CÓDIGOS DE CUBIERTAS / DEDUCIBLES
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CÓDIGOS DE CUBIERTAS / COPAGOS 08/13/2015 1 VISITAS A DOMICILIO VISITAS A LA OFICINA CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA A-01 NADA $5.00 $10.00 $15.00 A-02 $15.00 $10.00 $15.00 $20.00 A-03 $15.00 $10.00 $10.00 $10.00 A-04 $15.00 $8.00 $15.00 $15.00 A-05 $15.00 $10.00 $15.00 $15.00 A-06 $15.00 $5.00 $10.00 $10.00 A-07 j f NADA NADA NADA A-08 $15.00 $5.00 $10.00 $12.00 A-09 NADA $5.00 $10.00 $15.00 A-10 $15.00 $12.00 $15.00 $18.00 A-11 $15.00 $10.00 $15.00 $15.00 A-12 $15.00 $5.00 $15.00 $15.00 A-13 j F NADA NADA NADA A-14 $15.00 $5.00 $15.00 $15.00 A-15 $15.00 $5.00 $15.00 $15.00 A-16 $15.00 $10.00 $20.00 $25.00 A-17 $15.00 $5.00 $10.00 $12.00 A-18 NADA $5.00 $15.00 $15.00 A-19 j $15.00 $5.00 $10.00 $15.00 A-20 $15.00 $5.00 $15.00 $15.00 A-21 $15.00 $10.00 $15.00 $15.00 A-22 N/C $5.00 $15.00 $20.00 A-23 N/C $5.00 $15.00 $20.00 A-24 $15.00 $5.00 $15.00 $15.00 A-25 $15.00 $5.00 $15.00 $15.00 A-26 $15.00 $5.00 $10.00 $12.00 A-27 $15.00 $5.00 $12.00 $15.00 A-28 g $15.00 $8.00 $10.00 $12.00 A-29 $15.00 $5.00 $15.00 $15.00 A-30 $15.00 $10.00 $15.00 $15.00 A-31 NADA $5.00 $10.00 $12.00 A-32 g, j $15.00 $9.00 $9.00 $9.00 A-33 $15.00 $6.00 $10.00 $12.00 A-34 $15.00 $5.00 $10.00 $10.00 A-35 j $15.00 $5.00 $10.00 $10.00 A-36 $15.00 $10.00 $15.00 $15.00 A-37 $15.00 $5.00 $12.00 $15.00 A-38 $15.00 $5.00 $10.00 $10.00 A-39 g, j $15.00 $5.00 $5.00 $5.00 A-40 * * * * A-41 * * * * A-42 * * * * A-43 $15.00 $5.00 $10.00 $15.00 A-44 $15.00 $5.00 $15.00 $15.00 A-45 $15.00 $10.00 $15.00 $15.00 A-46 $15.00 $10.00 $18.00 $20.00 A-47 * * * * A-48 $15.00 $5.00 $10.00 $15.00 A-49 $15.00 $10.00 $12.00 $15.00 A-50 $15.00 $5.00 $10.00 $15.00 A-51 a N/C $5.00 $10.00 $15.00 A-52 $15.00 $7.00 $18.00 $18.00
Transcript of CÓDIGOS DE CUBIERTAS / DEDUCIBLES
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
1
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
A-01 NADA $5.00 $10.00 $15.00
A-02 $15.00 $10.00 $15.00 $20.00
A-03 $15.00 $10.00 $10.00 $10.00
A-04 $15.00 $8.00 $15.00 $15.00
A-05 $15.00 $10.00 $15.00 $15.00
A-06 $15.00 $5.00 $10.00 $10.00
A-07 j f NADA NADA NADA
A-08 $15.00 $5.00 $10.00 $12.00
A-09 NADA $5.00 $10.00 $15.00
A-10 $15.00 $12.00 $15.00 $18.00
A-11 $15.00 $10.00 $15.00 $15.00
A-12 $15.00 $5.00 $15.00 $15.00
A-13 j F NADA NADA NADA
A-14 $15.00 $5.00 $15.00 $15.00
A-15 $15.00 $5.00 $15.00 $15.00
A-16 $15.00 $10.00 $20.00 $25.00
A-17 $15.00 $5.00 $10.00 $12.00
A-18 NADA $5.00 $15.00 $15.00
A-19 j $15.00 $5.00 $10.00 $15.00
A-20 $15.00 $5.00 $15.00 $15.00
A-21 $15.00 $10.00 $15.00 $15.00
A-22 N/C $5.00 $15.00 $20.00
A-23 N/C $5.00 $15.00 $20.00
A-24 $15.00 $5.00 $15.00 $15.00
A-25 $15.00 $5.00 $15.00 $15.00
A-26 $15.00 $5.00 $10.00 $12.00
A-27 $15.00 $5.00 $12.00 $15.00
A-28 g $15.00 $8.00 $10.00 $12.00
A-29 $15.00 $5.00 $15.00 $15.00
A-30 $15.00 $10.00 $15.00 $15.00
A-31 NADA $5.00 $10.00 $12.00
A-32 g, j $15.00 $9.00 $9.00 $9.00
A-33 $15.00 $6.00 $10.00 $12.00
A-34 $15.00 $5.00 $10.00 $10.00
A-35 j $15.00 $5.00 $10.00 $10.00
A-36 $15.00 $10.00 $15.00 $15.00
A-37 $15.00 $5.00 $12.00 $15.00
A-38 $15.00 $5.00 $10.00 $10.00
A-39 g, j $15.00 $5.00 $5.00 $5.00
A-40 * * * *
A-41 * * * *
A-42 * * * *
A-43 $15.00 $5.00 $10.00 $15.00
A-44 $15.00 $5.00 $15.00 $15.00
A-45 $15.00 $10.00 $15.00 $15.00
A-46 $15.00 $10.00 $18.00 $20.00
A-47 * * * *
A-48 $15.00 $5.00 $10.00 $15.00
A-49 $15.00 $10.00 $12.00 $15.00
A-50 $15.00 $5.00 $10.00 $15.00
A-51 a N/C $5.00 $10.00 $15.00
A-52 $15.00 $7.00 $18.00 $18.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
A-53 $15.00 $5.00 $15.00 $15.00 A-54 $15.00 $5.00 $10.00 $15.00 A-55 $15.00 $5.00 $10.00 $15.00 A-56 j $15.00 $8.00 $10.00 $12.00
A-57 $15.00 $8.00 $10.00 $10.00
A-58 * * * *
A-59 $15.00 $5.00 $10.00 $10.00
A-60 $15.00 $5.00 $15.00 $15.00 A-61 $15.00 $5.00 $15.00 $15.00 A-62 * * * *
A-63 * * * *
A-64 * * * *
A-65 j $15.00 $8.00 $10.00 $12.00 A-66 k $15.00 $4.00 $15.00 $20.00
A-67 NADA NADA NADA NADA A-68 g, j $15.00 $5.00 $15.00 $15.00
A-69 N/C $8.00 $12.00 $15.00 A-70 $15.00 $5.00 $12.00 $15.00 A-71 $15.00 $10.00 $15.00 $15.00
A-72 $15.00 $3.00 $7.00 $11.00 A-73 j $15.00 $10.00 $15.00 $15.00 A-74 g $15.00 $3.00 $5.00 $6.00 A-75 $15.00 $4.00 $12.00 $15.00 A-76 j, € $15.00 $5.00 $5.00 $5.00 A-77 $15.00 $5.00 $7.00 $10.00
A-78 $15.00 $2.00 $3.00 $5.00 A-79 $15.00 $7.00 $12.00 $12.00 A-80 $15.00 $10.00 $20.00 $20.00
A-81 $15.00 $5.00 $15.00 $15.00
A-82 j $15.00 $7.00 $12.00 $15.00 A-83 $15.00 $5.00 $10.00 $10.00 A-84 $15.00 $35.00 $35.00 $50.00
A-85 * * * *
A-86 $15.00 $8.00 $12.00 $15.00
A-87 * * * *
A-88 $15.00 $5.00 $15.00 $15.00
A-89 j, € $15.00 $10.00 $10.00 $10.00 A-90 * * * *
A-91 j, € $15.00 $10.00 $20.00 $20.00 A-92 j, € $15.00 $7.00 $7.00 $7.00 A-93 j, € $15.00 $10.00 $10.00 $10.00 A-94 $15.00 $5.00 $12.00 $15.00
A-95 g, j $15.00 $7.50 $10.00 $10.00 A-96 $15.00 $6.00 $10.00 $12.00 A-97 $15.00 $8.00 $12.00 $15.00 A-98 g $15.00 $5.00 $7.00 $7.00 A-99 j, € $15.00 $7.00 $7.00 $7.00 AA-01 j , $15.00 $7.00 $15.00 $15.00 AA-02 $15.00 $15.00 $20.00 $25.00 AA-03 NADA $2.00 $2.00 $2.00 AA-04 j $15.00 $8.00 $10.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AA-05 $15.00 $5.00 $7.00 $12.00 AA-06 j $15.00 $10.00 $15.00 $15.00 AA-07 $15.00 $10.00 $15.00 $15.00 AA-08 N/C $5.00 $10.00 $15.00
AA-09 j N/C NADA $10.00 $15.00 AA-10 $15.00 $5.00 $15.00 $15.00 AA-11 i $15.00 $5.00 $10.00 $12.00 AA-12 $15.00 $9.00 $13.00 $15.00 AA-13 $15.00 $8.00 $15.00 $20.00
AA-14 $15.00 $10.00 $12.00 $15.00 AA-15 $15.00 $5.00 $7.00 $12.00 AA-16 $15.00 $5.00 $15.00 $15.00 AA-17 * * * *
AA-18 $15.00 $4.00 $12.00 $15.00 AA-19 $15.00 $10.00 $18.00 $20.00 AA-20 NADA NADA NADA NADA AA-21 $15.00 $5.00 $10.00 $10.00 AA-22 $15.00 $5.00 $15.00 $15.00 AA-23 $15.00 $5.00 $10.00 $15.00
AA-24 j $15.00 $12.00 $12.00 $12.00 AA-25 $15.00 $10.00 $15.00 $20.00 AA-26 $15.00 $3.00 $10.00 $15.00 AA-27 $15.00 $5.00 $7.00 $10.00 AA-28 $15.00 $5.00 $5.00 $5.00 AA-29 $15.00 $5.00 $15.00 $15.00 AA-30 $15.00 $6.50 $12.00 $12.00 AA-31 s $15.00 $10.00 $10.00 $10.00 AA-32 $15.00 $5.00 $15.00 $15.00
AA-33 N/C $5.00 $10.00 $10.00 AA-34 * * * *
AA-35 $15.00 $3.00 $7.00 $11.00 AA-36 $15.00 $5.00 $15.00 $15.00 AA-37 j , $15.00 $10.00 $15.00 $15.00 AA-38 $15.00 $10.00 $15.00 $20.00 AA-39 * * * *
AA-40 j $15.00 $4.00 $7.00 $9.00
AA-41 $15.00 $8.00 $15.00 $15.00 AA-42 $15.00 $10.00 $15.00 $15.00 AA-43 * * * *
AA-44 $15.00 $5.00 $15.00 $15.00 AA-45 $15.00 $5.00 $15.00 $15.00 AA-46 $15.00 $5.00 $15.00 $15.00 AA-47 N/C $8.00 $12.00 $15.00 AA-48 * * * *
AA-49 N/C $5.00 $15.00 $15.00 AA-50 $15.00 $5.00 $15.00 $15.00 AA-51 N/C $10.00 $15.00 $15.00 AA-52 $15.00 $5.00 $15.00 $15.00 AA-53 g $15.00 $5.00 $10.00 $15.00 AA-54 $15.00 $8.00 $15.00 $15.00 AA-55 $15.00 $5.00 $10.00 $10.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AA-56 $15.00 $10.00 $10.00 $10.00 AA-57 $15.00 $5.00 $5.00 $5.00 AA-58 $15.00 $5.00 $15.00 $15.00 AA-59 N/C $10.00 $15.00 $20.00 AA-60 j, $15.00 $5.00 $10.00 $10.00 AA-61 N/C $5.00 $15.00 $20.00 AA-62 $15.00 $10.00 $10.00 $10.00 AA-63 $10.00 $7.00 $10.00 $10.00 AA-64 $15.00 $7.00 $10.00 $12.00 AA-65 $15.00 $5.00 $10.00 $12.00 AA-66 j, $10.00 $10.00 $12.00 $15.00
AA-67 $15.00 $10.00 $15.00 $15.00
AA-68 $15.00 $5.00 $10.00 $15.00 AA-69 h, j $12.00 $15.00 $20.00 $20.00 AA-70 $15.00 $10.00 $10.00 $10.00 AA-71 $15.00 $10.00 $10.00 $10.00 AA-72 g NADA $3.00 $5.00 $6.00 AA-73 j $15.00 $6.00 $12.00 $12.00 AA-74 N/C $5.00 $10.00 $15.00 AA-75 j $15.00 $10.00 $15.00 $18.00 AA-76 j $15.00 $5.00 $12.00 $15.00
AA-77 a N/C $5.00 $10.00 $10.00 AA-78 N/C $5.00 $10.00 $10.00 AA-79 a N/C $8.00 $12.00 $15.00 AA-80 N/C $8.00 $12.00 $15.00 AA-81 $15.00 $8.00 $15.00 $15.00
AA-82 j $15.00 $8.00 $15.00 $18.00
AA-83 * * * *
AA-84 *N/C $5.00 $15.00 $20.00
AA-85 $15.00 $5.00 $10.00 $10.00 AA-86 $15.00 $5.00 $15.00 $15.00 AA-87 $15.00 $5.00 $15.00 $15.00
AA-88 $15.00 $10.00 $15.00 $15.00 AA-89 N/C $10.00 $15.00 $20.00 AA-90 $15.00 $8.00 $8.00 $8.00
AA-91 $15.00 $7.00 $7.00 $7.00 AA-92 j, $15.00 $15.00 $15.00 $18.00 AA-93 $15.00 $6.00 $10.00 $15.00 AA-94 j, $15.00 $10.00 $12.00 $15.00 AA-95 $15.00 $5.00 $5.00 $5.00 AA-96 $15.00 $8.00 $12.00 $15.00 AA-97 $15.00 $5.00 $15.00 $15.00 AA-98 $15.00 $10.00 $15.00 $15.00 AA-99 g, j $15.00 $5.00 $10.00 $15.00 AB-01 g $15.00 $5.00 $10.00 $10.00 AB-02 j, $15.00 $10.00 $15.00 $18.00 AB-03 N/C $5.00 $15.00 $20.00
AB-04 j, $15.00 $8.00 $10.00 $12.00 AB-05 $15.00 $7.00 $18.00 $18.00
AB-06 $15.00 $4.00 $7.00 $10.00 AB-07 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AB-08 $15.00 $10.00 $15.00 $15.00
AB-09 $15.00 $15.00 $20.00 $20.00
AB-10 $15.00 $15.00 $18.00 $20.00
AB-11 j $15.00 $10.00 $15.00 $18.00
AB-12 $15.00 $10.00 $15.00 $15.00
AB-13 $15.00 $10.00 $15.00 $15.00
AB-14 $15.00 $5.00 $10.00 $10.00
AB-15 $15.00 $7.00 $20.00 $20.00
AB-16 $15.00 $15.00 $15.00 $18.00
AB-17 * * * *
AB-18 $15.00 $10.00 $15.00 $15.00
AB-19 $15.00 $6.00 $10.00 $12.00
AB-20 $15.00 $5.00 $15.00 $15.00
AB-21 * * * *
AB-22 $15.00 $10.00 $15.00 $15.00
AB-23 * * * *
AB-24 g, j $15.00 $5.00 $10.00 $15.00
AB-25 $15.00 $8.00 $12.00 $15.00
AB-26 $15.00 $10.00 $15.00 $15.00
AB-27 * * * *
AB-28 $15.00 $10.00 $10.00 $15.00
AB-29 j $15.00 $7.00 $7.00 $7.00
AB-30 $15.00 $5.00 $15.00 $15.00
AB-31 * * * *
AB-32 $15.00 $10.00 $18.00 $18.00
AB-33 g $15.00 $5.00 $10.00 $15.00
AB-34 $15.00 $10.00 $15.00 $15.00
AB-35 j, l $7.00 $4.00 $7.00 $10.00
AB-36 $15.00 $8.00 $15.00 $15.00
AB-37 g $15.00 $3.00 $12.00 $12.00
AB-38 $15.00 $10.00 $15.00 $18.00 AB-39 $15.00 $5.00 $10.00 $10.00
AB-40 j, l $12.00 $12.00 $12.00 $12.00
AB-41 $15.00 $4.00 $7.00 $10.00
AB-42 $15.00 $5.00 $15.00 $15.00
AB-43 $15.00 $5.00 $10.00 $10.00
AB-44 $15.00 $5.00 $15.00 $15.00
AB-45 $15.00 $8.00 $10.00 $12.00
AB-46 $15.00 $10.00 $15.00 $20.00
AB-47 $15.00 $5.00 $10.00 $10.00
AB-48 $15.00 $5.00 $10.00 $15.00
AB-49 $15.00 $6.00 $12.00 $12.00
AB-50 $15.00 $10.00 $15.00 $20.00
AB-51 $15.00 $5.00 $10.00 $10.00
AB-52 $15.00 $8.00 $12.00 $15.00
AB-53 $15.00 $10.00 $10.00 $10.00
AB-54 NADA $2.00 $2.00 $2.00
AB-55 * * * *
AB-56 $15.00 $5.00 $15.00 $15.00
AB-57 N/C $10.00 $15.00 $15.00
AB-58 $15.00 $10.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AB-59 * * * *
AB-60 j $15.00 $5.00 $15.00 $15.00
AB-61 j $15.00 $5.00 $15.00 $15.00
AB-62 N/C NADA $10.00 $15.00
AB-63 j $15.00 $5.00 $8.00 $10.00
AB-64 $15.00 $5.00 $8.00 $10.00
AB-65 $15.00 $10.00 $15.00 $15.00
AB-66 $15.00 $3.00 $7.00 $11.00
AB-67,§ $15.00 $10.00 $15.00 $15.00
AB-68 $15.00 $10.00 $15.00 $15.00
AB-69 N/C $8.00 $10.00 $15.00
AB-70 $15.00 $7.00 $7.00 $7.00
AB-71,j $15.00 $10.00 $15.00 $18.00
AB-72 j F $8.00 $10.00 $10.00
AB-73 $15.00 $10.00 $10.00 $10.00
AB-74 $15.00 $8.00 $12.00 $15.00
AB-75 $15.00 $3.00 $7.00 $11.00
AB-76,j $15.00 $10.00 $15.00 $18.00
AB-77 j $15.00 $10.00 $10.00 $10.00
AB-78 $15.00 $5.00 $10.00 $15.00
AB-79 $15.00 $7.00 $12.00 $15.00
AB-80 $15.00 $10.00 $15.00 $18.00
AB-81 g, j $15.00 $8.00 $8.00 $8.00
AB-82 $15.00 $10.00 $15.00 $15.00
AB-83 $15.00 $5.00 $15.00 $15.00
AB-84 $15.00 $10.00 $15.00 $20.00
AB-85 $15.00 $3.00 $5.00 $7.00
AB-86 j $15.00 $5.00 $10.00 $15.00
