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Health Insurance Census
*
Indicates required field
First Name
*
Last Name
*
Date of Birth
*
Sex
*
City
*
State
*
Zipcode
*
Starting April 1, 2024, would you like to accept or continue Health Insurance through H&H X-Ray Services?
*
Decline
Accept Employee Only
Accept Employee & Spouse
Accept Employee & Family
Which Plan would you choose? (Plan Information Below)
*
No Plan, Decline Health Insurance
Base Plan
Buy Up Plan
Services
Base Plan
Network
Non-Network
Buy Up Plan
Network
Non-Network
Deductible
(Individual/Family)
Out-of-pocket Maximum
(Individual/Family)
Coinsurance
Primary Care Copay
Specialist Copay
Prescription Drugs
- Tier 1
- Tier 2
- Tier 3
- Tier 4
$3,300
$6,600
$6,350
$12,700
70%
Deductible, then coinsurance
Deductible, then coinsurance
Deductible, then coinsurance
$6,600
$13,200
$12,700
$25,400
30%
Deductible, then coinsurance
Deductible, then coinsurance
Not Covered
$1,500
$4,500
$6,350
$12,700
60%
$40
$55
$7
$30
$70
$90
$3,000
$9,000
$12,700
$25,400
40%
Deductible, then coinsurance
Deductible, then coinsurance
Not Covered
Starting April 1, 2024, would you like to accept or continue Dental Insurance through H&H X-Ray Services?
*
Decline
Accept Employee Only
Accept Employee & Spouce
Accept Employee & Family
Submit
