%","$1,500","N/A","N/A","N/A"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-251265-1400",null,"2-251265-1400",null,"2-255255-5400","PPO","$25",500,"20%","20%","$5,500",500,"40%","None",null,"2-255255-5400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C5025","PREMIER OPTION C ","$50","80%","80%","50%","$2,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-251265-1500",null,"2-251265-1500",null,"2-255355-5500","PPO","$25",500,"30%","30%","$5,500",500,"50%","None",null,"2-255355-5500",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CP25","PPO OPTION C","$25","80%","80%","50%","$1,500","60%","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-251375-1500",null,"2-251375-1500",null,"2-257237-7400","PPO","$25",750,"20%","20%","$3,750",750,"40%","None",null,"2-257237-7400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CP251","PPO OPTION C","$25","80%","80%","50%","$1,000","60%","60%","50%"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-255355-5500",null,"2-255355-5500",null,"2-257257-7400","PPO","$25",750,"20%","20%","$5,750",750,"40%","None",null,"2-257257-7400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CP2525","PPO OPTION C","$25","80%","80%","50%","$2,500","60%","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-257237-7400",null,"2-257237-7400",null,"2-257337-7500","PPO","$25",750,"30%","30%","$3,750",750,"50%","None",null,"2-257337-7500",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CP3X25","PPO OPTION C FAMILY DEDUCTIBLE","$25/$75","80%","80%","50%","$1,500","60%","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-257247-7400",null,"2-257247-7400",null,"2-257347-7500","PPO","$25",750,"30%","30%","$4,750",750,"50%","None",null,"2-257347-7500",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CP3X251","PPO OPTION C FAMILY DEDUCTIBLE","$25/$75","80%","80%","50%","$1,000","60%","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-257257-7400",null,"2-257257-7400",null,"2-257357-7500","PPO","$25",750,"30%","30%","$5,750",750,"50%","None",null,"2-257357-7500",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CP3X252","PPO OPTION C FAMILY DEDUCTIBLE","$25/$75","80%","80%","50%","$2,000","60%","60%","50%"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-257357-7500",null,"2-257357-7500",null,"2-258375-8500","PPO","$25",2500,"30%","30%","$7,500",2500,"50%","None",null,"2-258375-8500",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CP3X501","PPO OPTION C FAMILY DEDUCTIBLE","$50/$150","80%","80%","50%","$1,000","60%","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-258305-8500",null,"2-258305-8500",null,"2-258675-8500","PPO","$25",2500,"25%","25%","$7,500",2500,"50%","None",null,"2-258675-8500",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CP3X502","PPO OPTION C FAMILY DEDUCTIBLE","$50/$150","80%","80%","50%","$2,000","60%","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-258375-8500",null,"2-258375-8500",null,"2-259204-9400","PPO","$25",1000,"20%","20%","$4,000",1000,"40%","None",null,"2-259204-9400",null,{"$f":"IF(AO156=AN156,\"\",\"here\")","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CP3X5025","PPO OPTION C FAMILY DEDUCTIBLE","$50/$150","80%","80%","50%","$2,500","60%","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-258675-8500",null,"2-258675-8500",null,"2-259205-9400","PPO","$25",1000,"20%","20%","$5,000",1000,"40%","None",null,"2-259205-9400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CP50","PPO OPTION C","$50","80%","80%","50%","$1,500","60%","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-259205-9400",null,"2-259205-9400",null,"2-259206-9400","PPO","$25",1000,"20%","20%","$6,000",1000,"40%","None",null,"2-259206-9400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CP501","PPO OPTION C","$50","80%","80%","50%","$1,000","60%","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-259206-9400",null,"2-259206-9400",null,"2-259235-9400","PPO","$25",1000,"20%","20%","$3,500",1000,"40%","None",null,"2-259235-9400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CP502","PPO OPTION C","$50","80%","80%","50%","$2,000","60%","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-259235-9400",null,"2-259235-9400",null,"2-259306-9500","PPO","$25",1000,"30%","30%","$6,000",1000,"50%","None",null,"2-259306-9500",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CP5025","PPO OPTION C","$50","80%","80%","50%","$2,500","60%","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-25D375-D500",null,"2-25D375-D500",null,"2-25D310-D500","PPO","$25",5000,"30%","30%","$10,000",5000,"50%","None",null,"2-25D310-D500",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"D25","PREMIER OPTION D","$25","80%(Ded. wavied)","50%","50%","$1,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-25D610-D500",null,"2-25D610-D500",null,"2-25D375-D500","PPO","$25",5000,"30%","30%","$7,500",5000,"50%","None",null,"2-25D375-D500",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"D251","PREMIER OPTION D","$25","80%(Ded. wavied)","50%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-306207-6400",null,"2-306207-6400",null,"2-25D610-D500","PPO","$25",5000,"25%","25%","$10,000",5000,"50%","None",null,"2-25D610-D500",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"D252","PREMIER OPTION D","$25","80%(Ded. wavied)","50%","50%","$2,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-351365-1500",null,"2-351365-1500",null,"2-25F310-F500","PPO","$25",3500,"30%","30%","$10,000",3500,"50%","None",null,"2-25F310-F500",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"D2525","PREMIER OPTION D","$25","80%(Ded. wavied)","50%","50%","$2,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-356307-6500",null,"2-356307-6500",null,"2-306207-6400","PPO","$30",2000,"20%","20%","$7,000",2000,"40%","None",null,"2-306207-6400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"D3X25","PREMIER OPTION D FAMILY DEDUCTIBLE","$25/$75","80%(Ded. wavied)","50%","50%","$1,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2-358375-8500",null,"2-358375-8500",null,"2-351365-1500","PPO","$35",1500,"30%","30%","$6,500",1500,"50%","None",null,"2-351365-1500",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"D3X251","PREMIER OPTION D FAMILY DEDUCTIBLE","$25/$75","80%(Ded. wavied)","50%","50%","$1,000","N/A","N/A","N/A"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"H-001235-1400","HSA PPO","-",1500,"20%","20%","$3,500",1500,"40%","None",null,"H-001235-1400",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DP252","PPO OPTION D","$25","80%(Ded. wavied)","50%","50%","$2,000","60% Ded. Waived","50%","50%"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"H-00H5LG-H500","HSA PPO","-",2800,"50%","50%","$2,200",2800,"50%","None",null,"H-00H5LG-H500",null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DP3X252","PPO OPTION D FAMILY DEDUCTIBLE","$25/$75","80%(Ded. wavied)","50%","50%","$2,000","60% Ded. Waived","50%","50%"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DP50","PPO OPTION D","$50","80%(Ded. wavied)","50%","50%","$1,500","60% Ded. Waived","50%","50%"]
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[]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CP3X501",null,null,"CP3X501","PPO OPTION C FAMILY DEDUCTIBLE","$50/$150","80%","80%","50%","$1,000","60%","60%","50%","$20 Copay","$200 Copay","$75/$150/$225",120,200,200,90,"$150 Copay",20,"DO5","Direct Option 5"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"D3X251",null,null,"D3X251","PREMIER OPTION D FAMILY DEDUCTIBLE","$25/$75","80%(Ded. wavied)","50%","50%","$1,000","N/A","N/A","N/A","$20 Copay","$200 Copay","$75/$150/$225",120,200,200,90,"$150 Copay",20,"DO5","Direct Option 5"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"D3X50",null,null,"D3X50","PREMIER OPTION D FAMILY DEDUCTIBLE","$50/$150","80%(Ded. wavied)","50%","50%","$1,500","N/A","N/A","N/A","$15 Copay","$150 Copay","$75/$150/$225",120,150,150,90,"$120 Copay",20,"DO3","Direct Option 3"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"D3X501",null,null,"D3X501","PREMIER OPTION D FAMILY DEDUCTIBLE","$50/$150","80%(Ded. wavied)","50%","50%","$1,000","N/A","N/A","N/A","$20 Copay","$200 Copay","$75/$150/$225",120,200,200,90,"$150 Copay",20,"DO5","Direct Option 5"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DP3X50",null,null,"DP3X50","PPO OPTION D FAMILY DEDUCTIBLE","$50/$150","80%(Ded. wavied)","50%","50%","$1,500","60% Ded. Waived","50%","50%","$20 Copay","$200 Copay","$75/$150/$225",120,200,200,90,"$150 Copay",20,"DO5","Direct Option 5"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"E01",null,null,"E01","PREMIER OPTION E ","$0","50%","50%","50%","$1,000","N/A","N/A","N/A","$25 Copay","$300 Copay","$150/$250/$350",100,400,500,250,"$190 Copay",25,"DO6","Direct Option 6"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"W3X50",null,null,"VB3X50","VOLUNTARY PREMIER OPTION B","$50/$150","100%(Ded. wavied)","80%","50%","$1,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"W3X501",null,null,"VB3X501","VOLUNTARY PREMIER OPTION B","$50/$150","100%(Ded. wavied)","80%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VB3X507","VOLUNTARY PREMIER OPTION B","$50/$150","100%(Ded. wavied)","80%","50%","See Summary","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VBP3X50","VOLUNTARY PPO OPTION B","$50/$150","100%(Ded. wavied)","80%","50%","$1,500","80%","50%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VBP3X501","VOLUNTARY PPO OPTION B","$50/$150","100%(Ded. wavied)","80%","50%","$1,000","80%","50%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VBP3X507","VOLUNTARY PPO OPTION B","$50/$150","100%(Ded. wavied)","80%","50%","See Summary","80%","50%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VC3X50","VOLUNTARY PREMIER OPTION C","$50/$150","80%","80%","50%","$1,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VC3X501","VOLUNTARY PREMIER OPTION C","$50/$150","80%","80%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VC3X507","VOLUNTARY