Subscriber Member: FIRST LAST M Member Id: xxxxxxxxxxx ---*

	Benefit Type: Active Coverage
	Coverage Type: Health Benefit Plan Coverage
	Plan Type: (PPO)
	Plan Description: LPPO-UNITEDHEALTHCARE GROUP MEDICARE ADVANTAGE (PP

	Benefit Type: Deductible
	Coverage Level: Family
	Coverage Type: Health Benefit Plan Coverage
	Coverage Period: Service Year
	Network Ind: In Network: N/A

	Benefit Type: Deductible
	Coverage Level: Individual
	Coverage Type: Health Benefit Plan Coverage
	Coverage Period: Service Year
	Network Ind: In Network: N/A

	Benefit Type: Out of Pocket (Stop Loss)
	Coverage Level: Family
	Coverage Type: Health Benefit Plan Coverage
	Plan Type: (PPO)
	Coverage Period: Service Year
	Amount: 99999.99
	Network Ind: In Network: N/A

	Benefit Type: Out of Pocket (Stop Loss)
	Coverage Level: Individual
	Coverage Type: Health Benefit Plan Coverage
	Plan Type: (PPO)
	Coverage Period: Service Year
	Amount: 3500.00
	Network Ind: In Network: N/A

	Benefit Type: Deductible
	Coverage Level: Family
	Coverage Type: Health Benefit Plan Coverage
	Coverage Period: Year to Date
	Network Ind: In Network: N/A

	Benefit Type: Deductible
	Coverage Level: Individual
	Coverage Type: Health Benefit Plan Coverage
	Coverage Period: Year to Date
	Network Ind: In Network: N/A

	Benefit Type: Out of Pocket (Stop Loss)
	Coverage Level: Family
	Coverage Type: Health Benefit Plan Coverage
	Plan Type: (PPO)
	Coverage Period: Year to Date
	Amount: 444.82
	Network Ind: In Network: N/A

	Benefit Type: Out of Pocket (Stop Loss)
	Coverage Level: Individual
	Coverage Type: Health Benefit Plan Coverage
	Plan Type: (PPO)
	Coverage Period: Year to Date
	Amount: 444.82
	Network Ind: In Network: N/A

	Benefit Type: Deductible
	Coverage Level: Family
	Coverage Type: Health Benefit Plan Coverage
	Coverage Period: Remaining
	Network Ind: In Network: N/A

	Benefit Type: Deductible
	Coverage Level: Individual
	Coverage Type: Health Benefit Plan Coverage
	Coverage Period: Remaining
	Network Ind: In Network: N/A

	Benefit Type: Out of Pocket (Stop Loss)
	Coverage Level: Family
	Coverage Type: Health Benefit Plan Coverage
	Plan Type: (PPO)
	Coverage Period: Remaining
	Amount: 99555.17
	Network Ind: In Network: N/A

	Benefit Type: Out of Pocket (Stop Loss)
	Coverage Level: Individual
	Coverage Type: Health Benefit Plan Coverage
	Plan Type: (PPO)
	Coverage Period: Remaining
	Amount: 3055.18
	Network Ind: In Network: N/A

	Benefit Type: Primary Care Provider

	Benefit Type: Active Coverage
	Coverage Type: Medical Care; Chiropractic; Hospitalization; Hospital - Inpatient; Emergency Services; Professional (Physician) Visit - Office; Mental Health; Physical Therapy; Urgent Care; 
	Network Ind: In Network: N/A

	Benefit Type: Active Coverage
	Coverage Type: Hospital - Outpatient
	Network Ind: In Network: N/A
	Message: OUTPATIENT SURGERY

	Benefit Type: Active Coverage
	Coverage Type: EB03 code 96 unknown 
	Network Ind: In Network: N/A
	Message: OFFICE VISIT SPECIALIST

	Benefit Type: Active Coverage
	Coverage Type: Optometry
	Network Ind: In Network: N/A
	Message: ROUTINE EYE EXAM

	Benefit Type: Active Coverage
	Coverage Type: Hospital - Outpatient
	Network Ind: In Network: N/A
	Message: OUTPATIENT HOSPITAL

	Benefit Type: Co-Insurance
	Coverage Level: Individual
	Coverage Type: EB03 code 96 unknown 
	Coverage Period: Day
	Network Ind: In Network: N/A
	Message: OFFICE VISIT SPECIALIST

	Benefit Type: Co-Insurance
	Coverage Level: Individual
	Coverage Type: EB03 code 9 unknown 
	Coverage Period: Visit
	Network Ind: In Network: N/A
	Message: VIRTUAL VISITS/TELEMEDICINE

	Benefit Type: Co-Insurance
	Coverage Level: Individual
	Coverage Type: Hospital - Outpatient
	Coverage Period: Day
	Network Ind: In Network: N/A
	Message: OUTPATIENT SURGERY

	Benefit Type: Co-Insurance
	Coverage Level: Individual
	Coverage Type: Hospital - Outpatient
	Coverage Period: Day
	Network Ind: In Network: N/A
	Message: OUTPATIENT HOSPITAL

	Benefit Type: Co-Insurance
	Coverage Level: Individual
	Coverage Type: Hospital - Inpatient
	Coverage Period: Day
	Percent: .2
	Network Ind: In Network: N/A

	Benefit Type: Co-Insurance
	Coverage Level: Individual
	Coverage Type: Chiropractic; Emergency Services; Professional (Physician) Visit - Office; Physical Therapy; Urgent Care; 
	Coverage Period: Day
	Network Ind: In Network: N/A

	Benefit Type: Co-Payment
	Coverage Level: Individual
	Coverage Type: EB03 code 96 unknown 
	Coverage Period: Day
	Amount: 30.00
	Network Ind: In Network: N/A
	Message: OFFICE VISIT SPECIALIST

	Benefit Type: Co-Payment
	Coverage Level: Individual
	Coverage Type: Chiropractic
	Coverage Period: Day
	Amount: 18.00
	Network Ind: In Network: N/A

	Benefit Type: Co-Payment
	Coverage Level: Individual
	Coverage Type: Hospital - Outpatient
	Coverage Period: Day
	Amount: 95.00
	Network Ind: In Network: N/A
	Message: OUTPATIENT SURGERY

	Benefit Type: Co-Payment
	Coverage Level: Individual
	Coverage Type: EB03 code 9 unknown 
	Coverage Period: Visit
	Network Ind: In Network: N/A
	Message: VIRTUAL VISITS/TELEMEDICINE

	Benefit Type: Co-Payment
	Coverage Level: Individual
	Coverage Type: Emergency Services
	Coverage Period: Day
	Amount: 50.00
	Network Ind: In Network: N/A

	Benefit Type: Co-Payment
	Coverage Level: Individual
	Coverage Type: Professional (Physician) Visit - Office; Physical Therapy; Urgent Care; 
	Coverage Period: Day
	Amount: 25.00
	Network Ind: In Network: N/A

	Benefit Type: Co-Payment
	Coverage Level: Individual
	Coverage Type: Hospital - Outpatient
	Coverage Period: Day
	Amount: 95.00
	Network Ind: In Network: N/A
	Message: OUTPATIENT HOSPITAL

	Benefit Type: Co-Payment
	Coverage Level: Individual
	Coverage Type: Hospital - Inpatient
	Coverage Period: Day
	Network Ind: In Network: N/A

	Benefit Type: Contact Entity for Information
	Coverage Type: Pharmacy

	Benefit Type: Health Care Facility