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
Formulary Generics
Formulary Brands
Non-Formulary
Mail Order Co-pay
Formulary Generics
Formulary Brands
Non-Formulary
Maximum Benefits Payable
Per Member Per Month
Monthly Rates
Individual
Individual + Spouse
Individual + Child(ren)
Family
Select this Plan
Generic Only
No Deductible
Rx Value
 
$10
100%
100%
 
$30
100%
100%
 
$300
 
$44.81
$74.72
$68.92
$90.18
Select this Plan
Brand Wrap 1
$100
Rx Balance
 
$10
$50 OR 50%
100%
 
$30
$150 OR 50%
100%
 
$400
 
$55.89
$97.16
$89.60
$117.35
Select this Plan
Brand Wrap 2
$100
Rx Balance
 
$10
$35 OR 50%
100%
 
$30
$105 OR 50%
100%
 
$400
 
$61.03
$107.60
$99.21
$129.99
PRIMARY MEMBER APPLICANT DETAILS
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Alternate effective date (optional) is the date you'd prefer to make your policy active. If nothing is designated here, the next possible effective date would be used.

APPLICANT ADDRESS

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