AB-87 $15.00 $8.00 $15.00 $15.00
AB-88 $15.00 $5.00 $15.00 $15.00
AB-89 $15.00 $8.00 $10.00 $12.00
AB-90 N/C $10.00 $18.00 $18.00
AB-91 N/C $10.00 $15.00 $15.00
AB-92 * * * *
AB-93 $15.00 $5.00 $15.00 $15.00
AB-94 $15.00 $10.00 $15.00 $15.00
AB-95 $15.00 $5.00 $10.00 $10.00
AB-96 $15.00 $10.00 $20.00 $20.00 AB-97 N/C $5.00 $15.00 $15.00
AB-98 j, N/C NADA $10.00 $15.00
AB-99 $15.00 $15.00 $20.00 $20.00
AC-01 j F NADA NADA NADA
AC-02 $15.00 $10.00 $15.00 $18.00
AC-03 $15.00 $10.00 $15.00 $15.00
AC-04 $15.00 $15.00 $15.00 $15.00
AC-05 $15.00 $8.00 $12.00 $15.00
AC-06 $15.00 $18.00 $22.00 $25.00
AC-07 * * * *
AC-08 j $15.00 $7.00 $7.00 $7.00
AC-09 $15.00 $5.00 $15.00 $15.00
AC-10 $15.00 $8.00 $12.00 $15.00
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AC-11 $10.00 $7.00 $10.00 $10.00
AC-12 $15.00 $5.00 $15.00 $15.00
AC-13 g $20.00 $10.00 $15.00 $15.00
AC-14 $15.00 $5.00 $15.00 $15.00
AC-15 $15.00 $10.00 $15.00 $15.00
AC-16 $15.00 $10.00 $15.00 $15.00
AC-17 * * * *
AC-19 $15.00 $6.00 $8.00 $8.00
AC-20 $15.00 $5.00 $10.00 $10.00
AC-21 $15.00 $5.00 $10.00 $10.00
AC-22 $15.00 $8.00 $12.00 $15.00
AC-23 $15.00 $8.00 $12.00 $15.00
AC-24 $15.00 $5.00 $15.00 $15.00
AC-25 $15.00 $5.00 $15.00 $15.00
AC-26 * * * *
AC-27 * * * *
AC-28 * * * *
AC-29 * * * *
AC-30 * * * *
AC-31 * * * *
AC-32 g, j $15.00 $10.00 $10.00 $10.00
AC-33 * * * *
AC-34 * * * *
AC-35 $15.00 $5.00 $15.00 $15.00
AC-36 $15.00 $8.00 $10.00 $12.00
AC-37 $15.00 $5.00 $15.00 $15.00
AC-38 $15.00 $10.00 $10.00 $10.00
AC-39 $15.00 $6.00 $12.00 $12.00
AC-40 $15.00 $5.00 $10.00 $15.00
AC-41 * * * *
AC-42 $15.00 $8.00 $15.00 $15.00
AC-43 * * * *
AC-44 * * * *
AC-45 * * * *
AC-46 * * * *
AC-47 $15.00 $5.00 $15.00 $15.00
AC-48 $15.00 $10.00 $15.00 $20.00
AC-49 j F NADA NADA NADA
AC-50 $15.00 $12.00 $15.00 $15.00
AC-51 $15.00 $10.00 $18.00 $18.00
AC-52 $15.00 $8.00 $15.00 $15.00
AC-53 $15.00 $8.00 $10.00 $12.00*
AC-54 NADA $5.00 $10.00 $10.00
AC-55 ,j N/C $8.00 $10.00 $15.00
AC-56 $15.00 $10.00 $12.00 $15.00
AC-57 N/C $3.00 $7.00 $10.00
AC-58 N/C $5.00 $10.00 $10.00
AC-59 $15.00 $5.00 $10.00 $12.00
AC-60 $15.00 NADA $18.00 $20.00
AC-61 $15.00 $5.00 $5.00 $5.00
AC-62 * * * *
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AC-63 $15.00 $7.00 $12.00 $12.00
AC-64 $15.00 $10.00 $10.00 $10.00
AC-65 g $15.00 $10.00 $10.00 $10.00
AC-66 $15.00 $5.00 $15.00 $15.00
AC-67 $15.00 $5.00 $15.00 $15.00
AC-68 * * * *
AC-69 $15.00 $5.00 $10.00 $10.00
AC-70 $15.00 $10.00 $18.00 $18.00
AC-71 $15.00 $8.00 $15.00 $15.00
AC-72 $15.00 $5.00 $15.00 $15.00
AC-73 $15.00 $8.00 $12.00 $15.00
AC-74 $15.00 $8.00 $10.00 $12.00
AC-75, j $15.00 $8.00 $12.00 $15.00
AC-76 NADA $6.00 $10.00 $12.00
AC-77 $15.00 $8.00 $15.00 $18.00
AC-78 $15.00 $10.00 $12.00 $15.00
AC-79 $15.00 $5.00 $15.00 $15.00
AC-80 $15.00 $10.00 $15.00 $15.00
AC-81 $15.00 $3.00 $3.00 $3.00
AC-82 $15.00 $6.00 $10.00 $12.00
AC-83 a $15.00 $5.00 $15.00 $15.00
AC-84 $10.00 $10.00 $10.00 $10.00
AC-85 j, $15.00 $5.00 $7.00 $12.00
AC-86,j $15.00 $10.00 $18.00 $20.00
AC-87 $15.00 $7.00 $10.00 $15.00
AC-88 $15.00 $8.00 $12.00 $12.00
AC-89 $15.00 $10.00 $15.00 $15.00
AC-90 $15.00 $7.00 $10.00 $12.00
AC-91 j f NADA NADA NADA
AC-92 * * * *
AC-93 f, j * $5.00 e $8.00 $8.00
AC-94 g $15.00 $5.00 $15.00 $15.00
AC-95 $12.00 $12.00 $15.00 $15.00
AC-96 $15.00 $8.00 $12.00 $15.00
AC-97 j $15.00 $5.00 $7.00 $10.00
AC-98,j $10.00 $10.00 $15.00 $15.00
AC-99 $15.00 $15.00 $20.00 $20.00
AD-18 $15.00 $7.00 $10.00 $12.00
AD-19 $15.00 $5.00 $15.00 $15.00
AD-20 $15.00 $10.00 $15.00 $15.00
AD-21 $15.00 $3.00 $7.00 $11.00
AD-22 j $15.00 $5.00 $10.00 $12.00
AD-23 $15.00 $15.00 $20.00 $20.00
AD-24 $15.00 $10.00 $15.00 $18.00
AD-25 $15.00 $5.00 $12.00 $15.00
AD-26 $15.00 $5.00 $10.00 $12.00
AD-27 $15.00 $5.00 $15.00 $15.00
AD-28 $15.00 $10.00 $15.00 $15.00
AD-29 g $15.00 $10.00 $10.00 $10.00
AD-30 g $15.00 $10.00 $12.00 $15.00
AD-31 j $15.00 $8.00 $12.00 $15.00
AD-32 $15.00 $10.00 $15.00 $15.00
AD-33 g, j $15.00 $5.00 $9.00 $9.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
9
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AD-34 g, j $15.00 $9.00 $12.00 $15.00
AD-35 $15.00 $5.00 $10.00 $15.00
AD-36 j f NADA NADA NADA
AD-37 j f NADA NADA NADA
AD-38 j f NADA NADA NADA
AD-39 j f NADA NADA NADA
AD-40 $15.00 $5.00 $15.00 $18.00
AD-41 f, j * $2.00 e $5.00 $5.00
AD-42 j $2.00 $5.00 $5.00
AD-43 N/C $10.00 $15.00 $15.00
AD-44 $15.00 $10.00 $15.00 $15.00
AD-45 $15.00 $8.00 $12.00 $15.00
AD-46 N/C $7.00 $15.00 $15.00
AD-47 $15.00 $5.00 $10.00 $15.00
AD-48 * * * *
AD-49 NADA NADA NADA NADA
AD-50 N/C $5.00 $10.00 $15.00
AD-51 $15.00 $5.00 $15.00 $15.00
AD-52 $15.00 $5.00 $7.00 $10.00
AD-53 g, j $15.00 $10.00 $12.00 $15.00
AD-54 $15.00 $5.00 $8.00 $10.00
AD-55 j $15.00 $5.00 $10.00 $15.00
AD-56 j $15.00 $5.00 $10.00 $15.00
AD-57 $15.00 $8.00 $12.00 $15.00
AD-58 $15.00 $12.00 $15.00 $18.00
AD-59 $15.00 $5.00 $8.00 $10.00
AD-60 N/C $8.00 $10.00 $15.00
AD-61 $15.00 $5.00 $15.00 $15.00
AD-62 j $15.00 $8.00 $12.00 $15.00
AD-63 * * * *
AD-64 $15.00 $10.00 $15.00 $20.00
AD-65 $15.00 $10.00 $20.00 $20.00
AD-66 * * * *
AD-67 * * * *
AD-68 $15.00 $8.00 $12.00 $15.00
AD-69 $15.00 $10.00 $15.00 $15.00
AD-70 j $15.00 $5.00 $10.00 $15.00
AD-71 j $15.00 $10.00 $15.00 $15.00
AD-72 g, j $15.00 $5.00 $15.00 $15.00
AD-73 $15.00 $5.00 $10.00 $15.00
AD-74 $15.00 $5.00 $10.00 $12.00
AD-75 $15.00 $5.00 $10.00 $15.00
AD-76 $15.00 $5.00 $15.00 $15.00
AD-77 NADA $10.00 $12.00 $15.00
AD-78 $15.00 $10.00 $10.00 $10.00
AD-79 * * * *
AD-80 $15.00 $7.00 $15.00 $18.00
AD-81 $15.00 $8.00 $12.00 $15.00
AD-82 $15.00 $8.00 $15.00 $15.00
AD-83 $15.00 $8.00 $15.00 $15.00
AD-84 $15.00 $8.00 $10.00 $12.00
AD-85 * * * *
AD-86 g $15.00 $5.00 $10.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
10
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AD-87 $15.00 $5.00 $10.00 $15.00
AD-88 $15.00 $6.00 $15.00 $15.00
AD-89 $15.00 $12.00 $12.00 $12.00
AD-90 $15.00 $5.00 $10.00 $15.00
AD-91 $15.00 $5.00 $15.00 $15.00
AD-92 * * * *
AD-93 $15.00 $5.00 $15.00 $15.00
AD-94 $15.00 $10.00 $15.00 $15.00
AD-95 $15.00 $10.00 $15.00 $15.00
AD-96 $15.00 $10.00 $15.00 $15.00
AD-97 j $15.00 $6.00 $12.00 $15.00
AD-98 j $15.00 $7.00 $7.00 $7.00
AD-99 j f NADA NADA NADA
AE-01 $15.00 $5.00 $15.00 $15.00
AE-02 $15.00 $12.00 $16.00 $16.00
AE-03 $15.00 $12.00 $15.00 $15.00
AE-04 $15.00 $10.00 $15.00 $15.00
AE-05 $15.00 $8.00 $10.00 $12.00
AE-06 $15.00 $10.00 $15.00 $15.00
AE-07 $15.00 $5.00 $15.00 $15.00
AE-08 * * * *
AE-09 * * * *
AE-10 $15.00 $4.00 $15.00 $20.00
AE-11 $15.00 $7.00 $15.00 $18.00
AE-12 * * * *
AE-13 $15.00 $8.00 $13.00 $15.00
AE-14 $15.00 $5.00 $10.00 $15.00
AE-15 $15.00 $10.00 $15.00 $15.00
AE-16 g $15.00 $8.00 $10.00 $12.00
AE-17 NADA $2.00 $7.00 $7.00
AE-18 NADA $2.00 $7.00 $7.00
AE-19 NADA $2.00 $5.00 $5.00
AE-20 NADA $2.00 $5.00 $5.00
AE-21 NADA $2.00 $5.00 $5.00
AE-22 * * * *
AE-23 $15.00 $5.00 $10.00 $10.00
AE-24 $15.00 $8.00 $12.00 $15.00
AE-25 $15.00 $8.00 $12.00 $15.00
AE-26 $15.00 $10.00 $15.00 $15.00
AE-27 $15.00 $5.00 $15.00 $15.00
AE-28 g NADA $5.00 $10.00 $12.00
AE-29 $15.00 $15.00 $20.00 $25.00
AE-30 $15.00 $5.00 $15.00 $15.00
AE-31 $15.00 $10.00 $15.00 $15.00
AE-32 $15.00 $10.00 $15.00 $15.00
AE-33 $15.00 $5.00 $10.00 $15.00
AE-34 $15.00 $10.00 $12.00 $15.00
AE-35 $15.00 $8.00 $12.00 $15.00
AE-36 $15.00 $10.00 $20.00 $20.00
AE-37 $15.00 $8.00 $15.00 $15.00
AE-38 $15.00 $10.00 $15.00 $20.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AE-39 $15.00 $12.00 $18.00 $20.00
AE-40 j $15.00 $5.00 $7.00 $10.00
AE-41 j $15.00 $5.00 $15.00 $15.00
AE-42,j $15.00 $10.00 $18.00 $20.00
AE-43 $15.00 $10.00 $15.00 $15.00
AE-44 N/C $5.00 $15.00 $20.00
AE-45 * * * *
AE-46 $15.00 $5.00 $15.00 $15.00
AE-47 $15.00 $5.00 $15.00 $15.00
AE-48 N/C $3.00 $6.00 $6.00
AE-49 g, j $12.00 $12.00 $12.00 $12.00
AE-50 g, j $10.00 $10.00 $10.00 $10.00
AE-51,j $15.00 $10.00 $18.00 $18.00
AE-52 Ω,j $20.00 $3.00 $7.00 $10.00
AE-53 $15.00 $3.00 $7.00 $11.00
AE-54 * * * *
AE-55 j $15.00 $5.00 $7.00 $10.00
AE-56 $15.00 $5.00 $15.00 $15.00
AE-57 $15.00 $10.00 $15.00 $15.00
AE-58 $15.00 $5.00 $15.00 $15.00
AE-59 j $15.00 $10.00 $15.00 $15.00
AE-60 * * * *
AE-61 k $15.00 $4.00 $15.00 $20.00
AE-62 k $15.00 $4.00 $15.00 $20.00
AE-63 j F NADA NADA NADA
AE-64 N/C $10.00 $15.00 $15.00
AE-65 j $15.00 $10.00 $12.00 $15.00
AE-66 $15.00 $10.00 $15.00 $15.00
AE-67 $12.00 $15.00 NADA NADA
AE-68 $15.00 $15.00 $15.00 $15.00
AE-69 $15.00 $5.00 $15.00 $15.00
AE-70 $15.00 $12.00 $15.00 $15.00
AE-71 $15.00 $10.00 $15.00 $15.00
AE-72,j $15.00 $8.00 $15.00 $20.00
AE-73 $15.00 $10.00 $15.00 $15.00
AE-74 $15.00 $10.00 $20.00 $20.00
AE-75 $15.00 $5.00 $15.00 $15.00
AE-76 j $15.00 $4.00 $7.00 $10.00
AE-77 $15.00 $10.00 $15.00 $15.00
AE-78 $15.00 $10.00 $15.00 $15.00
AE-79 $15.00 $10.00 $15.00 $15.00
AE-80 $15.00 $10.00 $20.00 $20.00
AE-81 $15.00 $5.00 $15.00 $15.00
AE-82 j f NADA NADA NADA
AE-83 k $15.00 $10.00 $18.00 $20.00
AE-84 * * * *
AE-85 j f NADA NADA NADA
AE-86 $15.00 $5.00 $15.00 $15.00
AE-87 j, $15.00 $7.00 $15.00 $15.00
AE-88 j f NADA NADA NADA
AE-89 $15.00 $15.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
12
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AE-90 $15.00 $10.00 $15.00 $15.00
AE-91 $15.00 $10.00 $15.00 $15.00
AE-92 $15.00 $5.00 $12.00 $15.00
AE-93 j $15.00 $7.50 $10.00 $10.00
AE-94 $15.00 $10.00 $18.00 $20.00
AE-95 j $15.00 $5.00 $10.00 $10.00
AE-96 $15.00 $5.00 $8.00 $12.00
AE-97 $15.00 $10.00 $10.00 $10.00
AE-98 $15.00 $8.00 $10.00 $12.00
AE-99 $15.00 $10.00 $15.00 $15.00
AF-01 $15.00 $10.00 $18.00 $18.00
AF-02 80% 80% 80% 80%
AF-03 $15.00 $10.00 $12.00 $15.00
AF-04 $15.00 $8.00 $15.00 $18.00
AF-05 g $20.00 $10.00 $15.00 $15.00
AF-06 * * * *
AF-07 $15.00 $5.00 $10.00 $10.00
AF-08 $15.00 $12.00 $15.00 $15.00
AF-09 $15.00 $10.00 $15.00 $15.00
AF-10 $15.00 $10.00 $12.00 $12.00
AF-11 j, l $10.00 $7.00 $10.00 $12.00
AF-12 $15.00 $15.00 $25.00 $25.00
AF-13 $15.00 $15.00 $20.00 $20.00
AF-14 $15.00 $10.00 $15.00 $15.00
AF-15 j $15.00 $8.00 $10.00 $12.00
AF-16 j $15.00 $5.00 $10.00 $12.00
AF-17 $15.00 $10.00 $18.00 $20.00
AF-18 * * * *
AF-19 a N/C $5.00 $10.00 $15.00
AF-20 N/C $5.00 $10.00 $15.00
AF-21 a N/C $10.00 $15.00 $20.00
AF-22 N/C $10.00 $15.00 $20.00
AF-23 j $15.00 $6.00 $10.00 $12.00
AF-24 j $15.00 $5.00 $15.00 $15.00
AF-25 $15.00 $10.00 $15.00 $15.00
AF-26 $15.00 $5.00 $15.00 $15.00
AF-27 $15.00 $10.00 $15.00 $15.00
AF-28 j $15.00 $10.00 $12.00 $15.00
AF-29 $15.00 $10.00 $15.00 $15.00
AF-30 * * * *
AF-31 N/C $7.00 $15.00 $18.00
AF-32 j $15.00 $5.00 $15.00 $15.00
AF-33 $15.00 $10.00 $15.00 $15.00
AF-34 j $15.00 $7.00 $10.00 $15.00
AF-35 $15.00 $12.00 $12.00 $12.00
AF-36 $15.00 $5.00 $15.00 $15.00
AF-37 $15.00 $10.00 $15.00 $15.00
AF-38 * * * *
AF-39 * * * *
AF-40 j, l, $15.00 $10.00 $10.00 $10.00
AF-41 j, l $15.00 $12.00 $12.00 $12.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
13
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AF-42 * * * *
AF-43 $15.00 $10.00 $15.00 $15.00
AF-44 $15.00 $10.00 $15.00 $15.00
AF-45 $15.00 $10.00 $20.00 $20.00
AF-46 $15.00 $6.00 $8.00 $8.00
AF-47 $15.00 $5.00 $10.00 $10.00
AF-48 $15.00 $5.00 $10.00 $10.00