PREMIER OPTION C","$50/$150","80%","80%","50%","See Summary","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VDPA","OLD VOLUNTARY PLAN A","$50","100%(Ded.waived)","50%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VDPAO","OLD VOLUNTARY PLAN A  W/ORTHO","$50","100%(Ded.waived)","50%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VDPB","OLD VOLUNTARY PLAN B","$50","80%(Ded. wavied)","50%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VDPBO","OLD VOLUNTARY PLAN B  W/ORTHO","$50","80%(Ded. wavied)","50%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VDPC","OLD VOLUNTARY PLAN C","$50","50%(Ded. wavied)","50%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VDPCO","OLD VOLUNTARY PLAN C  W/ORTHO","$50","50%(Ded. wavied)","50%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"W3X50","PREMIER OPTION W FAMILY DEDUCTIBLE","$50/$150","80%(Ded. wavied)","80%","50%","$1,500","N/A","N/A","N/A","$10 Copay","$150 Copay","$75/$150/$225",120,150,150,90,"$120 Copay",20,"DO2","Direct Option 2"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"W3X501","PREMIER OPTION W FAMILY DEDUCTIBLE","$50/$150","80%(Ded. wavied)","80%","50%","$1,000","N/A","N/A","N/A","$20 Copay","$150 Copay","$75/$150/$225",120,150,150,90,"$120 Copay",20,"DO4","Direct Option 4"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKV100","Vision: 100% w/ $200 Max"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKV1003","Vision: 100% w/ $300 Max"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKV80","Vision: 80% w/ No Max"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKVEO","Vision: 100% Eye Exam Only"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKVHI","Vision: High Option"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKVSUP","Vision: Super Option"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKH80","80% to $800 max every 3 yrs"]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3012]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"-"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"-"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3011]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3013]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Discount Card"," "," "," "," "," "," "," "," "," "," "," "," "," "," "," "]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Modified"," "," "," "," "," ","mail","mail"," "," ","mail"," mail"," "," "," "," "]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKRX21020%503XC90","Rx: PBM: $2/$10/20%/50%; 3x Mail Order (w/ contra.)",null,null,"$10","20%/50%","$30","20%/50%","20%","50%","20%","50%","Combined (Refer to Medical OOP)","$2","$6"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKRX21020503XC90","Rx: PBM: $2/$10/$20/50%; 3x Mail Order (w/ contra.)",null,null,"$10","$20/50%","$30","$60/50%","$20","50%","$60","50%","Combined (Refer to Medical OOP)","$2","$6"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKRX21025503XC90","Rx: PBM: $2/$10/$25/50%; 3x Mail Order (w/ contra.)",null,null,"$10","$25/50%","$30","$75/50%","$25","50%","$75","50%","Combined (Refer to Medical OOP)","$2","$6"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKRX21030503XC90","Rx: PBM: $2/$10/$30/$50; 3x Mail Order (w/ contra.)",null,null,"$10","$30/$50","$30","$90/$150","$30","$50","$90","$150","Combined (Refer to Medical OOP)","$2","$6"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKRX21040603XC90","Rx: PBM: $2/$10/$40/$60; 3x Mail Order (w/ contra.)",null,null,"$10","$40/$60","$30","$120/$180","$40","$60","$120","$180","Combined (Refer to Medical OOP)","$2","$6"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKRX21525503XC90","Rx: PBM: $2/$15/$25/50%; 3x Mail Order (w/ contra.)",null,null,"$15","$25/50%","$45","$75/50%","$25","50%","$75","50%","Combined (Refer to Medical OOP)","$2","$6"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKRX21535503XC90","Rx: PBM: $2/$15/$35/50%; 3x Mail Order (w/ contra.)",null,null,"$15","$35/50%","$45","$105/50%","$35","50%","$105","50%","Combined (Refer to Medical OOP)","$2","$6"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKRX15503XC90","Rx: PBM $15 or 50% (whichever's greater) w/ 3x Mail Order (w/ contra.); ",null,null,"$15/50%","$15/50%","$45/50%","$45/50%","$15/50%","$15/50%","$45/50%","$45/50%","Combined (Refer to Medical OOP)","$2","$6"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKRX250D21020503XC90","Rx: PBM: $250 Ded, then $2/$10/$20/$50, 3x Mail Order Copay",null,null,"$10 (Ded wvd)","$20/$50","$30 (Ded wvd)","$60/$150","$20","$50","$60","$150","Combined (Refer to Medical OOP)","$2 (Ded wvd)","$6 (Ded wvd)","$250Ded (wvd value/gen)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKRX25CA90","Rx: PBM: $5/20%; Mail Order: $5/20% (w/ contra.)",null,null,"$5/20%","$5/20%","$5/20%","$5/20%","$5/20%","$5/20%","$5/20%","$5/20%","Combined (Refer to Medical OOP)","$2","$6"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKRX30C90","Rx: PBM: 30%; Mail Order: 30% (w/ contra.)",null,null,"30%","30%","30%","30%","30%","30%","30%","30%","Combined (Refer to Medical OOP)","$2","$6"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKRX30CA90","Rx: PBM: $10/20%; Mail Order: $10/20% (w/ contra.)",null,null,"$10/20%","$10/20%","$10/20%","$10/20%","$10/20%","$10/20%","$10/20%","$10/20%","Combined (Refer to Medical OOP)","$2","$6"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKRX35CA90","Rx: PBM: $15/20%; Mail Order: $15/20% (w/ contra.)",null,null,"$15/20%","$15/20%","$15/20%","$15/20%","$15/20%","$15/20%","$15/20%","$15/20%","Combined (Refer to Medical OOP)","$2","$6"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKRX40C90","Rx: PBM: 40% Copay; Mail Order: 40% Copay (w/ contra.)",null,null,"40%","40%","40%","40%","40%","40%","40%","40%","Combined (Refer to Medical OOP)","$2","$6"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AKRX2515503XC90","Rx: PBM: $2/$5/$15/50%; 3x Mail Order (w/ contra.)",null,null,"$5","$15/50%","$15","$45/50%","$15","50%","$45","50%","Combined (Refer to Medical OOP)","$2","$6"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Dental Plans"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"A0","Dental Plan A, $1,500 Max","PREMIER OPTION A ","$0","70%/80%/90%/100%","70%/80%/90%/100%","50%","$1,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"A01","Dental Plan A, $1,000 Max","PREMIER OPTION A ","$0","70%/80%/90%/100%","70%/80%/90%/100%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"A02","Dental Plan A, $2,000 Max","PREMIER OPTION A ","$0","70%/80%/90%/100%","70%/80%/90%/100%","50%","$2,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"A025","Dental Plan A, $2,500 Max","PREMIER OPTION A ","$0","70%/80%/90%/100%","70%/80%/90%/100%","50%","$2,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B50","Dental Plan B, $50 Ded, $1,500 Max","PREMIER OPTION B","$50","100%(Ded. wavied)","80%","50%","$1,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B501","Dental Plan B, $50 Ded, $1,000 Max","PREMIER OPTION B","$50","100%(Ded. wavied)","80%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B502","Dental Plan B, $50 Ded, $2,000 Max","PREMIER OPTION B","$50","100%(Ded. wavied)","80%","50%","$2,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B5025","Dental Plan B, $50 Ded, $2,500 Max","PREMIER OPTION B","$50","100%(Ded. wavied)","80%","50%","$2,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"W50","Dental Plan W, $50 Ded, $1,500 Max","PREMIER OPTION W","$50","80%(Ded. wavied)","80%","50%","$1,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"W501","Dental Plan W, $50 Ded, $1,000 Max","PREMIER OPTION W","$50","80%(Ded. wavied)","80%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"W502","Dental Plan W, $50 Ded, $2,000 Max","PREMIER OPTION W","$50","80%(Ded. wavied)","80%","50%","$2,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"W5025","Dental Plan W, $50 Ded, $2,500 Max","PREMIER OPTION W","$50","80%(Ded. wavied)","80%","50%","$2,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B3X50","Dental Plan B, $50/$150 Ded, $1,500 Max","PREMIER OPTION B FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$1,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B3X501","Dental Plan B, $50/$150 Ded, $1,000 Max","PREMIER OPTION B FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B3X502","Dental Plan B, $50/$150 Ded, $2,000 Max","PREMIER OPTION B FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$2,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B3X5025","Dental Plan B, $50/$150 Ded, $2,500 Max","PREMIER OPTION B FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$2,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"W3X50","Dental Plan W, $50/$150 Ded, $1,500 Max","PREMIER OPTION W FAMILY DEDUCTIBLE","$50/$150","80%(Ded. wavied)","80%","50%","$1,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"W3X501","Dental Plan W, $50/$150 Ded, $1,000 Max","PREMIER OPTION W FAMILY DEDUCTIBLE","$50/$150","80%(Ded. wavied)","80%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"W3X502","Dental Plan W, $50/$150 Ded, $2,000 Max","PREMIER OPTION W FAMILY DEDUCTIBLE","$50/$150","80%(Ded. wavied)","80%","50%","$2,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"W3X5025","Dental Plan W, $50/$150 Ded, $2,500 Max","PREMIER OPTION W FAMILY DEDUCTIBLE","$50/$150","80%(Ded. wavied)","80%","50%","$2,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X50","Dental Plan B, $50/$150 Ded, $1,500 Max","PPO OPTION BP FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$1,500","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X501","Dental Plan B, $50/$150 Ded, $1,000 Max","PPO OPTION BP FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$1,000","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X502","Dental Plan B, $50/$150 Ded, $2,000 Max","PPO OPTION BP FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$2,000","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X5025","Dental Plan