AGENT DETAILS
Sarah Leb (LEB INSURANCE GROUP)
ASKFORSARAH@YAHOO.COM
920.552.4846 Cell
920.243.4100 Office
PLAN SECTION
LEB INSURANCE GROUP
Choose a Plan
Annual Deductible Per Member
Formulary
Retail Co-pay
Copay-1
Copay-2
Copay-3
Mail Order Co-pay
Copay-1
Copay-2
Copay-3
Maximum Benefits Payable
Per Member Per Month
Monthly Rates
Individual
Individual + Spouse
Individual + Child(ren)
Family
Select this Plan
Affordable
No Deductible
 
$10 FG
100% FB
100% NF
 
$30 FG
100% FB
100% NF
 
$300
 
$41.24
$68.77
$63.43
$83.00
Select this Plan
Signature
$100
 
$10 FG
$50 OR 50% FB
Whichever is Greater
100% NF
 
$30 FG
$150 OR 50% FB
Whichever is Greater
100% NF
 
$400
 
$51.42
$89.39
$82.43
$107.96
Select this Plan
Enhanced
$100
Select
 
$10 FG
$30 PB
Whichever is Greater
$70 OR 50% NPB
 
$30 FG
$90 PB
Whichever is Greater
$210 OR 50% NPB
 
$500
 
$102.50
$186.65
$175.43
$224.05
FG = Formulary Generic
FB = Formulary Brand
NF = Non-Formulary
PB = Preferred Brand
NPB = Non-Preferred Brand
PRIMARY MEMBER APPLICANT DETAILS
This is not required. If left blank, we will populate with an alternative ID for our records.
Select the desired effective date from the list of available options above.

APPLICANT ADDRESS

#PAYMENTMETHODACTIVE#
#PAYMENTMETHODACTIVE#