AF-49 $15.00 $8.00 $12.00 $15.00
AF-50 $15.00 $8.00 $12.00 $15.00
AF-51 $15.00 $5.00 $15.00 $15.00
AF-52 $15.00 $5.00 $15.00 $15.00
AF-53 $15.00 $15.00 $18.00 $20.00
AF-54 $15.00 $10.00 $15.00 $18.00
AF-55 $15.00 $10.00 $18.00 $20.00
AF-56 $15.00 $10.00 $15.00 $15.00
AF-57 NADA $8.00 $12.00 $20.00
AF-58 g $15.00 $15.00 $20.00 $25.00
AF-59 $15.00 $5.00 $10.00 $15.00
AF-60 * * * *
AF-61 $15.00 $10.00 $15.00 $15.00
AF-62 $15.00 $10.00 $18.00 $20.00
AF-63 NADA $10.00 $15.00 $15.00
AF-64 $15.00 $8.00 $15.00 $18.00
AF-65 NADA $8.00 $10.00 $12.00
AF-66 $15.00 $10.00 $15.00 $15.00
AF-67 $15.00 $5.00 $15.00 $15.00
AF-68 $15.00 $10.00 $18.00 $20.00
AF-69 NADA $10.00 $15.00 $15.00
AF-70 * * * *
AF-71 * * * *
AF-72 * * * *
AF-73 * * * *
AF-74 * * * *
AF-75 * * * *
AF-76 * * * *
AF-77 * * * *
AF-78 * * * *
AF-79 * * * *
AF-80 * * * *
AF-81 * * * *
AF-82 * * * *
AF-83 * * * *
AF-84 * * * *
AF-85 * * * *
AF-86 NADA NADA NADA NADA
AF-87 * * * *
AF-88 $15.00 $10.00 $15.00 $20.00
AF-89 * * * *
AF-90 * * * *
AF-91 * * * *
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
14
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AF-92 $15.00 $10.00 $15.00 $15.00
AF-93 * * * *
AF-94 f NADA $5.00 $10.00
AF-95 $15.00 $5.00 $15.00 $15.00
AF-96 j $15.00 $10.00 $18.00 $18.00
AF-97 $15.00 $10.00 $15.00 $15.00
AF-98 $15.00 $7.00 $15.00 $18.00
AF-99 $15.00 $8.00 $15.00 $15.00
AG-01 $15.00 $10.00 $15.00 $15.00
AG-02 $15.00 $8.00 $15.00 $15.00
AG-03 $15.00 $10.00 $15.00 $15.00
AG-04 $15.00 $8.00 $12.00 $15.00
AG-05 $15.00 $5.00 $15.00 $15.00
AG-06 $15.00 $10.00 $15.00 $15.00
AG-07 f NADA $7.00 $10.00
AG-08 $15.00 $5.00 $10.00 $12.00
AG-09 $15.00 $8.00 $12.00 $15.00
AG-10 $15.00 $8.00 $12.00 $15.00
AG-11 NADA NADA NADA NADA
AG-12 $15.00 $10.00 $15.00 $20.00
AG-13 N/C $10.00 $15.00 $15.00
AG-14 $15.00 $8.00 $12.00 $15.00
AG-15 j $15.00 $8.00 $15.00 $18.00
AG-16 $15.00 $10.00 $15.00 $15.00
AG-17 $15.00 $10.00 $15.00 $15.00
AG-18 $15.00 $4.00 $15.00 $20.00
AG-19 * * * *
AG-20 v N/C NADA $10.00 $15.00
AG-21 $15.00 $5.00 $15.00 $15.00
AG-22 $15.00 $10.00 $15.00 $15.00
AG-23 $15.00 $5.00 $15.00 $15.00
AG-24 $15.00 $10.00 $15.00 $15.00
AG-25 $15.00 $5.00 $10.00 $10.00
AG-26 $15.00 $8.00 $12.00 $15.00
AG-27 $15.00 $5.00 $15.00 $15.00
AG-28 $15.00 $5.00 $15.00 $20.00
AG-29 $15.00 $10.00 $15.00 $20.00
AG-30 $15.00 $10.00 $15.00 $15.00
AG-31 $15.00 $12.00 $15.00 $15.00
AG-32 j $15.00 $5.00 $15.00 $15.00
AG-33 $15.00 $5.00 $15.00 $15.00
AG-34 N/C $5.00 $15.00 $20.00
AG-35 $15.00 $10.00 $15.00 $15.00
AG-36 N/C NADA $10.00 $15.00
AG-37 $15.00 $10.00 $15.00 $15.00
AG-38 j $15.00 $5.00 $7.00 $10.00
AG-39 N/C $8.00 $10.00 $15.00
AG-40 $15.00 $8.00 $12.00 $15.00
AG-41 $10.00 $5.00 $10.00 $10.00
AG-42 j $15.00 $8.00 $12.00 $15.00
AG-43 $15.00 $5.00 $10.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
15
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AG-44 $15.00 $10.00 $12.00 $15.00
AG-45 j $15.00 $10.00 $15.00 $18.00
AG-46 $15.00 $10.00 $15.00 $15.00
AG-47 $15.00 $5.00 $10.00 $10.00
AG-48 $15.00 $5.00 $15.00 $15.00
AG-49 j $15.00 $5.00 $18.00 $18.00
AG-50 j $15.00 $5.00 $8.00 $8.00
AG-51 $15.00 $10.00 $15.00 $15.00
AG-52 $15.00 $8.00 $15.00 $15.00
AG-53 $15.00 $10.00 $15.00 $15.00
AG-54 $15.00 $5.00 $15.00 $15.00
AG-55 $15.00 $8.00 $12.00 $12.00
AG-56 $15.00 $7.00 $10.00 $15.00
AG-57 * * * *
AG-58 $15.00 $7.00 $7.00 $7.00
AG-59 g, j $15.00 $7.00 $17.00 $17.00
AG-60 $15.00 $10.00 $15.00 $15.00
AG-61 $15.00 $5.00 $10.00 $10.00
AG-62 $15.00 $10.00 $12.00 $15.00
AG-63 $15.00 $5.00 $10.00 $10.00
AG-64 $15.00 $5.00 $15.00 $15.00
AG-65 $15.00 $10.00 $15.00 $15.00
AG-66 $15.00 $8.00 $12.00 $15.00
AG-67 $15.00 $5.00 $15.00 $15.00
AG-68 $15.00 $5.00 $15.00 $15.00
AG-69 N/C $10.00 $15.00 $15.00
AG-70 $15.00 $10.00 $15.00 $15.00
AG-71 j $15.00 $5.00 $15.00 $15.00
AG-72 j $15.00 $5.00 $15.00 $15.00
AG-73 j $15.00 $5.00 $10.00 $10.00
AG-74 $15.00 $5.00 $15.00 $18.00
AG-75 $15.00 $5.00 $20.00 $20.00
AG-76 j $15.00 $5.00 $15.00 $15.00
AG-77 N/C $10.00 $18.00 $20.00
AG-78 $15.00 $6.00 $12.00 $15.00
AG-79 $15.00 $5.00 $10.00 $15.00
AG-80 $15.00 $10.00 $18.00 $20.00
AG-81 $15.00 $5.00 $10.00 $10.00
AG-82 $15.00 $10.00 $15.00 $15.00
AG-83 $15.00 $10.00 $15.00 $15.00
AG-84 j $15.00 $10.00 $15.00 $15.00
AG-85 $15.00 $5.00 $15.00 $15.00
AG-86 j $15.00 $10.00 $20.00 $20.00
AG-87 $15.00 $10.00 $15.00 $15.00
AG-88 $15.00 $10.00 $15.00 $15.00
AG-89 * * * *
AG-90 $15.00 $5.00 $15.00 $15.00
AG-91 $15.00 $12.00 $15.00 $15.00
AG-92 j $15.00 $8.00 $12.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
16
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AG-93 j $15.00 $7.00 $12.00 $15.00
AG-94 $15.00 $10.00 $10.00 $20.00
AG-95 $15.00 $15.00 $20.00 $25.00
AG-96 $15.00 $10.00 $15.00 $20.00
AG-97 $15.00 $10.00 $15.00 $15.00
AG-98 N/C $8.00 $15.00 $15.00
AG-99 j $15.00 $5.00 $15.00 $15.00
AH-01 $15.00 $10.00 $15.00 $15.00
AH-02 $15.00 $6.00 $12.00 $15.00
AH-03 $15.00 $8.00 $15.00 $15.00
AH-04 $15.00 $5.00 $15.00 $20.00
AH-05 $15.00 $5.00 $10.00 $10.00
AH-06 j, l, $15.00 $8.00 $10.00 $15.00
AH-07 j, $15.00 $15.00 $15.00 $15.00
AH-08 N/C $5.00 $15.00 $20.00
AH-09 j $15.00 $10.00 $12.00 $15.00
AH-10 $15.00 $5.00 $15.00 $15.00
AH-11 s N/C $8.00 $10.00 $15.00
AH-12 N/C $10.00 $17.00 $18.00
AH-13 $15.00 $12.00 $18.00 $20.00
AH-14 $15.00 $5.00 $15.00 $15.00
AH-15 j $15.00 $5.00 $10.00 $10.00
AH-16 $15.00 $10.00 $18.00 $20.00
AH-17 $15.00 $5.00 $15.00 $15.00
AH-18 $15.00 $5.00 $10.00 $15.00
AH-19 $15.00 $5.00 $15.00 $18.00
AH-20 $15.00 $5.00 $15.00 $15.00
AH-21 $15.00 $5.00 $15.00 $15.00
AH-22 j $15.00 $8.00 $12.00 $15.00
AH-23 $15.00 $5.00 $15.00 $15.00
AH-24 $15.00 $5.00 $15.00 $15.00
AH-25 $15.00 $10.00 $20.00 $20.00
AH-26 j $15.00 $8.00 $12.00 $15.00
AH-27 j $15.00 $10.00 $15.00 $18.00
AH-28 j $15.00 $5.00 $8.00 $8.00
AH-29 * * * *
AH-30 $15.00 $15.00 $20.00 $22.00
AH-31 $15.00 $10.00 $15.00 $15.00
AH-32 $15.00 $12.00 $18.00 $20.00
AH-33 $15.00 $8.00 $12.00 $15.00
AH-34 j, $15.00 $8.00 $12.00 $15.00
AH-35 j $15.00 $8.00 $12.00 $15.00
AH-36 j N/C NADA NADA NADA
AH-37 $15.00 $5.00 $15.00 $18.00
AH-38 $15.00 $5.00 $15.00 $15.00
AH-39 $15.00 $10.00 $20.00 $20.00
AH-40 $15.00 $10.00 $20.00 $20.00
AH-41 $15.00 $5.00 $20.00 $20.00
AH-42 $15.00 $5.00 $18.00 $20.00
AH-43 N/C $8.00 $10.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
17
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AH-44 $15.00 $5.00 $10.00 $15.00
AH-45 $15.00 $5.00 $12.00 $15.00
AH-46 N/C $8.00 $12.00 $15.00
AH-47 g, j $15.00 $7.00 $14.00 $16.00
AH-48 g, j $15.00 $10.00 $10.00 $10.00
AH-49 g, j $15.00 $8.00 $12.00 $15.00
AH-50 $15.00 $5.00 $8.00 $10.00
AH-51 $15.00 $5.00 $8.00 $10.00
AH-52 j $15.00 $12.00 $12.00 $12.00
AH-53 $15.00 $10.00 $18.00 $20.00
AH-54 NADA $5.00 $10.00 $10.00
AH-55 j $15.00 $10.00 $10.00 $10.00
AH-56 NADA $2.00 $2.00 $2.00
AH-57 NADA $5.00 $10.00 $10.00
AH-58 h, j $15.00 $10.00 $10.00 $15.00
AH-59 j N/C $10.00 $10.00 $15.00
AH-60 $15.00 $4.00 $15.00 $20.00
AH-61 $15.00 $4.00 $15.00 $20.00
AH-62 $15.00 $4.00 $15.00 $20.00
AH-63 $15.00 $12.00 $15.00 $18.00
AH-64 j N/C NADA NADA NADA
AH-65 * * * *
AH-66 $15.00 $12.00 $15.00 $18.00
AH-67 * * * *
AH-68 $15.00 $8.00 $15.00 $15.00
AH-69 * * * *
AH-70 $15.00 $5.00 $15.00 $15.00
AH-71 $15.00 $5.00 $15.00 $15.00
AH-72 $15.00 $10.00 $15.00 $18.00
AH-73 # $15.00 $15.00 $20.00 $20.00
AH-74 $15.00 $10.00 $15.00 $15.00
AH-75 $15.00 $18.00 $22.00 $25.00
AH-76 $15.00 $5.00 $15.00 $15.00
AH-77 $15.00 $10.00 $18.00 $20.00
AH-78 j $15.00 $5.00 $10.00 $12.00
AH-79 $15.00 $15.00 $20.00 $20.00
AH-80 $15.00 $15.00 $18.00 $20.00
AH-81 $15.00 $12.00 $15.00 $18.00
AH-82 $15.00 $10.00 $15.00 $15.00
AH-83 * * * *
AH-84 $15.00 $8.00 $12.00 $15.00
AH-85 $15.00 $10.00 $12.00 $15.00
AH-86 $15.00 $5.00 $12.00 $18.00
AH-87 $15.00 $10.00 $18.00 $20.00
AH-88 $15.00 $8.00 $12.00 $15.00
AH-89 j $15.00 $7.00 $10.00 $15.00
AH-90 $15.00 $5.00 $15.00 $15.00
AH-91 i $15.00 $10.00 $12.00 $15.00
AH-92 i $15.00 $10.00 $12.00 $15.00
AH-93 j, w N/C NADA NADA NADA
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
18
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AH-94 ^ N/C $10.00 $15.00 $15.00
AH-95 $15.00 $8.00 $10.00 $15.00
AH-96 $15.00 $10.00 $15.00 $20.00
AH-97 $15.00 $5.00 $15.00 $15.00
AH-98 $15.00 $5.00 $10.00 $12.00
AH-99 $15.00 $7.00 $12.00 $15.00
AI-01 $15.00 $8.00 $18.00 $20.00
AI-02 j $15.00 $8.00 $10.00 $12.00
AI-03 j $15.00 $15.00 $15.00 $15.00
AI-04 j $15.00 $10.00 $15.00 $15.00
AI-05 w N/C NADA NADA NADA
AI-06 * * * *
AI-07 j, v $10.00 $10.00 $10.00 $10.00
AI-08 j, w N/C $3.00 $7.00 $11.00
AI-09 N/C $10.00 $15.00 $15.00
AI-10 h $15.00 $5.00 $8.00 $12.00
AI-11 v $15.00 $8.00 $12.00 $15.00
AI-12 $15.00 $5.00 $15.00 $15.00
AI-13 $15.00 $10.00 $15.00 $18.00
AI-14 $15.00 $5.00 $10.00 $10.00
AI-15 $15.00 $5.00 $15.00 $15.00
AI-16 ^ $15.00 $5.00 $15.00 $15.00
AI-17 $15.00 $10.00 $15.00 $20.00
AI-18 $15.00 $5.00 $15.00 $15.00
AI-19 $15.00 $7.00 $15.00 $15.00
AI-20 w $15.00 $10.00 $20.00 $20.00
AI-21 $15.00 $5.00 $10.00 $15.00
AI-22 g $15.00 $8.00 $15.00 $15.00
AI-23 i $15.00 $8.00 $12.00 $15.00
AI-24 $15.00 $15.00 $20.00 $20.00
AI-25 i $15.00 $8.00 $12.00 $15.00
AI-26 j, w $15.00 $10.00 $17.00 $20.00
AI-27 w $15.00 $10.00 $18.00 $20.00
AI-28 j $15.00 $10.00 $12.00 $15.00
AI-29 $15.00 $5.00 $10.00 $15.00
AI-30 j N/C NADA NADA NADA
AI-31 $15.00 $5.00 $10.00 $10.00
AI-32 $15.00 $5.00 $18.00 $20.00
AI-33 $15.00 $5.00 $10.00 $10.00
AI-34 $15.00 $10.00 $15.00 $15.00
AI-35 $15.00 $5.00 $10.00 $12.00
AI-36 $15.00 $5.00 $15.00 $15.00
AI-37 $15.00 $5.00 $10.00 $15.00
AI-38 $15.00 $15.00 $20.00 $25.00
AI-39 j $15.00 $5.00 $15.00 $15.00
AI-40 $15.00 $8.00 $12.00 $15.00
AI-41 $15.00 $5.00 $10.00 $15.00
AI-42 $15.00 $10.00 $15.00 $15.00
AI-43 $15.00 $5.00 $15.00 $15.00
AI-44 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
19
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AI-45 $15.00 $5.00 $10.00 $15.00
AI-46 $15.00 $5.00 $10.00 $15.00
AI-47 $15.00 $5.00 $15.00 $15.00
AI-48 $15.00 $5.00 $10.00 $10.00
AI-49 N/C $8.00 $10.00 $15.00
AI-50 N/C $8.00 $10.00 $12.00
AI-51 * * * *
AI-52 * * * *
AI-53 $15.00 $5.00 $10.00 $10.00
AI-54 * * * *
AI-55 * * * *
AI-56 * * * *
AI-57 * * * *
AI-58 * * * *
AI-59 $15.00 $10.00 $15.00 $15.00
AI-60 * * * *
AI-61 * * * *
AI-62 $15.00 $8.00 $12.00 $15.00
AI-63 * * * *
AI-64 $15.00 $10.00 $15.00 $15.00
AI-65 $15.00 $8.00 $12.00 $15.00
AI-66 $15.00 $10.00 $15.00 $15.00
AI-67 $15.00 $10.00 $15.00 $20.00
AI-68 $15.00 $8.00 $18.00 $20.00
AI-69 j $15.00 $7.00 $12.00 $15.00
AI-70 j $15.00 $7.00 $12.00 $15.00
AI-71 * * * *
AI-72 * * * *
AI-73 * * * *
AI-74 * * * *
AI-75 * * * *
AI-76 * * * *
AI-77 * * * *
AI-78 * * * *
AI-79 * * * *
AI-80 * * * *
AI-81 * * * *
AI-82 * * * *
AI-83 * * * *
AI-84 $15.00 $5.00 $7.00 $10.00
AI-85 * * * *
AI-86 * * * *
AI-87 $15.00 $8.00 $12.00 $15.00
AI-88 $15.00 $8.00 $15.00 $15.00
AI-89 $15.00 $5.00 $10.00 $10.00
AI-90 j f NADA NADA NADA
AI-91 $15.00 $10.00 $15.00 $15.00
AI-92 $15.00 $5.00 $10.00 $15.00
AI-93 $15.00 $10.00 $15.00 $15.00
AI-94 $15.00 $6.00 $8.00 $8.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
20
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AI-95 $15.00 $5.00 $10.00 $12.00