B, $50/$150 Ded, $2,500 Max","PPO OPTION BP FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$2,500","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BPA3X50","Dental Plan B, $50/$150 Ded, $1,500 Max","PPO OPTION BPA FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","90%","50%","$1,500","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BPA3X501","Dental Plan B, $50/$150 Ded, $1,000 Max","PPO OPTION BPA FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","90%","50%","$1,000","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BPA3X502","Dental Plan B, $50/$150 Ded, $2,000 Max","PPO OPTION BPA FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","90%","50%","$2,000","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BPA3X5025","Dental Plan B, $50/$150 Ded, $2,500 Max","PPO OPTION BPA FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","90%","50%","$2,500","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BPB3X50","Dental Plan B, $50/$150 Ded, $1,500 Max","PPO OPTION BPB FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$1,500","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BPB3X501","Dental Plan B, $50/$150 Ded, $1,000 Max","PPO OPTION BPB FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$1,000","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BPB3X502","Dental Plan B, $50/$150 Ded, $2,000 Max","PPO OPTION BPB FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$2,000","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BPB3X5025","Dental Plan B, $50/$150 Ded, $2,500 Max","PPO OPTION BPB FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$2,500","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B3X50_PF","Dental Plan B w/ Preventive First, $50/$150 Ded, $1,500 Max","PREMIER OPTION B FAMILY DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","80%","50%","$1,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B3X501_PF","Dental Plan B w/ Preventive First, $50/$150 Ded, $1,000 Max","PREMIER OPTION B FAMILY DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","80%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B3X502_PF","Dental Plan B w/ Preventive First, $50/$150 Ded, $2,000 Max","PREMIER OPTION B FAMILY DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","80%","50%","$2,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"B3X5025_PF","Dental Plan B w/ Preventive First, $50/$150 Ded, $2,500 Max","PREMIER OPTION B FAMILY DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","80%","50%","$2,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"W3X50_PF","Dental Plan W w/ Preventive First, $50/$150 Ded, $1,500 Max","PREMIER OPTION W FAMILY DED W/ PREVENTIVE FIRST","$50/$150","80%(Ded. wavied)","80%","50%","$1,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"W3X501_PF","Dental Plan W w/ Preventive First, $50/$150 Ded, $1,000 Max","PREMIER OPTION W FAMILY DED W/ PREVENTIVE FIRST","$50/$150","80%(Ded. wavied)","80%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"W3X502_PF","Dental Plan W w/ Preventive First, $50/$150 Ded, $2,000 Max","PREMIER OPTION W FAMILY DED W/ PREVENTIVE FIRST","$50/$150","80%(Ded. wavied)","80%","50%","$2,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"W3X5025_PF","Dental Plan W w/ Preventive First, $50/$150 Ded, $2,500 Max","PREMIER OPTION W FAMILY DED W/ PREVENTIVE FIRST","$50/$150","80%(Ded. wavied)","80%","50%","$2,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X50_PF","Dental Plan B w/ Preventive First, $50/$150 Ded, $1,500 Max","PPO OPTION BP FAMILY DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","80%","50%","$1,500","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X501_PF","Dental Plan B w/ Preventive First, $50/$150 Ded, $1,000 Max","PPO OPTION BP FAMILY DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","80%","50%","$1,000","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X502_PF","Dental Plan B w/ Preventive First, $50/$150 Ded, $2,000 Max","PPO OPTION BP FAMILY DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","80%","50%","$2,000","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BP3X5025_PF","Dental Plan B w/ Preventive First, $50/$150 Ded, $2,500 Max","PPO OPTION BP FAMILY DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","80%","50%","$2,500","80%(Ded. wavied)","60%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BPA3X50_PF","Dental Plan B w/ Preventive First, $50/$150 Ded, $1,500 Max","PPO OPTION BPA FAMILY DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","90%","50%","$1,500","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BPA3X501_PF","Dental Plan B w/ Preventive First, $50/$150 Ded, $1,000 Max","PPO OPTION BPA FAMILY DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","90%","50%","$1,000","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BPA3X502_PF","Dental Plan B w/ Preventive First, $50/$150 Ded, $2,000 Max","PPO OPTION BPA FAMILY DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","90%","50%","$2,000","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BPA3X5025_PF","Dental Plan B w/ Preventive First, $50/$150 Ded, $2,500 Max","PPO OPTION BPA FAMILY DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","90%","50%","$2,500","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BPB3X50_PF","Dental Plan B w/ Preventive First, $50/$150 Ded, $1,500 Max","PPO OPTION BPB FAMILY DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","80%","50%","$1,500","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BPB3X501_PF","Dental Plan B w/ Preventive First, $50/$150 Ded, $1,000 Max","PPO OPTION BPB FAMILY DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","80%","50%","$1,000","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BPB3X502_PF","Dental Plan B w/ Preventive First, $50/$150 Ded, $2,000 Max","PPO OPTION BPB FAMILY DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","80%","50%","$2,000","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"BPB3X5025_PF","Dental Plan B w/ Preventive First, $50/$150 Ded, $2,500 Max","PPO OPTION BPB FAMILY DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","80%","50%","$2,500","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"L3X50_PF","Dental Plan L, $50/$150 Ded, $1,500 Max, includes Preventive First, Composites and Nitrous Oxide","PREMIER OPTION L FAMILY  DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","80%","50%","$1,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"L3X502_PF","Dental Plan L, $50/$150 Ded, $2,000 Max, includes Preventive First, Composites and Nitrous Oxide","PREMIER OPTION L FAMILY  DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","80%","50%","$2,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"L3X5025_PF","Dental Plan L, $50/$150 Ded, $2,500 Max, includes Preventive First, Composites and Nitrous Oxide","PREMIER OPTION L FAMILY  DED W/ PREVENTIVE FIRST","$50/$150","100%(Ded. wavied)","80%","50%","$2,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VB3X50","Voluntary Dental Plan B, $50/$150 Ded, $1,500 Max","VOLUNTARY PREMIER OPTION B FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$1,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VB3X501","Voluntary Dental Plan B, $50/$150 Ded, $1,000 Max","VOLUNTARY PREMIER OPTION B FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","80%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VW3X50","Voluntary Dental Plan W, $50/$150 Ded, $1,500 Max","VOLUNTARY PREMIER OPTION W FAMILY DEDUCTIBLE","$50/$150","80%(Ded. wavied)","80%","50%","$1,500","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VW3X501","Voluntary Dental Plan W, $50/$150 Ded, $1,000 Max","VOLUNTARY PREMIER OPTION W FAMILY DEDUCTIBLE","$50/$150","80%(Ded. wavied)","80%","50%","$1,000","N/A","N/A","N/A"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VBPA3X50","Voluntary Dental Plan B, $50/$150 Ded, $1,500 Max","VOLUNTARY PPO OPTION BPA FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","90%","50%","$1,500","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VBPA3X501","Voluntary Dental Plan B, $50/$150 Ded, $1,000 Max","VOLUNTARY PPO OPTION BPA FAMILY DEDUCTIBLE","$50/$150","100%(Ded. wavied)","90%","50%","$1,000","90%(Ded. wavied)","70%","50%"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"A500","Adult Ortho, 50% to $500 Maximum"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"A1000","Adult Ortho, 50% to $1,000 Maximum"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"A1500","Adult Ortho, 50% to $1,500 Maximum"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"A2000","Adult Ortho, 50% to $2,000 Maximum"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C500","Child Ortho, 50% to $500 Maximum"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C1000","Child Ortho, 50% to $1,000 Maximum"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C1500","Child Ortho, 50% to $1,500 Maximum"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C2000","Child Ortho, 50% to $2,000 Maximum"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AC500","Adult & Child Ortho, 50% to $500 Maximum"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AC1000","Adult & Child Ortho, 50% to $1,000 Maximum"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AC1500","Adult & Child Ortho, 50% to $1,500 Maximum"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AC2000","Adult & Child Ortho, 50% to $2,000 Maximum"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VCO1000","Voluntary Child Ortho, 50% to $1,000 Maximum; 24-month Exclusionary Period"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"VCO1500","Voluntary Child Ortho, 50% to $1,500 Maximum; 24-month Exclusionary Period"]

{"sheet":"Plan Info Lookups","index":5,"n_rows":114,"n_cols":30,"rows_kept":114,"cut":false,"hidden":true,"merged":[]}
[]
["Medical 11-Digit Plan Codes",null,null,null,null,null,"Yellow cells are drop down boxes.  Select your plan's benefit and 11 digit code will populate below."]
