AGENT DETAILS
Robyne Martin (HEALTHCARE SOLUTIONS TEAM, LLC)
rmartin@myhst.com
314-229-3744 Cell
314-229-3744 Office
PLAN SECTION
HEALTHCARE SOLUTIONS TEAM, LLC
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
 
$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
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APPLICANT ADDRESS

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