AI-96 $15.00 $15.00 $20.00 $20.00
AI-97 $15.00 $10.00 $15.00 $15.00
AI-98 $15.00 $10.00 $15.00 $15.00
AI-99 j $15.00 $8.00 $10.00 $12.00
AJ-01 o,p, j $15.00 $2.00 $6.00 $8.00
AJ-02 j $20.00 $6.00 $6.00 $6.00
AJ-03 x $20.00 $5.00 $5.00 $5.00
AJ-04 x,y, j NADA $2.00 $3.00 $5.00
AJ-05 x,y NADA $2.00 $3.00 $5.00
AJ-06 N/C $2.00 $3.00 $5.00
AJ-07 $15.00 $4.00 $7.00 $10.00
AJ-08 $15.00 $3.00 $7.00 $11.00
AJ-09 u,r $20.00 $3.00 $5.00 $10.00
AJ-10 $15.00 $8.00 $13.00 $15.00
AJ-11 j, l $15.00 $5.00 $12.00 $15.00
AJ-12 N/C $10.00 $15.00 $20.00
AJ-13 * * * *
AJ-14 $15.00 $5.00 $10.00 $15.00
AJ-15 $15.00 $3.00 $7.00 $11.00
AJ-16 $15.00 $3.00 $3.00 $3.00
AJ-17 $15.00 $6.00 $12.00 $15.00
AJ-18 r $15.00 $6.00 $12.00 $15.00
AJ-19 t $15.00 $6.00 $12.00 $15.00
AJ-20 N/C $10.00 $15.00 $20.00
AJ-21 N/C $10.00 $15.00 $20.00
AJ-22 N/C $10.00 $15.00 $20.00
AJ-23 $15.00 $8.00 $15.00 $15.00
AJ-24 $15.00 $7.00 $12.00 $15.00
AJ-25 j $15.00 $6.00 $10.00 $15.00
AJ-26 $15.00 $7.00 $15.00 $15.00
AJ-27 $15.00 $5.00 $9.00 $12.00
AJ-28 m,n $15.00 $3.00 $7.00 $11.00
AJ-29 m,n $15.00 $5.00 $10.00 $15.00
AJ-30 $15.00 $15.00 $20.00 $25.00
AJ-31 m,n $15.00 $5.00 $10.00 $12.00
AJ-32 m,n $15.00 $7.00 $12.00 $15.00
AJ-33 $15.00 $10.00 $15.00 $15.00
AJ-34 * * * *
AJ-35 v $15.00 $5.00 $10.00 $12.00
AJ-36 $15.00 $10.00 $12.00 $15.00
AJ-37 $15.00 $8.00 $15.00 $15.00
AJ-38 $15.00 $12.00 $15.00 $15.00
AJ-39 $15.00 $8.00 $12.00 $15.00
AJ-40 $15.00 $5.00 $15.00 $15.00
AJ-41 $15.00 $12.00 $15.00 $15.00
AJ-42 $15.00 $10.00 $15.00 $15.00
AJ-43 $15.00 $10.00 $15.00 $15.00
AJ-44 * * * *
AJ-45 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
21
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AJ-46 $15.00 $10.00 $15.00 $15.00
AJ-47 $15.00 $3.00 $5.00 $10.00
AJ-48 $15.00 $10.00 $15.00 $15.00
AJ-49 * * * *
AJ-50 $15.00 $10.00 $15.00 $15.00
AJ-51 $15.00 $10.00 $15.00 $15.00
AJ-52 $15.00 $7.00 $12.00 $15.00
AJ-53 * * * *
AJ-54 $15.00 $5.00 $15.00 $18.00
AJ-55 j $15.00 $5.00 $12.00 $15.00
AJ-56 $15.00 $8.00 $12.00 $15.00
AJ-57 $15.00 $10.00 $10.00 $15.00
AJ-58 $15.00 $5.00 $10.00 $12.00
AJ-59 $15.00 $5.00 $15.00 $15.00
AJ-60 $15.00 $3.00 $7.00 $11.00
AJ-61 * * * *
AJ-62 $15.00 $10.00 $15.00 $15.00
AJ-63 r, s $15.00 $5.00 $10.00 $12.00
AJ-64 $15.00 $3.00 $7.00 $11.00
AJ-65 * * * *
AJ-66 * * * *
AJ-67 $15.00 $10.00 $15.00 $20.00
AJ-68 $15.00 $8.00 $15.00 $15.00
AJ-69 * * * *
AJ-70 $15.00 $10.00 $15.00 $15.00
AJ-71 $15.00 $8.00 $15.00 $15.00
AJ-72 $15.00 $4.00 $7.00 $10.00
AJ-73 $15.00 $7.00 $10.00 $15.00
AJ-74 * * * *
AJ-75 $15.00 $7.00 $12.00 $15.00
AJ-76 $15.00 $8.00 $15.00 $15.00
AJ-77 * * * *
AJ-78 r,g $15.00 $10.00 $10.00 $10.00
AJ-79 * * * *
AJ-80 $15.00 $8.00 $15.00 $15.00
AJ-81 $15.00 $8.00 $15.00 $15.00
AJ-82 $15.00 NADA NADA NADA
AJ-83 $15.00 $5.00 $10.00 $15.00
AJ-84 * * * *
AJ-85 $15.00 $5.00 $10.00 $15.00
AJ-86 $15.00 $3.00 $4.00 $6.00
AJ-87 $15.00 $3.00 $7.00 $11.00
AJ-88 $15.00 $5.00 $8.00 $12.00
AJ-89 $15.00 $7.00 $12.00 $12.00
AJ-90 * * * *
AJ-91 m,n N/C $9.00 $13.00 $17.00
AJ-92 * * * *
AJ-93 m,n N/C $5.00 $10.00 $15.00
AJ-94 $15.00 $3.00 $7.00 $11.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
22
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AJ-95 $15.00 $7.00 $12.00 $15.00
AJ-96 j $15.00 $8.00 $12.00 $15.00
AJ-97 ç $15.00 $5.00 $10.00 $15.00
AJ-98 ç $15.00 $8.00 $12.00 $15.00
AJ-99 n $15.00 $8.00 $12.00 $12.00
AK-01 $15.00 $8.00 $12.00 $15.00
AK-02 j $15.00 $8.00 $12.00 $15.00
AK-03 j $15.00 $10.00 $15.00 $20.00
AK-04 $15.00 $7.00 $18.00 $18.00
AK-05 g, j $5.00 $12.00 $12.00 $12.00
AK-06 j, g $15.00 $10.00 $10.00 $10.00
AK-07 j, g $15.00 $5.00 $15.00 $15.00
AK-08 $15.00 $5.00 $10.00 $10.00
AK-09 $15.00 $8.00 $12.00 $15.00
AK-10 $15.00 $5.00 $15.00 $18.00
AK-11 v $15.00 $7.00 $10.00 $15.00
AK-12 $15.00 $8.00 $12.00 $15.00
AK-13 N/C $4.00 $4.00 $4.00
AK-14 $15.00 $5.00 $10.00 $10.00
AK-15 $15.00 $15.00 $20.00 $20.00
AK-16 $15.00 $10.00 $15.00 $18.00
AK-17 w $15.00 $10.00 $15.00 $15.00
AK-18 * * * *
AK-19 $15.00 $10.00 $15.00 $15.00
AK-20 $15.00 $10.00 $10.00 $10.00
AK-21 $15.00 $5.00 $10.00 $10.00
AK-22 $15.00 $5.00 $15.00 $15.00
AK-23 $15.00 $10.00 $15.00 $20.00
AK-24 $15.00 $5.00 $15.00 $15.00
AK-25 ^ $15.00 $5.00 $15.00 $15.00
AK-26 $15.00 $15.00 $20.00 $20.00
AK-27 $15.00 $5.00 $15.00 $18.00
AK-28 $15.00 $10.00 $15.00 $15.00
AK-29 $15.00 $5.00 $10.00 $10.00
AK-30 $15.00 $5.00 $15.00 $15.00
AK-31 $15.00 $10.00 $20.00 $20.00
AK-32 $15.00 $10.00 $17.00 $20.00
AK-33 $15.00 $10.00 $15.00 $20.00
AK-34 $15.00 $10.00 $18.00 $18.00
AK-35 ¥ $15.00 $7.00 $18.00 $20.00
AK-36 ¥ $15.00 $7.00 $18.00 $20.00
AK-37 ¥ $15.00 $7.00 $18.00 $20.00
AK-38 $15.00 $10.00 $15.00 $18.00
AK-39 $15.00 $10.00 $15.00 $15.00
AK-40 ¥ $15.00 $10.00 $15.00 $15.00
AK-41 $15.00 $7.00 $18.00 $20.00
AK-42 $15.00 $8.00 $12.00 $15.00
AK-43 j f NADA NADA NADA
AK-44 $15.00 $4.00 $15.00 $20.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
23
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AK-45 $15.00 $4.00 $15.00 $20.00
AK-46 $15.00 $15.00 $15.00 $20.00
AK-47 $15.00 $15.00 $15.00 $20.00
AK-48 $15.00 $7.00 $18.00 $20.00
AK-49 j f NADA NADA NADA
AK-50 j f NADA NADA NADA
AK-51 $15.00 $4.00 $15.00 $20.00
AK-52 $15.00 $10.00 $16.00 $16.00
AK-53 $15.00 $10.00 $18.00 $20.00
AK-54 $15.00 $10.00 $15.00 $20.00
AK-55 j $15.00 $10.00 $15.00 $15.00
AK-56 $15.00 $10.00 $15.00 $15.00
AK-57 $15.00 $5.00 $10.00 $15.00
AK-58 j, l $15.00 $12.00 $12.00 $12.00
AK-59 $15.00 $5.00 $10.00 $15.00
AK-60 $15.00 $5.00 $10.00 $15.00
AK-61 * * * *
AK-62 NADA NADA NADA NADA
AK-63 $15.00 $10.00 $15.00 $15.00
AK-64 j $15.00 $10.00 $15.00 $15.00
AK-65 * * * *
AK-66 $15.00 $5.00 $15.00 $15.00
AK-67 $15.00 $10.00 $15.00 $15.00
AK-68 * * * *
AK-69 * * * *
AK-70 * * * *
AK-71 * * * *
AK-72 $15.00 $10.00 $15.00 $15.00
AK-73 * * * *
AK-74 * * * *
AK-75 $15.00 $8.00 $12.00 $15.00
AK-76 * * * *
AK-77 $15.00 $5.00 $15.00 $15.00
AK-78 * * * *
AK-79 * * * *
AK-80 * * * *
AK-81 * * * *
AK-82 * * * *
AK-83 * * * *
AK-84 * * * *
AK-85 NADA $10.00 $15.00 $15.00
AK-86 $15.00 $4.00 $15.00 $20.00
AK-87 $15.00 $10.00 $15.00 $17.00
AK-88 $15.00 $10.00 $15.00 $20.00
AK-89 * * * *
AK-90 * * * *
AK-91 * * * *
AK-92 * * * *
AK-93 * * * *
CÓDIGOS DE CUBIERTAS / COPAGOS
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AK-94 $15.00 $8.00 $12.00 $15.00
AK-95 $15.00 $8.00 $15.00 $15.00
AK-96 $15.00 $4.00 $15.00 $20.00
AK-97 * * * *
AK-98 * * * *
AK-99 * * * *
AL-01 $15.00 $8.00 $15.00 $15.00
AL-02 g $15.00 $10.00 $15.00 $15.00
AL-03 g $15.00 $8.00 $12.00 $15.00
AL-04 g $15.00 $10.00 $12.00 $15.00
AL-05 $15.00 $10.00 $15.00 $15.00
AL-06 $15.00 $10.00 $15.00 $15.00
AL-07 $15.00 $10.00 $15.00 $15.00
AL-08 $15.00 $10.00 $15.00 $15.00
AL-09 $15.00 $5.00 $15.00 $15.00
AL-10 $15.00 $10.00 $15.00 $15.00
AL-11 $15.00 $8.00 $12.00 $15.00
AL-12 $15.00 $8.00 $12.00 $15.00
AL-13 $15.00 $5.00 $15.00 $15.00
AL-14 $15.00 $5.00 $15.00 $15.00
AL-15 $15.00 $10.00 $15.00 $15.00
AL-16 $15.00 $5.00 $15.00 $15.00
AL-17 $15.00 $10.00 $15.00 $15.00
AL-18 $15.00 $5.00 $15.00 $15.00
AL-19 $15.00 $10.00 $15.00 $15.00
AL-20 $15.00 $5.00 $15.00 $15.00
AL-21 $15.00 $5.00 $15.00 $15.00
AL-22 $15.00 $5.00 $15.00 $15.00
AL-23 $15.00 $10.00 $15.00 $20.00
AL-24k $15.00 $4.00 $15.00 $20.00
AL-25 j f NADA NADA NADA
AL-26 $15.00 $5.00 $10.00 $15.00
AL-27 $15.00 $5.00 $12.00 $15.00
AL-28 $15.00 $10.00 $15.00 $15.00
AL-29 $15.00 $5.00 $12.00 $15.00
AL-30 $15.00 $5.00 $12.00 $15.00
AL-31 $15.00 $6.00 $10.00 $12.00
AL-32 $15.00 $6.00 $10.00 $12.00
AL-33 $15.00 $6.00 $10.00 $12.00
AL-34 $15.00 $10.00 $15.00 $15.00
AL-35 $15.00 $5.00 $15.00 $15.00
AL-36 $15.00 $10.00 $15.00 $15.00
AL-37 $15.00 $6.00 $8.00 $8.00
AL-38 $15.00 $6.00 $8.00 $8.00
AL-39 $15.00 $5.00 $10.00 $10.00
AL-40 $15.00 $5.00 $10.00 $10.00
AL-41 $15.00 $8.00 $12.00 $15.00
AL-42 $15.00 $5.00 $10.00 $10.00
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AL-43 $15.00 $8.00 $12.00 $15.00
AL-44 $15.00 $5.00 $15.00 $15.00
AL-45 $15.00 $5.00 $15.00 $15.00
AL-46 $15.00 $5.00 $15.00 $15.00
AL-47 $15.00 $10.00 $15.00 $15.00
AL-48 $15.00 $10.00 $15.00 $15.00
AL-49 $15.00 $10.00 $15.00 $15.00
AL-50 $15.00 $5.00 $10.00 $10.00
AL-51 $15.00 $5.00 $10.00 $10.00
AL-52 $15.00 $8.00 $12.00 $15.00
AL-53 $15.00 $8.00 $12.00 $15.00
AL-54 $15.00 $10.00 $15.00 $15.00
AL-55 $15.00 $5.00 $15.00 $15.00
AL-56 $15.00 $5.00 $15.00 $15.00
AL-57 $15.00 $4.00 $15.00 $20.00
AL-58 $15.00 $8.00 $15.00 $15.00
AL-59 $15.00 $4.00 $15.00 $20.00
AL-60 j $15.00 $10.00 $15.00 $18.00
AL-61 $15.00 $4.00 $15.00 $20.00
AL-62 $15.00 $4.00 $15.00 $20.00
AL-63 $15.00 $4.00 $15.00 $20.00
AL-64 $15.00 $4.00 $15.00 $20.00
AL-65 $15.00 $8.00 $12.00 $12.00
AL-66 $15.00 $4.00 $15.00 $20.00
AL-67 $15.00 $8.00 $12.00 $12.00
AL-68 $15.00 $10.00 $15.00 $15.00
AL-69 $15.00 $10.00 $18.00 $18.00
AL-70 $15.00 $10.00 $18.00 $18.00
AL-71 g, j $15.00 $7.00 $15.00 $20.00
AL-72 $15.00 $4.00 $15.00 $20.00
AL-73 $15.00 $10.00 $15.00 $15.00
AL-74 $15.00 $4.00 $15.00 $20.00
AL-75 $15.00 $4.00 $15.00 $20.00
AL-76 $15.00 $10.00 $15.00 $15.00
AL-77 $15.00 $8.00 $12.00 $15.00
AL-78 $15.00 $5.00 $15.00 $18.00
AL-79 $15.00 $15.00 $15.00 $15.00
AL-80 $15.00 $5.00 $15.00 $15.00
AL-81 $15.00 $5.00 $15.00 $15.00
AL-82 $15.00 $5.00 $15.00 $18.00
AL-83 $15.00 $10.00 $15.00 $15.00
AL-84 $15.00 $5.00 $10.00 $15.00
AL-85 $15.00 $8.00 $12.00 $15.00
AL-86 $15.00 $5.00 $15.00 $15.00
AL-87 $15.00 $5.00 $12.00 $12.00
AL-88 $15.00 $5.00 $15.00 $15.00
AL-89 $15.00 $4.00 $15.00 $20.00
AL-90 $15.00 $10.00 $15.00 $15.00
AL-91 $15.00 $4.00 $15.00 $20.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AL-92 $15.00 $10.00 $15.00 $15.00
AL-93 $15.00 $4.00 $15.00 $20.00
AL-94 , a $15.00 $10.00 $15.00 $20.00
AL-95 $15.00 $10.00 $15.00 $20.00
AL-96 , a $15.00 $5.00 $10.00 $15.00
AL-97 $15.00 $5.00 $10.00 $15.00
AL-98 , a $15.00 $5.00 $10.00 $15.00
AM-01 $15.00 $7.00 $15.00 $20.00
AM-02 j N/C $5.00 $10.00 $12.00
AM-03 j N/C $8.00 $12.00 $15.00
AM-04 NADA $2.00 $5.00 $5.00
AM-05 $15.00 $8.00 $20.00 $20.00
AM-06 NADA $5.00 $10.00 $10.00
AM-07 $15.00 $5.00 $12.00 $15.00
AM-08 NADA $5.00 $10.00 $10.00
AM-09 j f NADA NADA NADA
AM-10 $15.00 $10.00 $15.00 $20.00
AM-11 $15.00 $6.00 $12.00 $12.00
AM-12 $15.00 $10.00 $15.00 $15.00
AM-13 g NADA $5.00 $10.00 $12.00
AM-14 j $15.00 $10.00 $18.00 $18.00
AM-15 $15.00 $5.00 $15.00 $15.00
AM-16 $15.00 $4.00 $15.00 $20.00
AM-17 $15.00 $10.00 $15.00 $25.00
AM-18 $15.00 $10.00 $15.00 $25.00
AM-19 $15.00 $10.00 $15.00 $25.00
AM-20 $15.00 $10.00 $15.00 $25.00
AM-21 j, $15.00 $5.00 $7.00 $12.00
AM-22 $15.00 $8.00 $15.00 $15.00
AM-23 N/C $3.00 $6.00 $6.00
AM-24 $15.00 $7.00 $12.00 $15.00
AM-25 $15.00 $8.00 $12.00 $15.00
AM-26 $15.00 $10.00 $12.00 $15.00
AM-27 $15.00 $12.00 $18.00 $18.00
AM-28 $15.00 $8.00 $10.00 $15.00
AM-29 j $15.00 $10.00 $12.00 $15.00
AM-30 NADA $5.00 $10.00 $10.00
AM-31 $15.00 $5.00 $15.00 $15.00
AM-32 $15.00 $5.00 $15.00 $15.00
AM-33 $15.00 $5.00 $15.00 $15.00
AM-34 $15.00 $6.00 $10.00 $12.00
AM-35 $15.00 $10.00 $12.00 $15.00
AM-36 $15.00 $5.00 $12.00 $15.00
AM-37 $15.00 $5.00 $10.00 $10.00
AM-38 $15.00 $8.00 $15.00 $15.00
AM-39 $15.00 $5.00 $15.00 $15.00
AM-40 $15.00 $10.00 $15.00 $15.00