[]
[null,null,null,null,null,null,"Plan Type","OV Copay","In-Net Ded","In-Net Coins",null,"In-Net OOP",null,"Out Ded","Out Coins","Out OOP"]
[null,null,null,"Your Plan:",null,null,"PPO","$30","$2000","20%",null,"$3,000",null,"$2000","50%","$15,000"]
[]
[null,null,null,"Your Plan's Code:",null,null,{"$f":"IFERROR(VLOOKUP(G5,C56:D63,2,FALSE)&\"-\"&VLOOKUP(H5,H56:I63,2,FALSE)&VLOOKUP(I5,N56:O371,2,FALSE)&VLOOKUP(J5,T56:U63,2,FALSE)&VLOOKUP(L5,AA56:AB81,2,FALSE)&\"-\"&VLOOKUP(N5,N56:O78,2,FALSE)&VLOOKUP(O5,T56:U63,2,FALSE)&VLOOKUP(P5,AA56:AB96,2,FALSE),\"\")","v":""}]
[]
[null,null,null,"Your Plan's Description:",null,null,{"$f":"IF(G5=\"Beneficial PPO\",G5&\" : \"&H5&\"(5) OV, \"&I5&\" In-net Ded, \"&J5&\" (\"&L5&\")\"&\"; Out: \"&N5&\" Ded, \"&O5&\" (\"&P5&\")\",IF(G5=\"HSA PPO\",G5&\" : \"&I5&\" In-net Ded, \"&J5&\" (\"&L5&\")\"&\"; Out: \"&N5&\" Ded, \"&O5&\" (\"&P5&\")\",G5&\" : \"&H5&\" OV, \"&I5&\" In-net Ded, \"&J5&\" (\"&L5&\")\"&\"; Out: \"&N5&\" Ded, \"&O5&\" (\"&P5&\")\"))","v":"PPO : $30 OV, $2000 In-net Ded, 20% ($3,000); Out: $2000 Ded, 50% ($15,000)"}]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"Example:","2-150202-2404"," = PPO Copay: $15 ov, 20% ($2,000),Out: $250 Ded/ 40% ($4,000)"]
[null,null,"A-BBCDEE-FGHH"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
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[]
[null,"Plan Type Options: A",null,null,null,null,"OV Copay Options - BB",null,null,null,null,null,"Deduct Options: C and F",null,null,null,null,null,"Coinsurance: D and G",null,null,null,null,null,null,"OOP Max - EE and  HH"]
[null,"Source:","Quotes_51.xls",null,null,null,"Source:","Quotes_51.xls",null,null,null,null,"Source:","Quotes_51.xls",null,null,null,null,"Source:","Quotes_51.xls",null,null,null,null,null,"Source:","Quotes_51.xls"]
[null,"Updated:","2/28/2008 TS",null,null,null,"Updated:","2/28/2008 TS",null,null,null,null,"Updated:","2/28/2008 TS",null,null,null,null,"Updated:","2/28/2008 TS",null,null,null,null,null,"Updated:","2/28/2008 TS"]
[null,"Notes:","Named Range \"PlanID_type\"",null,null,null,null,"Named Range \"PlanID_Copay\"",null,null,null,null,"Notes:","Named Range \"PlanID_ded\"",null,null,null,null,"Notes:","Named Range \"PlanID_coinsurance\"",null,null,null,null,null,"Notes:","Named Range \"PlanID_OOP\""]
[]
[]
[null,"Code","Description","Code (restated)",null,null,"Code","Description","Code (restated)","Copay Value",null,null,"Code","Description","Code (restated)","Deductible Value",null,null,"Code","Description","Code (restated)","Coinsurance Value","HSA RX Descriptoin",null,null,"Code","Description","Code (restated)","Value"]
[null,"1","Indemnity (51+)","1",1,null,"00","Deductible Applies","00",0,1,null,"0","No Ded","0",0,1,null,"0","0%","0",0,"100% MM RX Subject to Deductible",1,null,"00","No OOP Max","00",0,1]
[null,"2","PPO","2",2,null,"10","$10","10",10,2,null,"2","$250","2",250,2,null,"1","10%","1",0.1,"90% MM RX Subject to Deductible",2,null,"01","$1,000","01",1000,2]
[null,"3","POS","3",3,null,"15","$15","15",15,3,null,"5","$500","5",500,3,null,"2","20%","2",0.2,"80% MM RX Subject to Deductible",3,null,"11","$1,500","11",1500,3]
[null,"B","Beneficial PPO","B",6,null,"20","$20","20",20,4,null,"7","$750","7",750,4,null,"6","25%","6",0.25,"75% MM RX Subject to Deductible",4,null,"16","$1,600","16",1600,4]
[null,"D","HSA PPO Deductible Embedded","D",7,null,"25","$25","25",25,5,null,"9","$1000","9",1000,5,null,"3","30%","3",0.3,"70% MM RX Subject to Deductible",5,null,"17","$1,750","17",1750,5]
[null,"E","HSA Embedded Individual OOP","E",8,null,"30","$30","30",30,6,null,"L","$1200","L",1200,6,null,"4","40%","4",0.4,"60% MM RX Subject to Deductible",6,null,"02","$2,000","02",2000,6]
[null,"H","HSA PPO","H",9,null,"35","$35","35",35,7,null,"R","$1300","R",1300,7,null,"5","50%","5",0.5,"50% MM RX Subject to Deductible",7,null,"LG","$2,200","LG",2200,7]
[null,"V","Value PPO","V",12,null,"40","$40","40",40,8,null,"X","$1,350","X",1350,31,null,"7","$100/Day In-Hosp (5), 10% Coins","7","NA",null,8,null,"22","$2,250","22",2250,8]
[null,null,null,null,null,null,"50","$50","50",50,null,null,"1","$1500","1",1500,8,null,null,null,null,null,null,null,null,"25","$2,500","25",2500,9]
[null,null,null,null,null,null,"75","$75","75",75,null,null,"6","$2000","6",2000,9,null,null,null,null,null,null,null,null,"28","$2,800","28",2800,10]
[null,null,null,null,null,null,null,null,null,null,null,null,"T","$2400","T",2400,10,null,null,null,null,null,null,null,null,"03","$3,000","03",3000,11]
[null,null,null,null,null,null,null,null,null,null,null,null,"8","$2500","8",2500,11,null,null,null,null,null,null,null,null,"32","$3,200","32",3200,12]
[null,null,null,null,null,null,null,null,null,null,null,null,"S","$2600","S",2600,12,null,null,null,null,null,null,null,null,"33","$3,250","33",3250,13]
[null,null,null,null,null,null,null,null,null,null,null,null,"Z","$2,700","Z",2700,32,null,null,null,null,null,null,null,null,"34","$3,275","34",3275,14]
[null,null,null,null,null,null,null,null,null,null,null,null,"H","$2800","H",2800,13,null,null,null,null,null,null,null,null,"35","$3,500","35",3500,15]
[null,null,null,null,null,null,null,null,null,null,null,null,"3","$3000","3",3000,14,null,null,null,null,null,null,null,null,"37","$3,750","37",3750,16]
[null,null,null,null,null,null,null,null,null,null,null,null,"U","$3,275","U",3275,15,null,null,null,null,null,null,null,null,"SM","$3,800","SM",3800,17]
[null,null,null,null,null,null,null,null,null,null,null,null,"F","$3500","F",3500,16,null,null,null,null,null,null,null,null,"04","$4,000","04",4000,18]
[null,null,null,null,null,null,null,null,null,null,null,null,"4","$4000","4",4000,17,null,null,null,null,null,null,null,null,"MX","$4,400","MX",4400,19]
[null,null,null,null,null,null,null,null,null,null,null,null,"Q","$4500","Q",4500,18,null,null,null,null,null,null,null,null,"45","$4,500","45",4500,20]
[null,null,null,null,null,null,null,null,null,null,null,null,"D","$5000","D",5000,19,null,null,null,null,null,null,null,null,"47","$4,750","47",4750,21]
[null,null,null,null,null,null,null,null,null,null,null,null,"B","$5600","B",5600,20,null,null,null,null,null,null,null,null,"05","$5,000","05",5000,22]
