№ lp_1_12170
Health insurance disclosure document outlining covered health care services and cost-sharing terms for a family PPO plan during the 2025 coverage period.
Coverage period: 01/01/2025–12/31/2025
Plan name: Plan Option 1
Plan type: PPO
Coverage level: Family
Insurance company: Insurance Company 1
Document type: Summary of Benefits and Coverage
Overall deductible: $500 individual / $1,000 family
Out-of-pocket limit: $2,500 individual / $5,000 family (network); $4,000 individual / $8,000 family (out-of-network)
Referral requirement: Required for specialist visits
Prescription drug coverage: Included with tiered cost sharing
Preventive services coverage: Covered before deductible
Price: 8 / 10 USD
The file will be delivered to the email address provided at checkout within 12 hours.

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