AM-41 $15.00 $4.00 $15.00 $20.00
AM-42 $15.00 $5.00 $10.00 $15.00
AM-43 j $15.00 $5.00 $12.00 $20.00
AM-44 j $15.00 $5.00 $10.00 $12.00
AM-45 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AM-46 * * * *
AM-47 * * * *
AM-48 * * * *
AM-49 j $15.00 $5.00 $15.00 $15.00
AM-50 $15.00 $15.00 $18.00 $20.00
AM-51 j, $15.00 $4.00 $7.00 $10.00
AM-52 j, $15.00 $4.00 $7.00 $10.00
AM-53 $15.00 $10.00 $18.00 $20.00
AM-54 $15.00 $8.00 $12.00 $15.00
AM-55 $15.00 $5.00 $12.00 $12.00
AM-56 $15.00 $8.00 $12.00 $15.00
AM-57 j $15.00 $5.00 $15.00 $20.00
AM-58 $15.00 $10.00 $15.00 $15.00
AM-59 $15.00 $5.00 $10.00 $10.00
AM-60 $15.00 $10.00 $15.00 $15.00
AM-61 * * * *
AM-62 $15.00 $8.00 $12.00 $15.00
AM-63 $15.00 $10.00 $12.00 $15.00
AM-64 $15.00 $5.00 $15.00 $15.00
AM-65 $15.00 $10.00 $12.00 $15.00
AM-66 $15.00 $10.00 $12.00 $15.00
AM-67 $15.00 $3.00 $3.00 $3.00
AM-68 * * * *
AM-69 * * * *
AM-70 * * * *
AM-71 * * * *
AM-72 j $15.00 $5.00 $7.00 $10.00
AM-73 j $15.00 $5.00 $15.00 $15.00
AM-74 $15.00 $8.00 $12.00 $15.00
AM-75 $15.00 $10.00 $15.00 $15.00
AM-76 $15.00 $7.00 $18.00 $18.00
AM-77 * * * *
AM-78 $15.00 $5.00 $15.00 $15.00
AM-79 $15.00 $15.00 $15.00 $15.00
AM-80 $15.00 $10.00 $15.00 $15.00
AM-81 $15.00 $10.00 $15.00 $15.00
AM-82 j f NADA NADA NADA
AM-83 $15.00 $5.00 $15.00 $15.00
AM-84 j $15.00 $10.00 $20.00 $20.00
AM-85 $15.00 $5.00 $10.00 $10.00
AM-86 $15.00 $5.00 $10.00 $10.00
AM-87 $15.00 $5.00 $15.00 $15.00
AM-88 N/C $6.00 $10.00 $15.00
AM-89 $15.00 $10.00 $18.00 $20.00
AM-90 $15.00 $10.00 $15.00 $15.00
AM-91 $15.00 $8.00 $12.00 $15.00
AM-92 $15.00 $8.00 $12.00 $15.00
AM-93 $15.00 $10.00 $15.00 $15.00
AM-94 j $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AM-95 $15.00 $10.00 $15.00 $15.00
AM-96 $15.00 $10.00 $15.00 $15.00
AM-97 $15.00 $6.00 $8.00 $8.00
AM-98 $15.00 $6.00 $8.00 $8.00
AM-99 $15.00 $5.00 $10.00 $10.00
AN-01 $15.00 $5.00 $10.00 $10.00
AN-02 w $15.00 $8.00 $12.00 $15.00
AN-03 $15.00 $8.00 $12.00 $15.00
AN-04 $15.00 $5.00 $15.00 $15.00
AN-05 $15.00 $5.00 $15.00 $15.00
AN-06 $15.00 $5.00 $15.00 $15.00
AN-07 $15.00 $5.00 $15.00 $15.00
AN-08 j F, b NADA 5.00 10.00
AN-09 j F, b NADA 5.00 10.00
AN-10 j F, b NADA 5.00 10.00
AN-11 j $15.00 $10.00 $10.00 $15.00
AN-12 j $15.00 $10.00 $10.00 $15.00
AN-13 $15.00 $10.00 $15.00 $15.00
AN-14 $15.00 $10.00 $15.00 $15.00
AN-15 N/C $10.00 $15.00 $15.00
AN-16 $15.00 $10.00 $15.00 $15.00
AN-17 $15.00 $10.00 $15.00 $15.00
AN-18 $15.00 $6.00 $8.00 $8.00
AN-19 $15.00 $6.00 $8.00 $8.00
AN-20 $15.00 $5.00 $10.00 $10.00
AN-20 $15.00 $5.00 $10.00 $10.00
AN-21 $15.00 $5.00 $10.00 $10.00
AN-22 $15.00 $8.00 $12.00 $15.00
AN-23 $15.00 $8.00 $12.00 $15.00
AN-24 $15.00 $5.00 $15.00 $15.00
AN-25 $15.00 $5.00 $15.00 $15.00
AN-26 $15.00 $5.00 $18.00 $20.00
AN-27 $15.00 $5.00 $10.00 $10.00
AN-28 $15.00 $7.00 $12.00 $15.00
AN-29 $15.00 $12.00 $17.00 $20.00
AN-30 $15.00 $5.00 $15.00 $15.00
AN-31 $15.00 $10.00 $15.00 $20.00
AN-32 $15.00 $10.00 $20.00 $20.00
AN-33 $15.00 $5.00 $10.00 $12.00
AN-34 $15.00 $5.00 $10.00 $10.00
AN-35 $15.00 $10.00 $15.00 $18.00
AN-36 $15.00 $10.00 $15.00 $18.00
AN-37 $15.00 $8.00 $10.00 $12.00
AN-38 $15.00 $10.00 $12.00 $15.00
AN-39 $15.00 $10.00 $18.00 $18.00
AN-40 $15.00 $10.00 $20.00 $20.00
AN-41 $15.00 $10.00 $15.00 $15.00
AN-42 j $15.00 $10.00 $15.00 $18.00
AN-43 $15.00 $10.00 $15.00 $20.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AN-44 j F, b NADA $5.00 $10.00
AN-45 * * * *
AN-46 $15.00 $10.00 $15.00 $15.00
AN-47 j $15.00 $20.00 $30.00 $40.00
AN-48 j $15.00 $10.00 $15.00 $15.00
AN-49 $15.00 $8.00 $18.00 $18.00
AN-50 j $15.00 $3.00 $10.00 $12.00
AN-51 $15.00 $10.00 $15.00 $18.00
AN-52 $15.00 $10.00 $15.00 $15.00
AN-53 j $15.00 $10.00 $15.00 $18.00
AN-54 $15.00 $5.00 $20.00 $20.00
AN-55 $15.00 $10.00 $15.00 $15.00
AN-56 $15.00 $5.00 $10.00 $12.00
AN-57 $15.00 $8.00 $20.00 $25.00
AN-58 $15.00 $6.00 $8.00 $8.00
AN-59 $15.00 $10.00 $15.00 $20.00
AN-60 $15.00 $5.00 $10.00 $15.00
AN-61 $15.00 $4.00 $15.00 $20.00
AN-62 $15.00 $10.00 $18.00 $18.00
AN-63 f NADA NADA NADA
AN-64 $15.00 $10.00 $15.00 $15.00
AN-65 $15.00 $10.00 $12.00 $12.00
AN-66 $15.00 $15.00 $15.00 $15.00
AN-67 $15.00 $5.00 $18.00 $18.00
AN-68 $15.00 $8.00 $12.00 $15.00
AN-69 $15.00 $8.00 $12.00 $15.00
AN-70 $15.00 $5.00 $15.00 $15.00
AN-71 * * * *
AN-72 $15.00 $10.00 $15.00 $15.00
AN-73 $15.00 $10.00 $18.00 $20.00
AN-74 j $15.00 $7.00 $15.00 $15.00
AN-75 $15.00 $5.00 $15.00 $15.00
AN-76 $15.00 $5.00 $10.00 $15.00
AN-77 $15.00 $15.00 $20.00 $20.00
AN-78 $15.00 $15.00 $20.00 $20.00
AN-79 $15.00 $10.00 $15.00 $15.00
AN-80 $15.00 $5.00 $15.00 $15.00
AN-81 $15.00 $8.00 $17.00 $20.00
AN-82 $15.00 $7.00 $18.00 $18.00
AN-83 $15.00 $10.00 $15.00 $15.00
AN-84 $15.00 $5.00 $12.00 $15.00
AN-85 $15.00 $5.00 $15.00 $15.00
AN-86 $15.00 $10.00 $15.00 $20.00
AN-87 $15.00 $10.00 $15.00 $20.00
AN-88 $15.00 $12.00 $18.00 $20.00
AN-89 $15.00 $10.00 $15.00 $20.00
AN-90 $15.00 $8.00 $12.00 $15.00
AN-91 $15.00 $8.00 $12.00 $15.00
AN-92 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AN-93 $15.00 $4.00 $15.00 $20.00
AN-94 $15.00 $10.00 $15.00 $15.00
AN-95 NADA $7.00 $12.00 $15.00
AN-96 * * * *
AN-97 * * * *
AN-98 $15.00 $7.00 $18.00 $20.00
AN-99 $15.00 $7.00 $18.00 $20.00
AP-01 * * * *
AP-02 $15.00 $10.00 $15.00 $15.00
AP-03 $15.00 $8.00 $12.00 $15.00
AP-04 $15.00 $10.00 $15.00 $15.00
AP-05 $15.00 $8.00 $12.00 $15.00
AP-06 $15.00 $15.00 $15.00 $20.00
AP-07 $15.00 $8.00 $15.00 $15.00
AP-08 r,s $15.00 $8.00 $10.00 $15.00
AP-09 $15.00 $10.00 $15.00 $15.00
AP-10 $15.00 $3.00 $7.00 $11.00
AP-11 $15.00 $8.00 $15.00 $15.00
AP-12 $15.00 $7.00 $10.00 $12.00
AP-13 o $15.00 $10.00 $15.00 $15.00
AP-14 r $15.00 $6.00 $12.00 $15.00
AP-15 $15.00 $6.00 $12.00 $15.00
AP-16 t $15.00 $6.00 $12.00 $15.00
AP-17 r $15.00 $6.00 $12.00 $15.00
AP-18 * * * *
AP-19 o, $15.00 $5.00 $15.00 $15.00
AP-20 o $15.00 $12.00 $15.00 $15.00
AP-21 o $15.00 $12.00 $15.00 $18.00
AP-22 $15.00 $10.00 $15.00 $15.00
AP-23 $15.00 $10.00 $15.00 $15.00
AP-24 $15.00 $12.00 $15.00 $18.00
AP-25 $15.00 $10.00 $12.00 $15.00
AP-26 $15.00 $8.00 $10.00 $15.00
AP-27 * * * *
AP-28 $15.00 $8.00 $10.00 $12.00
AP-29 $15.00 $8.00 $12.00 $15.00
AP-30 $15.00 $10.00 $15.00 $15.00
AP-31 20% 20% 20% 20%
AP-32 $15.00 $10.00 $12.00 $15.00
AP-33 N/C $5.00 $15.00 $20.00
AP-34 * * * *
AP-35 j $15.00 $2.00 $6.00 $8.00
AP-36 $15.00 $10.00 $15.00 $15.00
AP-37 $15.00 $10.00 $15.00 $15.00
AP-38 $15.00 $5.00 $10.00 $15.00
AP-39 $15.00 $8.00 $12.00 $15.00
AP-40 $15.00 $12.00 $18.00 $20.00
AP-41 $15.00 $4.00 $4.00 $4.00
AP-42 N/C NADA NADA NADA
AP-43 $15.00 $12.00 $15.00 $18.00
AP-44 $15.00 $10.00 $12.00 $15.00
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AP-45 $15.00 $10.00 $12.00 $15.00
AP-46 N/C $10.00 $15.00 $15.00
AP-47 $15.00 $12.00 $15.00 $18.00
AP-48 ^ $15.00 $10.00 $15.00 $18.00
AP-49 ^ $15.00 $10.00 $15.00 $18.00
AP-50 $15.00 $15.00 $15.00 $15.00
AP-51 $15.00 $10.00 $15.00 $20.00
AP-52 $15.00 $5.00 $15.00 $15.00
AP-53 $15.00 $5.00 $10.00 $10.00
AP-54 $15.00 $10.00 $20.00 $20.00
AP-55 $15.00 $12.00 $15.00 $18.00
AP-56 ^ $15.00 $10.00 $15.00 $15.00
AP-57 $15.00 $8.00 $12.00 $15.00
AP-58 $15.00 $10.00 $18.00 $20.00
AP-59 $15.00 $7.00 $15.00 $15.00
AP-60 $15.00 $10.00 $15.00 $20.00
AP-61 $15.00 $10.00 $20.00 $20.00
AP-62 $15.00 $10.00 $20.00 $20.00
AP-63 $15.00 $10.00 $15.00 $15.00
AP-64 * * * *
AP-65 * * * *
AP-66 $15.00 $10.00 $15.00 $18.00
AP-67 $15.00 $15.00 $20.00 $20.00
AP-68 $15.00 $7.00 $18.00 $18.00
AP-69 $15.00 $10.00 $15.00 $15.00
AP-70 $15.00 $5.00 $15.00 $15.00
AP-71 $15.00 $10.00 $15.00 $18.00
AP-72 $15.00 $10.00 $15.00 $18.00
AP-73 $15.00 $5.00 $15.00 $15.00
AP-74 $20.00 $5.00 $12.00 $15.00
AP-75 $15.00 $8.00 $15.00 $15.00
AP-76 $15.00 $5.00 $12.00 $20.00
AP-77 $15.00 $5.00 $15.00 $15.00
AP-78 $15.00 $10.00 $18.00 $20.00
AP-79 $15.00 $8.00 $12.00 $15.00
AP-80 $15.00 $10.00 $15.00 $15.00
AP-81 $15.00 $10.00 $15.00 $15.00
AP-82 j $15.00 $7.00 $15.00 $15.00
AP-83 ^ $15.00 $10.00 $15.00 $15.00
AP-84 j $15.00 $10.00 $15.00 $15.00
AP-85 * * * *
AP-86 j $15.00 $12.00 $12.00 $12.00
AP-87 j $15.00 $12.00 $15.00 $15.00
AP-88 $15.00 $8.00 $12.00 $15.00
AP-89 $15.00 $10.00 $15.00 $15.00
AP-90 $15.00 $12.00 $18.00 $20.00
AP-91 $15.00 $10.00 $15.00 $20.00
AP-92 $15.00 $10.00 $15.00 $20.00
AP-93 * * * *
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
32
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
AP-94 * * * *
AP-95 * * * *
AP-96 * * * *
AP-97 * * * *
AP-98 * * * *
AP-99 $15.00 $15.00 $20.00 $20.00
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
* * * * *
CÓDIGOS DE CUBIERTAS / COPAGOS
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33
NOTAS: N/C No cubre * Código sin asignar (a) Aplica periodo de espera (b) Deducible de generalista aplica para las especialidades de medicina familiar, geriatras, medicina
interna, obstetras y ginecólogos (c) Deducible de generalista ($5.00) aplica para las especialidades de medicina familiar, pediatras,
medicina interna, obstetras y ginecólogos (d) Aplica deducible de $8.00 para médico de familia. (e) Deducible de generalista ($2.00) aplica para las especialidades de médico de cabecera, médico
de familia, internista y geriatra (f) Aplica al Programa Medicare Advantage (g) No paga deducible por visitas prenatales. (h) $8.00 de deducible para visitas prenatales. (i) $12.00 de deducible para visitas prenatales. (j) Cubre Thin Prep Pap. (k) Deducible de generalista ($4.00) aplica para las especialidades de generalista, médico de
familia, internista, ginecólogo, pediatra, optómetra, podiatra y audiólogos. (l) Cubre copago de visita inicial correspondiente en la primera visita. Visitas subsiguientes
posteriores no le aplica copago. (m) Deducible de especialista aplica para las especialidades de optómetras o quiroprácticos. (n) Deducible de subespecialista aplica para la especialidad de podiatra. (o) Deducible de especialista aplica para las especialidades de optómetra, podiatra y quiropráctico. (p) Deducible de generalista aplica para la especialidad de audiólogo. (q) Deducible de subespecialista aplica para la especialidad de quiropráctico, optómetra (r) $15.00 de deducible para quiropráctico, psicólogo o podiatras (s) $10.00 de deducible para optómetra, psicólogo o podiatra
(t) No cubre quiropráctico, psicólogo
(u) 20% para psicólogo
(v) $10.00 de deducible para Visitas Prenatales iniciales o subsiguientes
(w) No cubre Visitas Prenatales
(X) $6.00 de deducible para podiatra, quiropráctico
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
34
(y) $5.00 para optómetras.
(z) Cubre Visitas Prenatales por indemnización.
(#) $20.00 de deducible para Visitas Prenatales iniciales o subsiguientes
(^) $15.00 de deducible para visitas prenatales.
(ç) Deducible de generalista aplica para la especialidad de Podiatra y Optómetra
(¥) Cubre visitas prenatales con deducible de Especialista
(€) Visitas pre y post natales: Aplica copago de especialista, pero si la asegurada se subscribe al programa Prenatal durante el primer trimestre pagarán $0.00 copago por las visitas pre y post natales. Aseguradas que se registren luego del primer trimestre no aplican a este incentivo.