[null,null,null,null,null,null,null,null,null,null,null,null,"A","$6000","A",6000,21,null,null,null,null,null,null,null,null,"52","$5,250","52",5250,23]
[null,null,null,null,null,null,null,null,null,null,null,null,"M","$7000","M",7000,22,null,null,null,null,null,null,null,null,"55","$5,500","55",5500,24]
[null,null,null,null,null,null,null,null,null,null,null,null,"E","$7500","E",7500,23,null,null,null,null,null,null,null,null,"57","$5,750","57",5750,25]
[null,null,null,null,null,null,null,null,null,null,null,null,"C","$8000","C",8000,24,null,null,null,null,null,null,null,null,"06","$6,000","06",6000,26]
[null,null,null,null,null,null,null,null,null,null,null,null,"P","$9000","P",9000,25,null,null,null,null,null,null,null,null,"63","$6,350","63",6350,27]
[null,null,null,null,null,null,null,null,null,null,null,null,"G","$10000","G",10000,26,null,null,null,null,null,null,null,null,"64","$6,400","64",6400,28]
[null,null,null,null,null,null,null,null,null,null,null,null,"I","$15000","I",15000,27,null,null,null,null,null,null,null,null,"19","$6,450","19",6450,29]
[null,null,null,null,null,null,null,null,null,null,null,null,"N","$21,000","N",21000,28,null,null,null,null,null,null,null,null,"65","$6,500","65",6500,30]
[null,null,null,null,null,null,null,null,null,null,null,null,"J","$22,500","J",22500,29,null,null,null,null,null,null,null,null,"67","$6,550","67",6550,31]
[null,null,null,null,null,null,null,null,null,null,null,null,"K","$30,000","K",30000,30,null,null,null,null,null,null,null,null,"66","$6,600","66",6600,32]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"H6","$6,650","H6",6650,56]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"H1","$6,850","H1",6850,33]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"07","$7,000","07",7000,34]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"71","$7,150","71",7150,35]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"H8","$7,350","H8",7350,58]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"75","$7,500","75",7500,36]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MN","$7,600","MN",7600,37]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"08","$8,000","08",8000,38]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"85","$8,500","85",8500,39]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"09","$9,000","09",9000,40]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"10","$10,000","10",10000,41]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"13","$10,500","13",10500,42]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"56","$11,000","56",11000,43]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"12","$12,000","12",12000,44]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"29","$12,500","29",12500,45]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"27","$12,700","27",12700,46]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"62","$12,900","62",12900,47]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"43","$13,100","43",13100,48]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"86","$13,200","86",13200,49]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"H7","$13,300","H7",13300,57]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"14","$13,500","14",13500,50]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"H2","$13,700","H2",13700,51]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"74","$14,300","74",14300,52]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"H9","$14,700","H9",14700,59]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"15","$15,000","15",15000,53]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"87","$20,000","87",20000,54]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"30","$30,000","30",30000,55]

{"sheet":"Page 4 - Rates Insured","index":6,"n_rows":37,"n_cols":7,"rows_kept":37,"cut":false,"hidden":false,"merged":[[6,2,6,3],[5,4,5,5],[15,6,15,8],[20,6,20,8],[18,6,18,8],[17,6,17,8],[14,6,14,8],[6,5,6,6],[8,6,8,8],[9,6,9,8],[10,6,10,8],[15,0,15,2],[0,0,1,8],[4,0,4,1],[4,2,4,3],[4,7,4,8],[3,4,3,5],[4,4,4,5],[31,0,31,3],[33,4,33,8],[31,4,31,8],[29,4,29,8],[26,6,26,8],[29,0,29,3],[28,0,28,2],[36,4,36,8],[33,0,33,3],[34,0,34,3],[35,0,35,3],[36,0,36,3],[34,4,34,8],[35,4,35,8],[21,0,21,2],[21,6,21,8],[19,6,19,8],[16,0,16,2],[11,6,11,8],[12,6,12,8],[13,6,13,8],[20,0,20,2],[16,6,16,8]]}
["RATE INFORMATION - Insured"]
[]
[]
["Funding Type:"]
["Rate Structure:"]
["Rating Area:",null,null,null,{"$f":"IFERROR(IF(VLOOKUP('Page 1'!#REF!,#REF!,1,FALSE)='Page 1'!#REF!,VLOOKUP('Page 1'!#REF!,#REF!,2,FALSE)),\"\")","v":""}]
["Effective Date: ",null,"",null,"Ending Date:",{"$f":"IF(C7=\"\",\"\",(C7+364))","v":""}]
[]
["RATES",null,null,{"$f":"IF(E5=\"\",\"\",IF(E5=\"4 Tier\",\"EE Only\",IF(E5=\"3 Tier\",\"Emp Only\",IF(E5=\"Composite\",\"\",IF(E5=\"ASO\",\"\",IF(E5=\"Other-see comments\",\"\"))))))","v":""},{"$f":"IF(E5=\"\",\"\",IF(E5=\"4 Tier\",\"EE + SP\",IF(E5=\"3 Tier\",\"Emp + 1\",IF(E5=\"Composite\",\"\",IF(E5=\"ASO\",\"\",IF(E5=\"Other-see comments\",\"\"))))))","v":""},{"$f":"IF(E5=\"\",\"\",IF(E5=\"4 Tier\",\"EE + Family\",IF(E5=\"3 Tier\",\"Emp + 2 or more\",IF(E5=\"Composite\",\"\",IF(E5=\"ASO\",\"\",IF(E5=\"Other-see comments\",\"\"))))))","v":""},{"$f":"IF(E5=\"\",\"\",IF(E5=\"4 Tier\",\"EE + Child(ren)\",IF(E5=\"3 Tier\",\"\",IF(E5=\"Composite\",\"\",IF(E5=\"ASO\",\"\",IF(E5=\"Other-see comments\",\"\"))))))","v":""}]
["Employee Counts"]
["Medical rate"]
["RX Buy Up rate"]
["Hearing Aid Rider"]
["Vision rate"]
["Wellness Services rate"]
["SUBTOTAL MEDICAL",null,null,{"$f":"SUM(D11:D15)","v":0},{"$f":"SUM(E11:E15)","v":0},{"$f":"SUM(F11:F15)","v":0},{"$f":"SUM(G11:G15)","v":0}]
["*SUBTOTAL VISION",null,null,0,0,0,0]
["Dental Employee Counts"]
["Dental rate"]
["Orthodontia rate"]
["SUBTOTAL DENTAL",null,null,{"$f":"SUM(D19:D20)","v":0},{"$f":"SUM(E19:E20)","v":0},{"$f":"SUM(F19:F20)","v":0},{"$f":"SUM(G19:I20)","v":0}]
["TOTAL BILLED",null,null,{"$f":"SUM(D21+D17+D16)","v":0},{"$f":"SUM(E21+E17+E16)","v":0},{"$f":"SUM(F21+F17+F16)","v":0},{"$f":"+G16+G17+G21","v":0}]
[]
["* Non-Standard - Unhide & Use Row 17 if Vision rates need to be broken out from Medical Rates on bill."]
