Premium Summary
for Conseco Medical Insurance Company's
Classic Choice
*** PPO (Beech Street) Quote *** |
| |
Deduct.
$1,000 |
| PPO 80/20
of $5,000 |
Co-Pay
$15 |
| Basic Premium |
$63.43 |
| Optional Benefits |
$.00 |
| SUBTOTAL: |
$63.43 |
| Fees: |
$11.66 |
| Total Mthly.
Premium: |
|
| Total Qrtly.
Premium: |
$225.27 |
|
|
|
| Austin
Curtis Darrow |
| NON-SMOKER |
|
|
There
is a one time $10.00
non-refundable application fee. |
| Prescription
Drug Card & mail Order Benfits |
|
| If
your plan deductible is |
| $500
or $750 .................... |
| $1,000,
$1,500 or $2,500 .. |
| $5,000
or $10,000 ............ |
|
| Rx
Deductible |
| $
100 |
| $
250 |
| $
1,000 |
|
|