(§) El copago para las siguientes especialidades será de $10.00: Pediatras, Ginecólogos,
Internistas y Médicos de Familia. (Ω) Cubre por Reembolso () Versión de Cubiertas de Reforma de Salud Federal que incluyen beneficios que se
considerarán como Servicios Preventivos
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
35
Grupo Triple-S
VISITAS A DOMICILIO VISITAS A LA OFICINA CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1 NADA $2.00 $2.00 $2.00
B2 $15.00 $5.00 $10.00 $15.00
B3 $15.00 $5.00 $10.00 $10.00
B4 $15.00 $5.00 $10.00 $10.00
B5 NADA $5.00 $10.00 $10.00
B6 NADA $5.00 $10.00 $10.00
B7 NADA $5.00 $10.00 $10.00
B8 NADA $5.00 $10.00 $10.00
B9 NADA $2.00 $2.00 $2.00
B10 NADA $2.00 $5.00 $5.00
B11 NADA $2.00 $5.00 $5.00
B12 NADA $5.00 $10.00 $10.00
B13 NADA $5.00 $10.00 $10.00
B14 NADA $5.00 $10.00 $10.00
B15 NADA $2.00 $2.00 $2.00
B16 NADA $2.00 $5.00 $5.00
B17 $15.00 $5.00 $10.00 $15.00
B18 NADA $5.00 $10.00 $10.00
B19 NADA $5.00 $10.00 $10.00
B20 NADA $5.00 $10.00 $10.00
B21 NADA $5.00 $10.00 $10.00
B22 NADA $5.00 $10.00 $10.00
B23 NADA $5.00 $10.00 $10.00
B24 NADA $2.00 $5.00 $5.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
36
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B25 $15.00 $10.00 $15.00 $15.00
B26 $15.00 $5.00 $10.00 $10.00
B27 $15.00 $8.00 $12.00 $15.00
B28 $15.00 $5.00 $15.00 $15.00
B29 $15.00 $5.00 $15.00 $15.00
B30 $15.00 $10.00 $15.00 $15.00
B31 $15.00 $5.00 $15.00 $15.00
B32 $15.00 $10.00 $15.00 $15.00
B33 $15.00 $5.00 $15.00 $15.00
B34 $15.00 $5.00 $10.00 $10.00
B35 $15.00 $5.00 $15.00 $15.00
B36 $15.00 $10.00 $15.00 $15.00
B37 $15.00 $10.00 $15.00 $15.00
B38 $15.00 $5.00 $10.00 $10.00
B39 $15.00 $8.00 $12.00 $15.00
B40 $15.00 $5.00 $15.00 $15.00
B41 $15.00 $10.00 $15.00 $15.00
B42 $15.00 $10.00 $15.00 $15.00
B43 $15.00 $5.00 $10.00 $10.00
B44 $15.00 $5.00 $15.00 $15.00
B45 $15.00 $5.00 $10.00 $10.00
B46 $15.00 $10.00 $15.00 $15.00
B47 $15.00 $5.00 $15.00 $15.00
B48 $15.00 $5.00 $15.00 $15.00
B49 $15.00 $5.00 $10.00 $10.00
B50 $15.00 $8.00 $12.00 $15.00
B51 $15.00 $5.00 $10.00 $10.00
B52 $15.00 $5.00 $15.00 $15.00
B53 $15.00 $5.00 $15.00 $15.00
B54 $15.00 $8.00 $12.00 $15.00
B55 $15.00 $5.00 $15.00 $15.00
B56 $15.00 $10.00 $15.00 $15.00
B57 $15.00 $10.00 $15.00 $15.00
B58 $15.00 $8.00 $12.00 $15.00
B59 $15.00 $8.00 $12.00 $15.00
B60 $15.00 $10.00 $15.00 $15.00
B61 $15.00 $8.00 $12.00 $15.00
B62 $15.00 $5.00 $15.00 $15.00
B63 $15.00 $5.00 $15.00 $15.00
B64 $15.00 $5.00 $10.00 $10.00
B65 $15.00 $10.00 $15.00 $15.00
B66 $15.00 $8.00 $12.00 $15.00
B67 $15.00 $5.00 $15.00 $15.00
B68 $15.00 $5.00 $10.00 $10.00
B69 $15.00 $10.00 $15.00 $15.00
B70 $15.00 $10.00 $15.00 $15.00
B71 $15.00 $5.00 $10.00 $10.00
B72 $15.00 $10.00 $15.00 $15.00
B73 $15.00 $8.00 $12.00 $15.00
B74 $15.00 $10.00 $15.00 $15.00
B75 $15.00 $5.00 $10.00 $10.00
B76 $15.00 $8.00 $12.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
37
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B77 $15.00 $5.00 $15.00 $15.00
B78 $15.00 $5.00 $15.00 $15.00
B79 $15.00 $5.00 $15.00 $15.00
B80 $15.00 $5.00 $15.00 $15.00
B81 $15.00 $10.00 $15.00 $15.00
B82 $15.00 $5.00 $15.00 $15.00
B83 $15.00 $5.00 $15.00 $15.00
B84 $15.00 $8.00 $12.00 $15.00
B85 $15.00 $5.00 $15.00 $15.00
B86 $15.00 $10.00 $15.00 $15.00
B87 $15.00 $5.00 $10.00 $10.00
B88 $15.00 $5.00 $15.00 $15.00
B89 $15.00 $8.00 $12.00 $15.00
B90 $15.00 $5.00 $15.00 $15.00
B91 $15.00 $5.00 $10.00 $10.00
B92 $15.00 $10.00 $15.00 $15.00
B93 $15.00 $10.00 $15.00 $15.00
B94 $15.00 $10.00 $15.00 $15.00
B95 $15.00 $5.00 $10.00 $10.00
B96 $15.00 $8.00 $12.00 $15.00
B97 $15.00 $5.00 $15.00 $15.00
B98 $15.00 $10.00 $15.00 $15.00
B99 $15.00 $5.00 $15.00 $15.00
B100 $15.00 $5.00 $15.00 $15.00
B101 $15.00 $10.00 $15.00 $15.00
B102 $15.00 $5.00 $10.00 $10.00
B103 $15.00 $5.00 $10.00 $10.00
B104 $15.00 $8.00 $12.00 $15.00
B105 $15.00 $5.00 $15.00 $15.00
B106 $15.00 $5.00 $10.00 $10.00
B107 $15.00 $5.00 $15.00 $15.00
B108 $15.00 $10.00 $15.00 $15.00
B109 $15.00 $5.00 $10.00 $10.00
B110 $15.00 $8.00 $12.00 $15.00
B111 $15.00 $5.00 $15.00 $15.00
B112 $15.00 $10.00 $15.00 $15.00
B113 $15.00 $5.00 $15.00 $15.00
B114 $15.00 $10.00 $15.00 $15.00
B115 $15.00 $5.00 $10.00 $10.00
B116 $15.00 $8.00 $12.00 $15.00
B117 $15.00 $5.00 $15.00 $15.00
B118 $15.00 $5.00 $15.00 $15.00
B119 $15.00 $5.00 $10.00 $10.00
B120 $15.00 $8.00 $12.00 $15.00
B121 $15.00 $10.00 $15.00 $15.00
B122 $15.00 $10.00 $15.00 $15.00
B123 $15.00 $5.00 $10.00 $10.00
B124 $15.00 $8.00 $12.00 $15.00
B125 $15.00 $5.00 $15.00 $15.00
B126 $15.00 $5.00 $15.00 $15.00
B127 $15.00 $10.00 $15.00 $15.00
B128 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
38
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B129 $15.00 $8.00 $12.00 $15.00
B130 $15.00 $5.00 $15.00 $15.00
B131 $15.00 $10.00 $15.00 $15.00
B132 $15.00 $5.00 $10.00 $10.00
B133 $15.00 $8.00 $12.00 $15.00
B134 $15.00 $5.00 $15.00 $15.00
B135 $15.00 $8.00 $12.00 $15.00
B136 $15.00 $10.00 $15.00 $15.00
B137 $15.00 $5.00 $10.00 $10.00
B138 $15.00 $8.00 $12.00 $15.00
B139 $15.00 $5.00 $15.00 $15.00
B140 $15.00 $5.00 $15.00 $15.00
B141 $15.00 $10.00 $15.00 $15.00
B142 $15.00 $5.00 $10.00 $10.00
B143 $15.00 $8.00 $12.00 $15.00
B144 $15.00 $10.00 $15.00 $15.00
B145 $15.00 $5.00 $10.00 $10.00
B146 $15.00 $8.00 $12.00 $15.00
B147 $15.00 $5.00 $15.00 $15.00
B148 $15.00 $5.00 $15.00 $15.00
B149 $15.00 $5.00 $15.00 $15.00
B150 $15.00 $10.00 $15.00 $15.00
B151 $15.00 $5.00 $10.00 $10.00
B152 $15.00 $5.00 $10.00 $10.00
B153 $15.00 $8.00 $12.00 $15.00
B154 $15.00 $5.00 $15.00 $15.00
B155 $15.00 $10.00 $15.00 $15.00
B156 $15.00 $5.00 $10.00 $10.00
B157 $15.00 $8.00 $12.00 $15.00
B158 $15.00 $5.00 $15.00 $15.00
B159 $15.00 $5.00 $15.00 $15.00
B160 $15.00 $10.00 $15.00 $15.00
B161 $15.00 $10.00 $15.00 $15.00
B162 $15.00 $8.00 $12.00 $15.00
B163 $15.00 $5.00 $15.00 $15.00
B164 $15.00 $10.00 $15.00 $15.00
B165 $15.00 $10.00 $15.00 $15.00
B166 $15.00 $5.00 $10.00 $10.00
B167 $15.00 $8.00 $12.00 $15.00
B168 $15.00 $5.00 $15.00 $15.00
B169 $15.00 $8.00 $12.00 $15.00
B170 $15.00 $10.00 $15.00 $15.00
B171 $15.00 $5.00 $10.00 $10.00
B172 $15.00 $8.00 $12.00 $15.00
B173 $15.00 $5.00 $15.00 $15.00
B174 $15.00 $5.00 $15.00 $15.00
B175 $15.00 $10.00 $15.00 $15.00
B176 $15.00 $5.00 $10.00 $10.00
B177 $15.00 $8.00 $12.00 $15.00
B178 $15.00 $5.00 $15.00 $15.00
B179 $15.00 $10.00 $15.00 $15.00
B180 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
39
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B181 $15.00 $10.00 $15.00 $15.00
B182 $15.00 $5.00 $10.00 $10.00
B183 $15.00 $8.00 $12.00 $15.00
B184 $15.00 $5.00 $15.00 $15.00
B185 $15.00 $10.00 $15.00 $15.00
B186 $15.00 $5.00 $10.00 $10.00
B187 $15.00 $10.00 $15.00 $15.00
B188 $15.00 $8.00 $12.00 $15.00
B189 $15.00 $5.00 $15.00 $15.00
B190 $15.00 $5.00 $10.00 $10.00
B191 $15.00 $10.00 $15.00 $15.00
B192 $15.00 $10.00 $15.00 $15.00
B193 $15.00 $5.00 $10.00 $10.00
B194 $15.00 $8.00 $12.00 $15.00
B195 $15.00 $5.00 $15.00 $15.00
B196 $15.00 $5.00 $10.00 $10.00
B197 $15.00 $5.00 $15.00 $15.00
B198 $15.00 $5.00 $10.00 $10.00
B199 $15.00 $10.00 $15.00 $15.00
B200 $15.00 $5.00 $15.00 $15.00
B201 $15.00 $8.00 $12.00 $15.00
B202 $15.00 $5.00 $15.00 $15.00
B203 $15.00 $5.00 $15.00 $15.00
B204 $15.00 $10.00 $15.00 $15.00
B205 $15.00 $5.00 $10.00 $10.00
B206 $15.00 $8.00 $12.00 $15.00
B207 $15.00 $5.00 $15.00 $15.00
B208 $15.00 $5.00 $15.00 $15.00
B209 $15.00 $10.00 $15.00 $15.00
B210 $15.00 $5.00 $15.00 $15.00
B211 $15.00 $5.00 $15.00 $15.00
B212 $15.00 $10.00 $15.00 $15.00
B213 $15.00 $10.00 $15.00 $15.00
B214 $15.00 $5.00 $10.00 $10.00
B215 $15.00 $8.00 $12.00 $15.00
B216 $15.00 $5.00 $15.00 $15.00
B217 $15.00 $10.00 $15.00 $15.00
B218 $15.00 $5.00 $15.00 $15.00
B219 $15.00 $5.00 $10.00 $10.00
B220 $15.00 $8.00 $12.00 $15.00
B221 $15.00 $10.00 $15.00 $15.00
B222 $15.00 $5.00 $10.00 $10.00
B223 $15.00 $8.00 $12.00 $15.00
B224 $15.00 $5.00 $15.00 $15.00
B225 $15.00 $10.00 $15.00 $15.00
B226 $15.00 $5.00 $15.00 $15.00
B227 $15.00 $10.00 $15.00 $15.00
B228 $15.00 $5.00 $15.00 $15.00
B229 $15.00 $10.00 $15.00 $15.00
B230 $15.00 $5.00 $10.00 $10.00
B231 $15.00 $5.00 $15.00 $15.00
B232 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
40
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B233 $15.00 $8.00 $12.00 $15.00
B234 $15.00 $5.00 $15.00 $15.00
B235 $15.00 $5.00 $15.00 $15.00
B236 $15.00 $10.00 $15.00 $15.00
B237 $15.00 $10.00 $15.00 $15.00
B238 $15.00 $5.00 $15.00 $15.00
B239 $15.00 $5.00 $15.00 $15.00
B240 $15.00 $10.00 $15.00 $15.00
B241 $15.00 $10.00 $15.00 $15.00
B242 $15.00 $5.00 $10.00 $10.00
B243 $15.00 $5.00 $15.00 $15.00
B244 $15.00 $5.00 $15.00 $15.00
B245 $15.00 $5.00 $10.00 $10.00
B246 $15.00 $10.00 $15.00 $15.00
B247 $15.00 $5.00 $15.00 $15.00
B248 $15.00 $5.00 $10.00 $10.00
B249 $15.00 $8.00 $12.00 $15.00
B250 $15.00 $5.00 $15.00 $15.00
B251 $15.00 $5.00 $15.00 $15.00
B252 $15.00 $10.00 $15.00 $15.00
B253 $15.00 $5.00 $15.00 $15.00
B254 $15.00 $5.00 $15.00 $15.00
B255 $15.00 $5.00 $15.00 $15.00
B256 $15.00 $10.00 $15.00 $15.00
B257 $15.00 $10.00 $15.00 $15.00
B258 $15.00 $10.00 $15.00 $15.00
B259 $15.00 $5.00 $15.00 $15.00
B260 $15.00 $10.00 $15.00 $15.00
B261 $15.00 $5.00 $15.00 $15.00
B262 $15.00 $10.00 $15.00 $15.00
B263 $15.00 $5.00 $10.00 $10.00
B264 $15.00 $5.00 $10.00 $10.00
B265 $15.00 $8.00 $12.00 $15.00
B266 $15.00 $5.00 $15.00 $15.00
B267 $15.00 $5.00 $10.00 $10.00
B268 $15.00 $5.00 $15.00 $15.00
B269 N/C $8.00 $12.00 $15.00
B270 $15.00 $5.00 $10.00 $10.00
B271 $15.00 $5.00 $15.00 $15.00
B272 $15.00 $5.00 $10.00 $10.00
B273 $15.00 $8.00 $12.00 $15.00
B274 $15.00 $5.00 $15.00 $15.00
B275 $15.00 $8.00 $12.00 $15.00
B276 $15.00 $5.00 $15.00 $15.00
B277 $15.00 $10.00 $15.00 $15.00
B278 $15.00 $5.00 $10.00 $10.00
B279 $15.00 $8.00 $12.00 $15.00
B280 $15.00 $5.00 $15.00 $15.00
B281 $15.00 $10.00 $15.00 $15.00
B282 $15.00 $5.00 $10.00 $10.00
B283 $15.00 $5.00 $15.00 $15.00
B284 $15.00 $6.00 $8.00 $8.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
41
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B285 $15.00 $5.00 $10.00 $10.00
B286 $15.00 $8.00 $12.00 $15.00
B287 $15.00 $5.00 $15.00 $15.00
B288 $15.00 $10.00 $15.00 $15.00
B289 $15.00 $6.00 $8.00 $8.00
B290 $15.00 $5.00 $15.00 $15.00
B291 $15.00 $10.00 $15.00 $15.00
B292 $15.00 $10.00 $15.00 $15.00
B293 $15.00 $5.00 $10.00 $10.00
B294 $15.00 $8.00 $12.00 $15.00
B295 $15.00 $5.00 $15.00 $15.00
B296 $15.00 $6.00 $8.00 $8.00
B297 $15.00 $8.00 $12.00 $15.00
B298 $15.00 $10.00 $15.00 $15.00
B299 $15.00 $6.00 $8.00 $8.00
B300 $15.00 $5.00 $10.00 $10.00
B301 $15.00 $8.00 $12.00 $15.00
B302 $15.00 $5.00 $15.00 $15.00
B303 $15.00 $10.00 $15.00 $15.00
B304 $15.00 $5.00 $10.00 $10.00
B305 $15.00 $8.00 $12.00 $15.00
B306 $15.00 $5.00 $15.00 $15.00
B307 $15.00 $5.00 $15.00 $15.00
B308 $15.00 $10.00 $15.00 $15.00
B309 $15.00 $5.00 $15.00 $15.00
B310 $15.00 $10.00 $15.00 $15.00
B311 $15.00 $10.00 $15.00 $15.00
B312 $15.00 $10.00 $15.00 $15.00
B313 $15.00 $6.00 $8.00 $8.00
B314 $15.00 $5.00 $10.00 $10.00
B315 $15.00 $8.00 $12.00 $15.00
B316 $15.00 $5.00 $15.00 $15.00
B317 $15.00 $10.00 $15.00 $15.00
B318 $15.00 $5.00 $10.00 $10.00
B319 $15.00 $5.00 $15.00 $15.00
B320 $15.00 $10.00 $15.00 $15.00
B321 $15.00 $6.00 $8.00 $8.00
B322 $15.00 $5.00 $10.00 $10.00
B323 $15.00 $8.00 $12.00 $15.00
B324 $15.00 $5.00 $15.00 $15.00
B325 $15.00 $5.00 $15.00 $15.00
B326 $15.00 $6.00 $8.00 $8.00
B327 $15.00 $5.00 $10.00 $10.00
B328 $15.00 $5.00 $15.00 $15.00
B329 $15.00 $10.00 $15.00 $15.00
B330 $15.00 $6.00 $8.00 $8.00
B331 $15.00 $5.00 $10.00 $10.00
B332 $15.00 $8.00 $12.00 $15.00
B333 $15.00 $5.00 $15.00 $15.00
B334 $15.00 $10.00 $15.00 $15.00
B335 $15.00 $6.00 $8.00 $8.00
B336 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
42
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B337 $15.00 $8.00 $12.00 $15.00
B338 $15.00 $5.00 $15.00 $15.00
B339 $15.00 $10.00 $15.00 $15.00
B340 $15.00 $5.00 $10.00 $10.00
B341 $15.00 $8.00 $12.00 $15.00
B342 $15.00 $5.00 $15.00 $15.00
B343 $15.00 $5.00 $15.00 $15.00
B344 $15.00 $5.00 $15.00 $15.00
B345 $15.00 $5.00 $10.00 $10.00
B346 $15.00 $5.00 $15.00 $15.00
B347 $15.00 $5.00 $15.00 $15.00
B348 $15.00 $10.00 $15.00 $15.00
B349 $15.00 $5.00 $15.00 $15.00
B350 $15.00 $10.00 $15.00 $15.00
B351 $15.00 $10.00 $15.00 $15.00
B352 $15.00 $10.00 $15.00 $15.00
B353 $15.00 $5.00 $15.00 $15.00
B354 $15.00 $5.00 $15.00 $15.00
B355 $15.00 $10.00 $15.00 $15.00
B356 $15.00 $5.00 $15.00 $15.00
B357 $15.00 $10.00 $15.00 $15.00
B358 $15.00 $6.00 $8.00 $8.00
B359 $15.00 $5.00 $10.00 $10.00
B360 $15.00 $5.00 $15.00 $15.00
B361 $15.00 $5.00 $15.00 $15.00
B362 $15.00 $5.00 $10.00 $10.00
B363 $15.00 $5.00 $15.00 $15.00
B364 $15.00 $5.00 $15.00 $15.00