["      (Vision rates would also need to be subtracted from Subtotal Medical, so they are not shown twice)"]
[]
["Rate Guarantee?",null,null,null,"Estimated First Month's Premium:",null,{"$f":"SUMPRODUCT(D10:I10,D16:I16)+SUMPRODUCT(D10:I10,D17:I17)+SUMPRODUCT(D18:I18,D21:I21)","v":0}]
[]
["Payment Information:"]
["Premium Payment Method "]
[]
[]
["Commission:"]
["Agent Commission (Medical)"]
["Agent Commission (Dental)"]
["Agent Commission (Pharmacy)"]
["Agent Commission (Vision)"]

{"sheet":"Page 4 - Rates ASO","index":7,"n_rows":77,"n_cols":6,"rows_kept":77,"cut":false,"hidden":false,"merged":[[44,1,44,2],[0,0,1,10],[2,0,2,1],[2,2,2,3],[2,5,2,7],[2,9,2,10],[4,9,4,10],[6,5,6,6],[11,5,11,6],[26,1,26,2],[27,1,27,2],[41,5,41,6],[63,0,63,3],[63,4,63,9],[45,1,45,2],[50,5,50,6],[52,12,52,14],[57,0,57,9],[58,0,58,3],[58,4,58,9],[58,11,58,14],[59,0,59,3],[59,4,59,9],[61,5,61,9],[62,0,62,3],[62,4,62,9],[73,0,73,3],[73,4,73,7],[64,0,64,9],[65,2,65,7],[66,2,66,7],[67,2,67,7],[68,2,68,7],[69,2,69,7],[72,0,72,3],[72,4,72,7],[74,0,74,3],[74,4,74,7],[75,0,75,3],[75,4,75,7],[76,0,76,3],[76,4,76,7]]}
["RATE INFORMATION - ASO"]
[]
["Effective Date: ",null,null,null,"Ending Date:"]
[]
["RATES"]
[null,null,null,null,null,"Amount:"]
["Dental",null,null,null,null,"PEPM"]
["Administration:"]
["Commission:"]
["Total:",null,null,null,null,{"$f":"SUM(F8:F9)","v":0}]
[]
["Medical ",null,null,null,null,"PEPM"]
["Administration:"]
["PPO Access Fee"]
["Commission:"]
["E-Doc & Nurseline Fee:"]
["Tobacco Cessation Fee (Alere):"]
["EAP (Employer Assistance Program) Fee:"]
["Injectable Benefits Management Fee (I-CORE):"]
["Subrogation Fee:",null,null,"25% of Savings"]
["Claims Management (CM2) Fee:",null,null,"25% of Savings"]
["ACHIA (Alaska Comprehensive Health Insurance Assoc):"]
["Alaska State Tax:"]
["Wellness Services:",null,null,"EE + Spouse"]
["Other:",null,null,"ID Cards"]
[]
[null,"Imaging Management (eviCore) (claim's expense)",null,"$0.55 pmpm","No"]
[null,"Enhanced Musculoskeletal Review (eviCore) (claim's expense)",null,"$1.00 pmpm","No"]
["Total:",null,null,null,null,{"$f":"SUM(F13:F25)","v":0}]
[]
["# of Subscribers:"]
["Stop Loss Contract Type:"]
["Specific Stop Loss Fee:",null,null,null,null,{"$f":"+D33","v":0}]
["Specific Level:"]
["Aggregate Stop Loss Fee:",null,null,null,null,{"$f":"+D35","v":0}]
["Aggregate Attachment Point:"]
["Aggregate Level:"]
["Minimum Aggregate Ded (85%):"]
["Stop Loss Interface Fee (for a Stop Loss carrier other than Moda)",null,null,null,null,0]
["Total Stop Loss Fees:",null,null,null,null,{"$f":"+F39+F35+F33","v":0}]
[]
["Pharmacy "]
["Administration:",null,"Commercial Group"]
[null,"Moda Administration",null,null,null,"Incl. in Medical"]
[null,"PBM fee (Rx claim's expense)",null,"$0.90 per script"]
[null,{"$f":"IF(C43=\"Consortium Group\",\"Eprescribing-Commercial fee (Rx claim's expense)\",\"\")","v":""},null,{"$f":"IF(C43=\"Consortium Group\",\"$0.20 per Eprescribed transaction\",\"\")","v":""}]
["PBM Interface Fee (for a PBM other than Moda)",null,null,null,null,0]
["Commission:"]
["Total:",null,null,null,null,{"$f":"SUM(F43:F48)","v":0}]
[]
["Vision"]
["Administration:",null,null,null,null,"Incl. in Medical"]
["Commission:"]
["Total :",null,null,null,null,{"$f":"SUM(F52:F53)","v":0}]
[]
[]
[]
["ASO Administration - Payment Information "]
["ASO Admin Billing Method:"]
["If list bill, Admin will be paid by:"]
[]
["ASO Claims - Payment Information"]
["ACH Claims Frequency:"]
["ASO Claims Payment Method:"]
["ASO Claims Billing  "]
["Contact Name:"]
["Address:"]
["Phone:"]
["Fax:"]
["Email:"]
[]
["Utilization Report"]
["Will report be sent with the bill or alone?"]
["Report style:"]
["Has PHI Agreement been submitted?"]
["How will group receive bill (mail, fax or email)?"]
