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Suburban EPO Plan — 2022

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In-Network Retail Pharmacy (30-day supply) In-Network Retail Pharmacy (90-day supply) Mail Order (90-day supply)
Plan Year Deductible
Individual $0 $0 $0
Family $0 $0 $0
Out-of-Pocket Maximum
Individual $4100 $4100 $4100
Family $8200 $8200 $8200
Lifetime Maximum
Individual Unlimited Unlimited Unlimited
Family Unlimited Unlimited Unlimited
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