B365 $15.00 $5.00 $10.00 $10.00
B366 $15.00 $5.00 $15.00 $15.00
B367 $15.00 $10.00 $15.00 $15.00
B368 $15.00 $5.00 $15.00 $15.00
B369 $15.00 $5.00 $15.00 $15.00
B370 $15.00 $10.00 $15.00 $15.00
B371 $15.00 $5.00 $15.00 $15.00
B372 $15.00 $10.00 $15.00 $15.00
B373 $15.00 $6.00 $8.00 $8.00
B374 $15.00 $5.00 $10.00 $10.00
B375 $15.00 $5.00 $15.00 $15.00
B376 $15.00 $5.00 $15.00 $15.00
B377 $15.00 $10.00 $15.00 $15.00
B378 $15.00 $6.00 $8.00 $8.00
B379 $15.00 $5.00 $15.00 $15.00
B380 $15.00 $10.00 $15.00 $15.00
B381 $15.00 $5.00 $15.00 $15.00
B382 $15.00 $8.00 $12.00 $15.00
B383 $15.00 $5.00 $15.00 $15.00
B384 $15.00 $5.00 $10.00 $10.00
B385 $15.00 $8.00 $12.00 $15.00
B386 $15.00 $5.00 $15.00 $15.00
B387 $15.00 $10.00 $15.00 $15.00
B388 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
43
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B389 $15.00 $10.00 $15.00 $15.00
B390 $15.00 $5.00 $10.00 $10.00
B391 $15.00 $8.00 $12.00 $15.00
B392 $15.00 $5.00 $15.00 $15.00
B393 $15.00 $5.00 $15.00 $15.00
B394 $15.00 $6.00 $8.00 $8.00
B395 $15.00 $5.00 $10.00 $10.00
B396 $15.00 $5.00 $15.00 $15.00
B397 $15.00 $5.00 $15.00 $15.00
B398 $15.00 $8.00 $12.00 $15.00
B399 $15.00 $5.00 $15.00 $15.00
B400 $15.00 $6.00 $8.00 $8.00
B401 $15.00 $5.00 $15.00 $15.00
B402 $15.00 $5.00 $15.00 $15.00
B403 $15.00 $5.00 $15.00 $15.00
B404 $15.00 $5.00 $10.00 $10.00
B405 $15.00 $8.00 $12.00 $15.00
B406 $15.00 $10.00 $15.00 $15.00
B407 $15.00 $8.00 $12.00 $15.00
B408 $15.00 $5.00 $15.00 $15.00
B409 $15.00 $8.00 $12.00 $15.00
B410 $15.00 $10.00 $15.00 $15.00
B411 $15.00 $5.00 $10.00 $10.00
B412 $15.00 $5.00 $15.00 $15.00
B413 $15.00 $5.00 $15.00 $15.00
B414 $15.00 $10.00 $15.00 $15.00
B415 $15.00 $5.00 $10.00 $10.00
B416 $15.00 $10.00 $15.00 $15.00
B417 $15.00 $8.00 $12.00 $15.00
B418 $15.00 $5.00 $15.00 $15.00
B419 $15.00 $10.00 $15.00 $15.00
B420 $15.00 $6.00 $8.00 $8.00
B421 $15.00 $8.00 $12.00 $15.00
B422 $15.00 $5.00 $15.00 $15.00
B423 $15.00 $10.00 $15.00 $15.00
B424 $15.00 $5.00 $10.00 $10.00
B425 $15.00 $5.00 $15.00 $15.00
B426 $15.00 $5.00 $15.00 $15.00
B427 $15.00 $10.00 $15.00 $15.00
B428 $15.00 $8.00 $12.00 $15.00
B429 $15.00 $10.00 $15.00 $15.00
B430 $15.00 $5.00 $15.00 $15.00
B431 $15.00 $10.00 $15.00 $15.00
B432 $15.00 $8.00 $12.00 $15.00
B433 $15.00 $5.00 $15.00 $15.00
B434 $15.00 $5.00 $15.00 $15.00
B435 $15.00 $10.00 $15.00 $15.00
B436 $15.00 $5.00 $10.00 $10.00
B437 $15.00 $5.00 $15.00 $15.00
B438 $15.00 $10.00 $15.00 $15.00
B439 $15.00 $10.00 $15.00 $15.00
B440 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
44
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B441 $15.00 $5.00 $15.00 $15.00
B442 $15.00 $5.00 $10.00 $10.00
B443 $15.00 $5.00 $15.00 $15.00
B444 $15.00 $5.00 $15.00 $15.00
B445 $15.00 $10.00 $15.00 $15.00
B446 $15.00 $10.00 $15.00 $15.00
B447 $15.00 $5.00 $10.00 $10.00
B448 $15.00 $8.00 $12.00 $15.00
B449 $15.00 $5.00 $15.00 $15.00
B450 $15.00 $8.00 $12.00 $15.00
B451 $15.00 $10.00 $15.00 $15.00
B452 $15.00 $5.00 $10.00 $10.00
B453 $15.00 $5.00 $15.00 $15.00
B454 $15.00 $5.00 $15.00 $15.00
B455 $15.00 $5.00 $15.00 $15.00
B456 $15.00 $5.00 $10.00 $10.00
B457 $15.00 $10.00 $15.00 $15.00
B458 $15.00 $10.00 $15.00 $15.00
B459 $15.00 $8.00 $12.00 $15.00
B460 $15.00 $10.00 $15.00 $15.00
B461 $15.00 $8.00 $12.00 $15.00
B462 $15.00 $5.00 $15.00 $15.00
B463 $15.00 $5.00 $15.00 $15.00
B464 $15.00 $5.00 $15.00 $15.00
B465 $15.00 $10.00 $15.00 $15.00
B466 $15.00 $8.00 $12.00 $15.00
B467 $15.00 $10.00 $15.00 $15.00
B468 $15.00 $10.00 $15.00 $15.00
B469 $15.00 $10.00 $15.00 $15.00
B470 $15.00 $5.00 $15.00 $15.00
B471 $15.00 $5.00 $10.00 $10.00
B472 $15.00 $10.00 $15.00 $15.00
B473 $15.00 $5.00 $10.00 $10.00
B474 $15.00 $5.00 $15.00 $15.00
B475 $15.00 $10.00 $15.00 $15.00
B476 $15.00 $8.00 $12.00 $15.00
B477 $15.00 $5.00 $10.00 $10.00
B478 $15.00 $5.00 $15.00 $15.00
B479 $15.00 $5.00 $10.00 $10.00
B480 $15.00 $10.00 $15.00 $15.00
B481 $15.00 $5.00 $10.00 $10.00
B482 $15.00 $8.00 $12.00 $15.00
B483 $15.00 $10.00 $15.00 $15.00
B484 $15.00 $5.00 $10.00 $10.00
B485 $15.00 $8.00 $12.00 $15.00
B486 $15.00 $5.00 $15.00 $15.00
B487 $15.00 $5.00 $15.00 $15.00
B488 $15.00 $10.00 $15.00 $15.00
B489 $15.00 $5.00 $10.00 $10.00
B490 $15.00 $5.00 $15.00 $15.00
B491 $15.00 $10.00 $15.00 $15.00
B492 $15.00 $8.00 $12.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
45
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B493 $15.00 $10.00 $15.00 $15.00
B494 $15.00 $5.00 $10.00 $10.00
B495 $15.00 $8.00 $12.00 $15.00
B496 $15.00 $5.00 $15.00 $15.00
B497 $15.00 $5.00 $15.00 $15.00
B498 $15.00 $10.00 $15.00 $15.00
B499 $15.00 $5.00 $10.00 $10.00
B500 $15.00 $8.00 $12.00 $15.00
B501 $15.00 $5.00 $15.00 $15.00
B502 $15.00 $10.00 $15.00 $15.00
B503 $15.00 $5.00 $10.00 $10.00
B504 $15.00 $8.00 $12.00 $15.00
B505 $15.00 $10.00 $15.00 $15.00
B506 $15.00 $5.00 $10.00 $10.00
B507 $15.00 $8.00 $12.00 $15.00
B508 $15.00 $5.00 $15.00 $15.00
B509 $15.00 $5.00 $15.00 $15.00
B510 $15.00 $10.00 $15.00 $15.00
B511 $15.00 $5.00 $10.00 $10.00
B512 $15.00 $5.00 $15.00 $15.00
B513 $15.00 $5.00 $15.00 $15.00
B514 $15.00 $5.00 $10.00 $10.00
B515 $15.00 $8.00 $12.00 $15.00
B516 $15.00 $10.00 $15.00 $15.00
B517 $15.00 $5.00 $10.00 $10.00
B518 $15.00 $8.00 $12.00 $15.00
B519 $15.00 $5.00 $15.00 $15.00
B520 $15.00 $10.00 $15.00 $15.00
B521 $15.00 $5.00 $10.00 $10.00
B522 $15.00 $8.00 $12.00 $15.00
B523 $15.00 $10.00 $15.00 $15.00
B524 $15.00 $5.00 $10.00 $10.00
B525 $15.00 $5.00 $15.00 $15.00
B526 $15.00 $5.00 $15.00 $15.00
B527 $15.00 $5.00 $10.00 $10.00
B528 $15.00 $8.00 $12.00 $15.00
B529 $15.00 $10.00 $15.00 $15.00
B530 $15.00 $5.00 $10.00 $10.00
B531 $15.00 $8.00 $12.00 $15.00
B532 $15.00 $8.00 $12.00 $15.00
B533 $15.00 $5.00 $15.00 $15.00
B534 $15.00 $5.00 $15.00 $15.00
B535 $15.00 $10.00 $15.00 $15.00
B536 $15.00 $8.00 $12.00 $15.00
B537 $15.00 $5.00 $15.00 $15.00
B538 $15.00 $10.00 $15.00 $15.00
B539 $15.00 $5.00 $10.00 $10.00
B540 $15.00 $8.00 $12.00 $15.00
B541 $15.00 $10.00 $15.00 $15.00
B542 $15.00 $5.00 $10.00 $10.00
B543 $15.00 $8.00 $12.00 $15.00
B544 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
46
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B545 $15.00 $5.00 $15.00 $15.00
B546 $15.00 $10.00 $15.00 $15.00
B547 $15.00 $8.00 $12.00 $15.00
B548 $15.00 $8.00 $12.00 $15.00
B549 $15.00 $5.00 $15.00 $15.00
B550 $15.00 $5.00 $15.00 $15.00
B551 $15.00 $10.00 $15.00 $15.00
B552 $15.00 $5.00 $10.00 $10.00
B553 $15.00 $10.00 $15.00 $15.00
B554 $15.00 $10.00 $15.00 $15.00
B555 $15.00 $5.00 $10.00 $10.00
B556 $15.00 $8.00 $12.00 $15.00
B557 $15.00 $5.00 $15.00 $15.00
B558 $15.00 $5.00 $15.00 $15.00
B559 $15.00 $5.00 $15.00 $15.00
B560 $15.00 $5.00 $15.00 $15.00
B561 $15.00 $10.00 $15.00 $15.00
B562 $15.00 $5.00 $10.00 $10.00
B563 $15.00 $8.00 $12.00 $15.00
B564 $15.00 $5.00 $15.00 $15.00
B565 $15.00 $10.00 $15.00 $15.00
B566 $15.00 $5.00 $10.00 $10.00
B567 $15.00 $5.00 $15.00 $15.00
B568 $15.00 $5.00 $10.00 $10.00
B569 $15.00 $8.00 $12.00 $15.00
B570 $15.00 $5.00 $15.00 $15.00
B571 $15.00 $5.00 $15.00 $15.00
B572 $15.00 $5.00 $15.00 $15.00
B573 $15.00 $10.00 $15.00 $15.00
B574 $15.00 $5.00 $10.00 $10.00
B575 $15.00 $10.00 $15.00 $15.00
B576 $15.00 $5.00 $10.00 $10.00
B577 $15.00 $8.00 $12.00 $15.00
B578 $15.00 $8.00 $12.00 $15.00
B579 $15.00 $5.00 $15.00 $15.00
B580 $15.00 $5.00 $10.00 $10.00
B581 $15.00 $10.00 $15.00 $15.00
B582 $15.00 $5.00 $10.00 $10.00
B583 $15.00 $8.00 $12.00 $15.00
B584 $15.00 $5.00 $15.00 $15.00
B585 $15.00 $10.00 $15.00 $15.00
B586 $15.00 $5.00 $15.00 $15.00
B587 $15.00 $5.00 $15.00 $15.00
B588 $15.00 $5.00 $10.00 $10.00
B589 $15.00 $8.00 $12.00 $15.00
B590 $15.00 $5.00 $15.00 $15.00
B591 $15.00 $8.00 $12.00 $15.00
B592 $15.00 $10.00 $15.00 $15.00
B593 $15.00 $10.00 $15.00 $15.00
B594 $15.00 $5.00 $10.00 $10.00
B595 $15.00 $8.00 $12.00 $15.00
B596 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
47
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B597 $15.00 $10.00 $15.00 $15.00
B598 $15.00 $8.00 $12.00 $15.00
B599 $15.00 $5.00 $15.00 $15.00
B600 $15.00 $5.00 $15.00 $15.00
B601 $15.00 $5.00 $10.00 $10.00
B602 $15.00 $10.00 $15.00 $15.00
B603 $15.00 $5.00 $15.00 $15.00
B604 $15.00 $5.00 $15.00 $15.00
B605 $15.00 $5.00 $15.00 $15.00
B606 $15.00 $10.00 $15.00 $15.00
B607 $15.00 $8.00 $12.00 $15.00
B608 $15.00 $5.00 $15.00 $15.00
B609 $15.00 $5.00 $10.00 $10.00
B610 $15.00 $5.00 $15.00 $15.00
B611 $15.00 $8.00 $12.00 $15.00
B612 $15.00 $5.00 $15.00 $15.00
B613 $15.00 $8.00 $12.00 $15.00
B614 $15.00 $5.00 $15.00 $15.00
B615 $15.00 $5.00 $10.00 $10.00
B616 $15.00 $8.00 $12.00 $15.00
B617 $15.00 $8.00 $12.00 $15.00
B618 $15.00 $10.00 $15.00 $15.00
B619 $15.00 $10.00 $15.00 $15.00
B620 $15.00 $5.00 $15.00 $15.00
B621 $15.00 $5.00 $15.00 $15.00
B622 $15.00 $5.00 $15.00 $15.00
B623 $15.00 $5.00 $15.00 $15.00
B624 $15.00 $10.00 $15.00 $15.00
B625 $15.00 $10.00 $15.00 $15.00
B626 $15.00 $5.00 $15.00 $15.00
B627 $15.00 $8.00 $12.00 $15.00
B628 $15.00 $5.00 $10.00 $10.00
B629 $15.00 $8.00 $12.00 $15.00
B630 $15.00 $5.00 $15.00 $15.00
B631 $15.00 $10.00 $15.00 $15.00
B632 $15.00 $10.00 $15.00 $15.00
B633 $15.00 $5.00 $15.00 $15.00
B634 $15.00 $5.00 $15.00 $15.00
B635 $15.00 $5.00 $15.00 $15.00
B636 $15.00 $5.00 $15.00 $15.00
B637 $15.00 $10.00 $15.00 $15.00
B638 $15.00 $5.00 $15.00 $15.00
B639 $15.00 $10.00 $15.00 $15.00
B640 $15.00 $10.00 $15.00 $15.00
B641 $15.00 $5.00 $15.00 $15.00
B642 $15.00 $8.00 $12.00 $15.00
B643 $15.00 $5.00 $15.00 $15.00
B644 $15.00 $10.00 $15.00 $15.00
B645 $15.00 $5.00 $15.00 $15.00
B646 $15.00 $10.00 $15.00 $15.00
B647 $15.00 $10.00 $15.00 $15.00
B648 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
48
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B649 $15.00 $5.00 $15.00 $15.00
B650 $15.00 $10.00 $15.00 $15.00
B651 $15.00 $10.00 $15.00 $15.00
B652 $15.00 $10.00 $15.00 $15.00
B653 $15.00 $8.00 $12.00 $15.00
B654 $15.00 $10.00 $15.00 $15.00
B655 $15.00 $10.00 $15.00 $15.00
B656 $15.00 $8.00 $12.00 $15.00
B657 $15.00 $8.00 $12.00 $15.00
B658 $15.00 $5.00 $15.00 $15.00
B659 $15.00 $10.00 $15.00 $15.00
B660 $15.00 $5.00 $10.00 $10.00
B661 $15.00 $5.00 $15.00 $15.00
B662 $15.00 $10.00 $15.00 $15.00
B663 $15.00 $5.00 $15.00 $15.00
B664 $15.00 $10.00 $15.00 $15.00
B665 $15.00 $10.00 $15.00 $15.00
B666 $15.00 $5.00 $15.00 $15.00
B667 $15.00 $10.00 $15.00 $15.00
B668 $15.00 $10.00 $15.00 $15.00
B669 $15.00 $5.00 $15.00 $15.00
B670 $15.00 $5.00 $15.00 $15.00
B671 $15.00 $8.00 $12.00 $15.00
B672 $15.00 $5.00 $15.00 $15.00
B673 $15.00 $10.00 $15.00 $15.00
B674 $15.00 $10.00 $15.00 $15.00
B675 $15.00 $10.00 $15.00 $15.00
B676 $15.00 $5.00 $15.00 $15.00
B677 $15.00 $8.00 $12.00 $15.00
B678 $15.00 $10.00 $15.00 $15.00
B679 $15.00 $10.00 $15.00 $15.00
B680 $15.00 $10.00 $15.00 $15.00
B681 $15.00 $5.00 $15.00 $15.00
B682 $15.00 $5.00 $15.00 $15.00
B683 $15.00 $10.00 $15.00 $15.00
B684 $15.00 $10.00 $15.00 $15.00
B685 $15.00 $8.00 $12.00 $15.00
B686 $15.00 $5.00 $15.00 $15.00
B687 $15.00 $5.00 $15.00 $15.00
B688 $15.00 $10.00 $15.00 $15.00
B689 $15.00 $5.00 $15.00 $15.00
B690 $15.00 $10.00 $15.00 $15.00
B691 $15.00 $5.00 $15.00 $15.00
B692 $15.00 $5.00 $15.00 $15.00
B693 $15.00 $10.00 $15.00 $15.00
B694 $15.00 $5.00 $10.00 $10.00
B695 $15.00 $10.00 $15.00 $15.00
B696 $15.00 $5.00 $10.00 $10.00
B697 $15.00 $10.00 $15.00 $15.00
B698 $15.00 $5.00 $10.00 $10.00
B699 $15.00 $10.00 $15.00 $15.00
B700 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
49
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B701 $15.00 $5.00 $10.00 $10.00
B702 $15.00 $5.00 $15.00 $15.00
B703 $15.00 $5.00 $15.00 $15.00
B704 $15.00 $10.00 $15.00 $15.00
B705 $15.00 $10.00 $15.00 $15.00
B706 $15.00 $10.00 $15.00 $15.00
B707 $15.00 $8.00 $12.00 $15.00
B708 $15.00 $5.00 $15.00 $15.00
B709 $15.00 $8.00 $12.00 $15.00
B710 $15.00 $5.00 $15.00 $15.00
B711 $15.00 $5.00 $15.00 $15.00
B712 $15.00 $10.00 $15.00 $15.00
B713 $15.00 $10.00 $15.00 $15.00
B714 $15.00 $8.00 $12.00 $15.00
B715 $15.00 $10.00 $15.00 $15.00
B716 $15.00 $5.00 $10.00 $10.00
B717 $15.00 $5.00 $15.00 $15.00
B718 $15.00 $5.00 $15.00 $15.00
B719 $15.00 $10.00 $15.00 $15.00
B720 $15.00 $10.00 $15.00 $15.00
B721 $15.00 $5.00 $15.00 $15.00
B722 $15.00 $5.00 $10.00 $10.00
B723 $15.00 $5.00 $15.00 $15.00
B724 $15.00 $10.00 $15.00 $15.00
B725 $15.00 $8.00 $12.00 $15.00
B726 $15.00 $5.00 $15.00 $15.00
B727 $15.00 $8.00 $12.00 $15.00
B728 $15.00 $5.00 $15.00 $15.00
B729 $15.00 $10.00 $15.00 $15.00
B730 $15.00 $5.00 $10.00 $10.00
B731 $15.00 $5.00 $15.00 $15.00
B732 $15.00 $5.00 $15.00 $15.00
B733 $15.00 $10.00 $15.00 $15.00
B734 $15.00 $5.00 $10.00 $10.00
B735 $15.00 $5.00 $15.00 $15.00
B736 $15.00 $10.00 $15.00 $15.00
B737 $15.00 $10.00 $15.00 $15.00