["Frequency of Utilization Report:"]

{"sheet":"Page 4 - Rates Minimum Premium","index":8,"n_rows":42,"n_cols":9,"rows_kept":42,"cut":false,"hidden":true,"merged":[[9,7,9,8],[28,7,28,8],[24,7,24,8],[27,7,27,8],[25,7,25,8],[26,7,26,8],[19,7,19,8],[18,7,18,8],[13,7,13,8],[10,7,10,8],[22,0,22,8],[24,0,24,2],[5,7,5,8],[6,7,6,8],[7,7,7,8],[8,7,8,8],[0,0,1,8],[3,0,3,1],[3,2,3,3],[3,7,3,8],[41,0,41,3],[41,4,41,8],[38,0,38,2],[39,0,39,3],[39,4,39,8],[40,0,40,3],[40,4,40,8],[30,0,30,2],[31,0,31,2],[30,7,30,8],[31,7,31,8],[32,7,32,8],[33,7,33,8],[34,7,34,8],[11,7,11,8],[12,7,12,8],[14,7,14,8],[16,7,16,8],[15,7,15,8],[17,7,17,8],[29,7,29,8]]}
["RATE INFORMATION - Minimum Premium"]
[]
[]
["Rate Structure:",null,null,null,"Effective Date:",null,"Ending Date:"]
[]
["RATES",null,null,{"$f":"IF(C4=\"\",\"\",IF(C4=\"4 Tier\",\"EE\",IF(C4=\"3 Tier\",\"Emp Only\",IF(C4=\"Composite\",\"PEPM\",IF(C4=\"ASO\",\"PEPM\",IF(C4=\"Other-see comments\",\"\"))))))","v":""},{"$f":"IF(C4=\"\",\"\",IF(C4=\"4 Tier\",\"EE + SP\",IF(C4=\"3 Tier\",\"Emp + 1\",IF(C4=\"Composite\",\"\",IF(C4=\"ASO\",\"\",IF(C4=\"Other-see comments\",\"\"))))))","v":""},{"$f":"IF(C4=\"\",\"\",IF(C4=\"4 Tier\",\"EE + Family\",IF(C4=\"3 Tier\",\"Emp + 2 or more\",IF(C4=\"Composite\",\"\",IF(C4=\"ASO\",\"\",IF(C4=\"Other-see comments\",\"\"))))))","v":""},{"$f":"IF(C4=\"\",\"\",IF(C4=\"4 Tier\",\"EE + Child(ren)\",IF(C4=\"3 Tier\",\"\",IF(C4=\"Composite\",\"\",IF(C4=\"ASO\",\"\",IF(C4=\"Other-see comments\",\"\"))))))","v":""},"Total"]
["Employee Counts",null,null,null,null,null,null,{"$f":"SUM(D7:G7)","v":0}]
["Medical Min. Premium Rate",null,null,null,null,null,null,{"$f":"($D$7*D8)+($E$7*E8)+($F$7*F8)+($G$7*G8)","v":0}]
["Medical MCL Premium Rate",null,null,null,null,null,null,0]
["Rx Min. Premium Rate",null,null,null,null,null,null,0]
["Rx MCL Premium Rate",null,null,null,null,null,null,0]
["Vision Min. Premium Rate",null,null,null,null,null,null,0]
["Vision MCL Premium Rate",null,null,null,null,null,null,0]
["SUBTOTAL MEDICAL",null,null,{"$f":"SUM(D8:D9)","v":0},{"$f":"SUM(E8:E9)","v":0},{"$f":"SUM(F8:F9)","v":0},{"$f":"SUM(G8:G9)","v":0},{"$f":"SUM(H8:I13)","v":0}]
["Dental Min. Premium Rate",null,null,null,null,null,null,{"$f":"($D$7*D15)+($E$7*E15)+($F$7*F15)+($G$7*G15)","v":0}]
["Dental MCL Premium Rate",null,null,null,null,null,null,{"$f":"($D$7*D16)+($E$7*E16)+($F$7*F16)+($G$7*G16)","v":0}]
["Ortho Min. Premium Rate",null,null,null,null,null,null,{"$f":"($D$7*D17)+($E$7*E17)+($F$7*F17)+($G$7*G17)","v":0}]
["Ortho MCL Premium Rate",null,null,null,null,null,null,{"$f":"($D$7*D18)+($E$7*E18)+($F$7*F18)+($G$7*G18)","v":0}]
["SUBTOTAL DENTAL",null,null,{"$f":"SUM(D15:D17)","v":0},{"$f":"SUM(E15:E17)","v":0},{"$f":"SUM(F15:F17)","v":0},{"$f":"SUM(G15:G17)","v":0},{"$f":"SUM(H15:I18)","v":0}]
["TOTAL BILLED",null,null,{"$f":"SUM(D14+D19)","v":0},{"$f":"SUM(E14+E19)","v":0},{"$f":"SUM(F14+F19)","v":0},{"$f":"SUM(G14+G19)","v":0},{"$f":"SUM(H14+H19)","v":0}]
["* Indicate only if Vision rates should be broken out from Medical and Dental Rates on bill."]
[]
[]
["Misc. Information",null,null,null,null,null,null,null,"Included in Minimum Premium rates above?"]
["Specific SL level"]
["Reserves: Medical"]
["Reserves: RX"]
["Reserves: Vision"]
["Reserves: Dental"]
["Reserves: Orthodontia"]
["Agent Commission: Medical"]
["Agent Commission: Rx"]
["Agent Commission: Vision"]
["Agent Commission: Dental"]
["Agent Commission: Orthodontia"]
[]
[]
[]
["Payment Information"]
["Premium Payment Method "]
["ACH  frequency"]
["Positive/Negative billing:"]

{"sheet":"Page 5 - Agent-Signature pg","index":9,"n_rows":41,"n_cols":31,"rows_kept":41,"cut":false,"hidden":false,"merged":[[0,0,0,10],[38,5,38,6],[31,5,31,6],[33,0,33,3],[35,5,35,6],[3,2,3,5],[36,5,36,6],[22,0,23,10],[3,7,3,10],[4,2,4,5],[11,0,14,10],[16,0,19,10],[2,2,2,5],[2,7,2,10]]}
["AGENT INFORMATION"]
[]
["Agent Name",null,"",null,null,null,"Tax ID #",""]
["Agency",null,"",null,null,null,"License #",""]
["NPN",null,null,null,null,null,null,null,null,null,null,"",null,null,null,null,null,null,null,null,null,null,null,null,null,"AGENT 1",7,8,null,"Tax ID / SS #",11]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Agency",9,null,null,"Phone #",20]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Comm. Address",18,null,null,"Fax #",21]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"City/St/Zip",19,null,null,"Email Address",22]
[null,null,null,null,null,null,null,null,"Split Commission Amount:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Physical Address",12,null,null,"License #",23]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"City/St/Zip",13,14,15,null,"Split Commission"]
[]
["I hereby make application to Moda Health/Delta Dental, on behalf of the Group, for the Group Policies indicated in this group application.  I understand that there is no coverage in effect until Moda Health/Delta Dental accepts this Application and premium deposit and establishes an effective date.  If this Application is not accepted, the premium deposit will be refunded."]
[]
[]
[]
[]
["I hereby certify all eligible employees are enrolling in the selected Group Policies and all enrolling employees meet the eligibility requirements specified above.  In addition, I hereby appoint the above agent as our Producer of Record to represent us in matters of group insurance benefits provided by Moda Health/Delta Dental.  This appointment is in effect on the same day as this Policy and will remain in force until rescinded in writing."]
[]
[]
[]
[]
["For all medical plans:"]
["In addition, I hereby acknowledge responsibility on behalf of the Group to provide the  Summary of Benefits & Coverage (SBC), Uniform Glossary, and the Initial Notice of HIPAA Special Enrollment Right and Exclusion Periods to all employees on or before the date they enroll in the selected Group Policies."]
[]
[]
[]
["By signing below, I agree that the signature will be the electronic representation of my signature"]
["and initials for all purposes when I (or my agent) uses them on documents, including legally binding contracts."]
[]
["X"]
["Authorized Signature for GROUP",null,null,null,null,null,null,"Authorized Signer's Title"]
[]
["Authorized Signer's Printed Name",null,null,null,null,null,null,null,"Date"]
[]
["X"]
["Authorized PRODUCER Signature"]
[]
["Authorized Producer's Printed Name",null,null,null,null,null,null,null,"Date"]
[]
["X"]
["Sales/Service Representative Signature",null,null,null,null,null,null,null,"Date"]

{"sheet":"Page 6 - Reports (Internal)","index":10,"n_rows":36,"n_cols":7,"rows_kept":36,"cut":false,"hidden":true,"merged":[[33,2,33,3],[0,0,0,6],[29,2,29,6]]}
["REPORTS"]
["Medical","51-100","100-300","300-999","1000+","To \n(Group/\nAgent)","CC \n(Group/\nAgent)"]
["Activity","N/A","M","M","M"]
["Large Claims","N/A","M","M","M"]
["Case Management","N/A","M","M","M"]
["Income-Cost Experience","N/A","N/A","Annual\n(Refunding)","Annual\n(Refunding)"]
["Lag Report (see below)","N/A","N/A","M (ASO)","M (ASO)"]
["Schedule A, form 5500 (fully-insured groups)","N/A","A","A","A"]
["CM2 ","N/A","M","M","M"]
["Actuarial Cost and Utilization Analysis","N/A","N/A","A","A"]
[]
["Pharmacy","51-100","100-300","300-999","1000+","To \nGroup","To \nAgent"]
["RX Report","N/A","Q","Q","Q"]
[]
["Dental","51-100","100-300","300-999","1000+","To \nGroup","To \nAgent"]
["Activity","N/A","M","M","M"]
["Income-Cost Experience","N/A","N/A","Annual\n(Refunding)","Annual\n(Refunding)"]
["Lag Report (see below)","N/A","N/A","M (ASO)","M (ASO)"]
["Schedule A, form 5500 (fully-insured groups)","N/A","A","A","A"]
["Standard Online Reporting Packages:"]
["Medical Monthly Reports",null,"Dental Monthly Reports"]
["Activity Report",null,"Activity Report"]
["Distribution of Charges",null,"Distribution of Charges"]
["Distribution of Paid",null,"Distribution of Paid"]
["Large Claims Report",null,"Savings Report"]
["Savings Report",null,"Tiered Enrollment Report"]
["Tiered Enrollment Report"]
[]
["Report Distribution:"]
["Group Contact Name"]
["Agent Contact Name"]
[]
["Online Reporting:"]
["Will group access online reporting:"]
["If yes, complete and attach Electronic Service Agreement."]
["Comments"]

{"sheet":"Page 7 - ESA Agreement ","index":11,"n_rows":0,"n_cols":0,"rows_kept":0,"cut":false,"hidden":false,"merged":[]}

{"sheet":"Nondiscrimination_Taglines","index":12,"n_rows":0,"n_cols":0,"rows_kept":0,"cut":false,"hidden":false,"merged":[]}

{"sheet":"Page 8 - Acct Structure ","index":13,"n_rows":48,"n_cols":7,"rows_kept":48,"cut":false,"hidden":false,"merged":[[0,1,0,8],[35,2,35,5],[38,2,38,7],[27,1,27,8],[12,2,12,5],[10,2,10,5],[14,2,14,5],[4,3,4,8],[6,2,6,4],[7,2,7,4],[2,1,2,8],[3,2,3,4],[3,6,3,8],[47,1,47,8],[7,6,7,8],[6,6,6,8],[5,6,5,8],[5,3,5,4],[15,1,15,8],[29,2,29,5],[31,2,31,5],[33,2,33,5]]}
[null,"Account Structure Worksheet"]
[null,null,"Cobra"]
[null,"Moda Health subsidiary, BenefitHelp Solutions (BHS), provides COBRA Administration at no additional cost to Moda Health Medical Groups or Moda Health Medical Groups with Delta Dental of Alaska with 51-99 members.  Fees will apply to groups with 100+ eligible.  If electing to use BHS to administer your COBRA, mark Yes for question 9b."]
[null,"9.","Does the group use a TPA for COBRA or Retiree Administration? ",null,null," (Y/N):"]
[null,"9a.","If yes, enter TPA name:"]
[null,null,"Phone:",null,null,"Contact:"]
[null,"9b","If no, will the group elect COBRA administration through BenefitHelp Solutions (BHS)?                                                                                                                      (Y/N):  "]
[null,"9c","Who will be paying the COBRA premiums?"]
[]
[null,"     Billing "]
[null,"1.","Are billing statements sent to multiple locations? If yes, please list each location and their billing address below."]
[null,null,null,null,null,null," (Y/N):"]
[null,"2.","Will the group need the members separated on the invoice?"]
[null,null,null,null,null,null," (Y/N):"]
[null,null,"If yes, please be sure to indicate the subgroup that each member belongs to on their enrollment form.  Please list these subgroups below."]
[null,"If you answered yes to any of the above questions, please list each location/subgroup and their billing address:"]
[]
[null,null,"Define Subgroups:",null,"Subgroup Address:"]
[null,"I.",null,null,"Address 1"]
[]
[null,"II.",null,null,"Address 2"]
[]
[null,"III.",null,null,"Address 3"]
[]
[]
[]
[null,null,"Class Structure"]
[null,"3.   Does the billing statement need to be sorted by classification?"]
[null,null,null,null,null,null," (Y/N):"]
[null,"4.","Do all employees have the same benefit options?"]
[null,null,null,null,null,null," (Y/N):"]
[null,"5.","Are there specific reporting requirements for each classification of employee?"]
[null,null,null,null,null,null," (Y/N):"]
[null,"6. ","Is the eligibility waiting period the same for each classification?"]
[null,null,null,null,null,null," (Y/N):"]
[null,"7. ","Does each class use the network listed on page 3?"]
[null,null,null,null,null,null," (Y/N):"]
[]
[null,"8.","If you answered yes to any of the above questions, please define the classes and benefits below."]
[null,null,"Define Classifications:",null,"Define Benefits:"]
[null,"I.",null,null,"Benefit 1"]
[null,"II.",null,null,"Benefit 2"]
[null,"III.",null,null,"Benefit 3"]
[null,"IV.",null,null,"Benefit 4"]
[null,"V.",null,null,"Benefit 5"]
[null,"VI.",null,null,"Benefit 6"]
[]
[null,"Comments:"]

{"sheet":"RX_ELIGIBILITY_LG_DROPDOWN (2)","index":14,"n_rows":18,"n_cols":5,"rows_kept":18,"cut":false,"hidden":true,"merged":[]}
[]
["Discount Card",null,null,null,"Date of Hire"]
["Modified",null,null,null,"1st of the month after DOH or DOH when 1st of the month"]
["RX01525502XC90",null,null,null,"1st of the month after DOH or DOH when 1st of the month plus one month orientation period"]
["RX01535502XC90",null,null,null,"30 days"]
["RX1020%502XC90",null,null,null,"30 days plus one month orientation period"]
["RX1020502XC90",null,null,null,"60 days"]
["RX1025502XC90",null,null,null,"60 days plus one month orientation period"]
["RX1525$502XC90",null,null,null,"90 days (dental only)"]
["RX1525502XC90",null,null,null,"90 days plus one month orientation period (dental only)"]
["RX15502XC90"]
["RX250D15DW25502XC90"]
["RX25CA90"]
["RX30CA90"]
["RX35CA90"]
["RX515502XC90"]
["RX60C90"]
["RX70C90"]

{"sheet":"Checklist","index":15,"n_rows":33,"n_cols":9,"rows_kept":33,"cut":false,"hidden":true,"merged":[[25,6,25,7],[20,0,20,3],[25,0,25,3],[22,8,22,9],[33,4,33,9],[27,8,27,9],[26,8,26,9],[32,4,32,9],[28,0,28,3],[28,4,28,5],[26,0,26,3],[26,6,26,7],[27,6,27,7],[28,6,28,7],[32,0,32,2],[27,4,27,5],[26,4,26,5],[30,0,30,9],[28,8,28,9],[31,4,31,9],[0,0,0,10],[18,0,18,10],[2,4,2,5],[2,8,2,9],[3,0,3,3],[7,0,9,9],[2,6,2,7],[3,6,3,7],[3,4,3,5],[3,8,3,9],[5,0,5,3],[4,8,4,9],[4,0,4,3],[4,4,4,5],[4,6,4,7],[5,6,5,7],[21,6,21,7],[25,4,25,5],[21,4,21,5],[27,0,27,3],[5,8,5,9],[5,4,5,5],[11,0,12,9],[22,0,22,3],[22,4,22,5],[21,0,21,2],[20,4,20,5],[20,6,20,7],[21,8,21,9],[22,6,22,7],[20,8,20,9],[25,8,25,9],[24,0,24,3]]}
["NEW & RENEWALS"]
["THE GROUP PLAN IS BEST DEFINED AS "]
[null,null,null,null,"Medical",null,"Pharmacy",null,"Dental"]
["ODS STANDARD PLAN - Group accepts contract comparison changes effective under plans pertaining to Medical (all 4-digit plans (2-50) and all 11- digit plans (51+)) and Dental (all plans)."]
["NON-STANDARD PLAN - Group does not accept all contract comparison changes effective under standard plans.  Intended benefits fall within the variables filed with the state and group is defined as a non-standard ODS plan.  If unknown, verify plan type with Contract Department."]
["NEGOTIATED PLAN - Group does not accept all contract comparison changes effective under standard plans.  Benefit design is unique to ODS and group plan is defined as a negotiated plan.  If unknown, verify plan type with Contract Department."]
[]
["PLEASE NOTE: Management approval is required for: 1) New groups with less than 100 employees/primary subscribers enrolled requesting a non-standard or negotiated plan, 2) Existing groups with less than 100 employees/primary subscribers enrolled switching."]
[]
[]
[]
["Management approval is not required for existing groups currently on a non-standard or negotiated plan to continue on a non-standard or negotiated plan."]
[]
[]
["Marketing Management Approval ",null,null,"Date"]
[null,null,null,null,null,null," "]
["Underwriting Management Approval ",null,null,"Date"]
[]
["RENEWALS ONLY"]
[]
["#1 Please Check One:",null,null,null,"Medical",null,"Pharmacy",null,"Dental"]
["Group is renewing with current Plan design."]
["Group is renewing with Plan design changes."]
[]
["#2 Please Check One:"]
["Group has accepted all changes indicated on plan comparison (do not include copy of contract comparison with the group app)."]
["**Group has not accepted changes on the plan comparison (include copy of contract comparison with the group app)."]
["Plan comparison is still being reviewed by the group/agent.  Upon receipt of approval, Marketing will forward a copy to the Contracts Department and the Benefits Programming Department."]
["The contract comparison is currently being drafted by the Contract Department and has NOT been sent to the group or agent.  Upon receipt of approval, Marketing will forward a copy to both the Contracts Department and the Benefits Programming Department."]
[]
["**If all benefits are not accepted, a contract comparison, whether it is signed by the group or not, must be included with all renewal group applications in order to begin programming and drafting contracts/member handbooks."]
[null,null,null,"Medical","Dental"]
["Indicate the Group Plan Changes version that was sent to the group            "]