B738 $15.00 $10.00 $15.00 $15.00
B739 $15.00 $5.00 $15.00 $15.00
B740 $15.00 $10.00 $15.00 $15.00
B741 $15.00 $10.00 $15.00 $15.00
B742 $15.00 $5.00 $15.00 $15.00
B743 $15.00 $10.00 $15.00 $15.00
B744 $15.00 $10.00 $15.00 $15.00
B745 $15.00 $10.00 $15.00 $15.00
B746 $15.00 $10.00 $15.00 $15.00
B747 $15.00 $8.00 $12.00 $15.00
B748 $15.00 $5.00 $15.00 $15.00
B749 $15.00 $5.00 $15.00 $15.00
B750 $15.00 $10.00 $15.00 $15.00
B751 $15.00 $10.00 $15.00 $15.00
B752 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
50
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B753 $15.00 $8.00 $12.00 $15.00
B754 $15.00 $10.00 $15.00 $15.00
B755 $15.00 $10.00 $15.00 $15.00
B756 $15.00 $5.00 $15.00 $15.00
B757 $15.00 $10.00 $15.00 $15.00
B758 $15.00 $10.00 $15.00 $15.00
B759 $15.00 $8.00 $12.00 $15.00
B760 $15.00 $5.00 $15.00 $15.00
B761 $15.00 $8.00 $12.00 $15.00
B762 $15.00 $10.00 $15.00 $15.00
B763 $15.00 $10.00 $15.00 $15.00
B764 $15.00 $10.00 $15.00 $15.00
B765 $15.00 $5.00 $15.00 $15.00
B766 $15.00 $5.00 $15.00 $15.00
B767 $15.00 $10.00 $15.00 $15.00
B768 $15.00 $10.00 $15.00 $15.00
B769 $15.00 $5.00 $10.00 $10.00
B770 $15.00 $5.00 $15.00 $15.00
B771 $15.00 $5.00 $15.00 $15.00
B772 $15.00 $10.00 $15.00 $15.00
B773 $15.00 $10.00 $15.00 $15.00
B774 $15.00 $8.00 $12.00 $15.00
B775 $15.00 $5.00 $15.00 $15.00
B776 $15.00 $10.00 $15.00 $15.00
B777 $15.00 $5.00 $10.00 $10.00
B778 $15.00 $8.00 $12.00 $15.00
B779 $15.00 $8.00 $12.00 $15.00
B780 $15.00 $5.00 $15.00 $15.00
B781 $15.00 $10.00 $15.00 $15.00
B782 $15.00 $10.00 $15.00 $15.00
B783 $15.00 $8.00 $12.00 $15.00
B784 $15.00 $10.00 $15.00 $15.00
B785 $15.00 $5.00 $15.00 $15.00
B786 $15.00 $10.00 $15.00 $15.00
B787 $15.00 $10.00 $15.00 $15.00
B788 $15.00 $5.00 $10.00 $10.00
B789 $15.00 $8.00 $12.00 $15.00
B790 $15.00 $5.00 $15.00 $15.00
B791 $15.00 $10.00 $15.00 $15.00
B792 $15.00 $10.00 $15.00 $15.00
B793 $15.00 $5.00 $15.00 $15.00
B794 $15.00 $8.00 $12.00 $15.00
B795 $15.00 $5.00 $15.00 $15.00
B796 $15.00 $10.00 $15.00 $15.00
B797 $15.00 $5.00 $10.00 $10.00
B798 $15.00 $10.00 $15.00 $15.00
B799 $15.00 $5.00 $10.00 $10.00
B800 $15.00 $5.00 $15.00 $15.00
B801 $15.00 $10.00 $15.00 $15.00
B802 $15.00 $5.00 $15.00 $15.00
B803 $15.00 $10.00 $15.00 $15.00
B804 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
51
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B805 $15.00 $5.00 $10.00 $10.00
B806 $15.00 $8.00 $12.00 $15.00
B807 $15.00 $8.00 $12.00 $15.00
B808 $15.00 $5.00 $15.00 $15.00
B809 $15.00 $10.00 $15.00 $15.00
B810 $15.00 $10.00 $15.00 $15.00
B811 $15.00 $8.00 $12.00 $15.00
B812 $15.00 $5.00 $15.00 $15.00
B813 $15.00 $5.00 $15.00 $15.00
B814 $15.00 $10.00 $15.00 $15.00
B815 $15.00 $10.00 $15.00 $15.00
B816 $15.00 $10.00 $15.00 $15.00
B817 $15.00 $10.00 $15.00 $15.00
B818 $15.00 $8.00 $12.00 $15.00
B819 $15.00 $5.00 $15.00 $15.00
B820 $15.00 $10.00 $15.00 $15.00
B821 $15.00 $10.00 $15.00 $15.00
B822 $15.00 $10.00 $15.00 $15.00
B823 $15.00 $10.00 $15.00 $15.00
B824 $15.00 $10.00 $15.00 $15.00
B825 $15.00 $8.00 $12.00 $15.00
B826 $15.00 $5.00 $15.00 $15.00
B827 $15.00 $5.00 $15.00 $15.00
B828 $15.00 $10.00 $15.00 $15.00
B829 $15.00 $10.00 $15.00 $15.00
B830 $15.00 $5.00 $15.00 $15.00
B831 $15.00 $10.00 $15.00 $15.00
B832 $15.00 $10.00 $15.00 $15.00
B833 $15.00 $8.00 $12.00 $15.00
B834 $15.00 $5.00 $15.00 $15.00
B835 $15.00 $5.00 $15.00 $15.00
B836 $15.00 $5.00 $10.00 $10.00
B837 $15.00 $5.00 $15.00 $15.00
B838 $15.00 $10.00 $15.00 $15.00
B839 $15.00 $5.00 $15.00 $15.00
B840 $15.00 $5.00 $10.00 $10.00
B841 $15.00 $8.00 $12.00 $15.00
B842 $15.00 $10.00 $15.00 $15.00
B843 $15.00 $10.00 $15.00 $15.00
B844 $15.00 $10.00 $15.00 $15.00
B845 $15.00 $10.00 $15.00 $15.00
B846 $15.00 $10.00 $15.00 $15.00
B847 $15.00 $10.00 $15.00 $15.00
B848 $15.00 $5.00 $15.00 $15.00
B849 $15.00 $10.00 $15.00 $15.00
B850 $15.00 $5.00 $10.00 $10.00
B851 $15.00 $5.00 $15.00 $15.00
B852 $15.00 $10.00 $15.00 $15.00
B853 $15.00 $10.00 $15.00 $15.00
B854 $15.00 $8.00 $12.00 $15.00
B855 $15.00 $10.00 $15.00 $15.00
B856 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
52
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B857 $15.00 $5.00 $15.00 $15.00
B858 $15.00 $5.00 $15.00 $15.00
B859 $15.00 $10.00 $15.00 $15.00
B860 $15.00 $10.00 $15.00 $15.00
B861 $15.00 $5.00 $15.00 $15.00
B862 $15.00 $10.00 $15.00 $15.00
B863 $15.00 $5.00 $10.00 $10.00
B864 $15.00 $10.00 $15.00 $15.00
B865 $15.00 $5.00 $15.00 $15.00
B866 $15.00 $10.00 $15.00 $15.00
B867 $15.00 $5.00 $15.00 $15.00
B868 $15.00 $8.00 $12.00 $15.00
B869 $15.00 $10.00 $15.00 $15.00
B870 $15.00 $5.00 $15.00 $15.00
B871 $15.00 $10.00 $15.00 $15.00
B872 $15.00 $5.00 $15.00 $15.00
B873 $15.00 $10.00 $15.00 $15.00
B874 $15.00 $5.00 $15.00 $15.00
B875 $15.00 $10.00 $15.00 $15.00
B876 $15.00 $10.00 $15.00 $15.00
B877 $15.00 $10.00 $15.00 $15.00
B878 $15.00 $10.00 $15.00 $15.00
B879 $15.00 $10.00 $15.00 $15.00
B880 $15.00 $10.00 $15.00 $15.00
B881 $15.00 $5.00 $15.00 $15.00
B882 $15.00 $5.00 $15.00 $15.00
B883 $15.00 $10.00 $15.00 $15.00
B884 $15.00 $5.00 $15.00 $15.00
B885 $15.00 $5.00 $15.00 $15.00
B886 $15.00 $10.00 $15.00 $15.00
B887 $15.00 $10.00 $15.00 $15.00
B888 $15.00 $10.00 $15.00 $15.00
B889 $15.00 $10.00 $15.00 $15.00
B890 $15.00 $8.00 $12.00 $15.00
B891 $15.00 $5.00 $15.00 $15.00
B892 $15.00 $10.00 $15.00 $15.00
B893 $15.00 $10.00 $15.00 $15.00
B894 $15.00 $8.00 $12.00 $15.00
B895 $15.00 $10.00 $15.00 $15.00
B896 $15.00 $10.00 $15.00 $15.00
B897 $15.00 $8.00 $12.00 $15.00
B898 $15.00 $10.00 $15.00 $15.00
B899 $15.00 $5.00 $15.00 $15.00
B900 $15.00 $10.00 $15.00 $15.00
B901 $15.00 $5.00 $15.00 $15.00
B902 $15.00 $10.00 $15.00 $15.00
B903 $15.00 $5.00 $10.00 $10.00
B904 $15.00 $5.00 $15.00 $15.00
B905 $15.00 $10.00 $15.00 $15.00
B906 $15.00 $10.00 $15.00 $15.00
B907 $15.00 $5.00 $10.00 $10.00
B908 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
53
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B909 $15.00 $10.00 $15.00 $15.00
B910 $15.00 $10.00 $15.00 $15.00
B911 $15.00 $5.00 $10.00 $10.00
B912 $15.00 $10.00 $15.00 $15.00
B913 $15.00 $10.00 $15.00 $15.00
B914 $15.00 $10.00 $15.00 $15.00
B915 $15.00 $10.00 $15.00 $15.00
B916 $15.00 $5.00 $15.00 $15.00
B917 $15.00 $10.00 $15.00 $15.00
B918 $15.00 $5.00 $10.00 $10.00
B919 $15.00 $8.00 $12.00 $15.00
B920 $15.00 $5.00 $15.00 $15.00
B921 $15.00 $10.00 $15.00 $15.00
B922 $15.00 $10.00 $15.00 $15.00
B923 $15.00 $10.00 $15.00 $15.00
B924 $15.00 $5.00 $10.00 $10.00
B925 $15.00 $10.00 $15.00 $15.00
B926 $15.00 $5.00 $15.00 $15.00
B927 $15.00 $10.00 $15.00 $15.00
B928 $15.00 $10.00 $15.00 $15.00
B929 $15.00 $5.00 $10.00 $10.00
B930 $15.00 $5.00 $15.00 $15.00
B931 $15.00 $5.00 $10.00 $10.00
B932 $15.00 $10.00 $15.00 $15.00
B933 $15.00 $10.00 $15.00 $15.00
B934 $15.00 $10.00 $15.00 $15.00
B935 $15.00 $10.00 $15.00 $15.00
B936 $15.00 $5.00 $15.00 $15.00
B937 $15.00 $10.00 $15.00 $15.00
B938 $15.00 $5.00 $10.00 $10.00
B939 $15.00 $5.00 $15.00 $15.00
B940 $15.00 $10.00 $15.00 $15.00
B941 $15.00 $5.00 $10.00 $10.00
B942 $15.00 $10.00 $15.00 $15.00
B943 $15.00 $10.00 $15.00 $15.00
B944 $15.00 $10.00 $15.00 $15.00
B945 $15.00 $5.00 $15.00 $15.00
B946 $15.00 $8.00 $12.00 $15.00
B947 $15.00 $10.00 $15.00 $15.00
B948 $15.00 $5.00 $15.00 $15.00
B949 $15.00 $10.00 $15.00 $15.00
B950 $15.00 $8.00 $12.00 $15.00
B951 $15.00 $5.00 $15.00 $15.00
B952 $15.00 $10.00 $15.00 $15.00
B953 $15.00 $5.00 $15.00 $15.00
B954 $15.00 $10.00 $15.00 $15.00
B955 $15.00 $10.00 $15.00 $15.00
B956 $15.00 $5.00 $15.00 $15.00
B957 $15.00 $10.00 $15.00 $15.00
B958 $15.00 $5.00 $15.00 $15.00
B959 $15.00 $10.00 $15.00 $15.00
B960 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
54
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B961 $15.00 $10.00 $15.00 $15.00
B962 $15.00 $10.00 $15.00 $15.00
B963 $15.00 $5.00 $10.00 $10.00
B964 $15.00 $8.00 $12.00 $15.00
B965 $15.00 $10.00 $15.00 $15.00
B966 $15.00 $10.00 $15.00 $15.00
B967 $15.00 $10.00 $15.00 $15.00
B968 $15.00 $10.00 $15.00 $15.00
B969 $15.00 $10.00 $15.00 $15.00
B970 $15.00 $10.00 $15.00 $15.00
B971 $15.00 $10.00 $15.00 $15.00
B972 $15.00 $10.00 $15.00 $15.00
B973 $15.00 $10.00 $15.00 $15.00
B974 $15.00 $10.00 $15.00 $15.00
B975 $15.00 $10.00 $15.00 $15.00
B976 $15.00 $10.00 $15.00 $15.00
B977 $15.00 $10.00 $15.00 $15.00
B978 $15.00 $8.00 $12.00 $15.00
B979 $15.00 $10.00 $15.00 $15.00
B980 $15.00 $10.00 $15.00 $15.00
B981 $15.00 $10.00 $15.00 $15.00
B982 $15.00 $10.00 $15.00 $15.00
B983 $15.00 $5.00 $15.00 $15.00
B984 $15.00 $10.00 $15.00 $15.00
B985 $15.00 $10.00 $15.00 $15.00
B986 $15.00 $10.00 $15.00 $15.00
B987 $15.00 $10.00 $15.00 $15.00
B988 $15.00 $10.00 $15.00 $15.00
B989 $15.00 $10.00 $15.00 $15.00
B990 $15.00 $10.00 $15.00 $15.00
B991 $15.00 $10.00 $15.00 $15.00
B992 $15.00 $10.00 $15.00 $15.00
B993 $15.00 $10.00 $15.00 $15.00
B994 $15.00 $10.00 $15.00 $15.00
B995 $15.00 $5.00 $15.00 $15.00
B996 $15.00 $10.00 $15.00 $15.00
B997 $15.00 $5.00 $15.00 $15.00
B998 $15.00 $10.00 $15.00 $15.00
B999 $15.00 $10.00 $15.00 $15.00
B1000 $15.00 $5.00 $15.00 $15.00
B1001 $15.00 $5.00 $15.00 $15.00
B1002 $15.00 $8.00 $12.00 $15.00
B1003 $15.00 $5.00 $15.00 $15.00
B1004 $15.00 $10.00 $15.00 $15.00
B1005 $15.00 $5.00 $15.00 $15.00
B1006 $15.00 $5.00 $10.00 $10.00
B1007 $15.00 $8.00 $12.00 $15.00
B1008 $15.00 $8.00 $12.00 $15.00
B1009 $15.00 $5.00 $15.00 $15.00
B1010 $15.00 $10.00 $15.00 $15.00
B1011 $15.00 $10.00 $15.00 $15.00
B1012 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
55
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1013 $15.00 $10.00 $15.00 $15.00
B1014 $15.00 $5.00 $10.00 $10.00
B1015 $15.00 $5.00 $10.00 $10.00
B1016 $15.00 $5.00 $10.00 $10.00
B1017 $15.00 $5.00 $10.00 $10.00
B1018 $15.00 $5.00 $15.00 $15.00
B1019 $15.00 $10.00 $15.00 $15.00
B1020 $15.00 $5.00 $15.00 $15.00
B1021 $15.00 $10.00 $15.00 $15.00
B1022 $15.00 $5.00 $10.00 $10.00
B1023 $15.00 $10.00 $15.00 $15.00
B1024 $15.00 $5.00 $10.00 $10.00
B1025 $15.00 $5.00 $10.00 $10.00
B1026 $15.00 $8.00 $12.00 $15.00
B1027 $15.00 $10.00 $15.00 $15.00
B1028 $15.00 $5.00 $10.00 $10.00
B1029 $15.00 $5.00 $10.00 $10.00
B1030 $15.00 $10.00 $15.00 $15.00
B1031 $15.00 $5.00 $15.00 $15.00
B1032 $15.00 $5.00 $15.00 $15.00
B1033 $15.00 $5.00 $10.00 $10.00
B1034 $15.00 $8.00 $12.00 $15.00
B1035 $15.00 $5.00 $15.00 $15.00
B1036 $15.00 $10.00 $15.00 $15.00
B1037 $15.00 $5.00 $15.00 $15.00
B1038 $15.00 $10.00 $15.00 $15.00
B1039 $15.00 $10.00 $15.00 $15.00
B1040 $15.00 $5.00 $10.00 $10.00
B1041 $15.00 $8.00 $12.00 $15.00
B1042 $15.00 $5.00 $15.00 $15.00
B1043 $15.00 $5.00 $15.00 $15.00
B1044 $15.00 $10.00 $15.00 $15.00
B1045 $15.00 $10.00 $15.00 $15.00
B1046 $15.00 $5.00 $10.00 $10.00
B1047 $15.00 $5.00 $15.00 $15.00
B1048 $15.00 $10.00 $15.00 $15.00
B1049 $15.00 $10.00 $15.00 $15.00
B1050 $15.00 $5.00 $10.00 $10.00
B1051 $15.00 $8.00 $12.00 $15.00
B1052 $15.00 $5.00 $15.00 $15.00
B1053 $15.00 $5.00 $15.00 $15.00
B1054 $15.00 $8.00 $12.00 $15.00
B1055 $15.00 $5.00 $15.00 $15.00
B1056 $15.00 $5.00 $10.00 $10.00
B1057 $15.00 $5.00 $10.00 $10.00
B1058 $15.00 $5.00 $10.00 $10.00
B1059 $15.00 $5.00 $15.00 $15.00
B1060 $15.00 $5.00 $10.00 $10.00
B1061 $15.00 $8.00 $12.00 $15.00
B1062 $15.00 $10.00 $15.00 $15.00
B1063 $15.00 $5.00 $10.00 $10.00
B1064 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
56
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1065 $15.00 $6.00 $8.00 $8.00
B1066 $15.00 $8.00 $12.00 $15.00
B1067 $15.00 $5.00 $15.00 $15.00
B1068 $15.00 $10.00 $15.00 $15.00
B1069 $15.00 $5.00 $10.00 $10.00
B1070 $15.00 $5.00 $15.00 $15.00
B1071 $15.00 $5.00 $15.00 $15.00
B1072 $15.00 $5.00 $15.00 $15.00
B1073 $15.00 $10.00 $15.00 $15.00
B1074 $15.00 $10.00 $15.00 $15.00
B1075 $15.00 $10.00 $15.00 $15.00
B1076 $15.00 $5.00 $15.00 $15.00
B1077 $15.00 $5.00 $15.00 $15.00
B1078 $15.00 $10.00 $15.00 $15.00
B1079 $15.00 $8.00 $12.00 $15.00
B1080 $15.00 $5.00 $15.00 $15.00
B1081 $15.00 $10.00 $15.00 $15.00
B1082 $15.00 $5.00 $10.00 $10.00
B1083 $15.00 $5.00 $15.00 $15.00
B1084 $15.00 $5.00 $10.00 $10.00
B1085 $15.00 $5.00 $15.00 $15.00
B1086 $15.00 $5.00 $15.00 $15.00
B1087 $15.00 $10.00 $15.00 $15.00
B1088 $15.00 $5.00 $15.00 $15.00
B1089 $15.00 $10.00 $15.00 $15.00
B1090 $15.00 $5.00 $15.00 $15.00
B1091 $15.00 $10.00 $15.00 $15.00
B1092 $15.00 $5.00 $15.00 $15.00
B1093 $15.00 $5.00 $15.00 $15.00
B1094 $15.00 $5.00 $15.00 $15.00
B1095 $15.00 $8.00 $12.00 $15.00
B1096 $15.00 $10.00 $15.00 $15.00
B1097 $15.00 $5.00 $10.00 $10.00
B1098 $15.00 $10.00 $15.00 $15.00
B1099 $15.00 $5.00 $15.00 $15.00
B1100 $15.00 $5.00 $15.00 $15.00
B1101 $15.00 $10.00 $15.00 $15.00
B1102 $15.00 $5.00 $10.00 $10.00
B1103 $15.00 $5.00 $15.00 $15.00
B1104 $15.00 $5.00 $15.00 $15.00
B1105 $15.00 $8.00 $12.00 $15.00
B1106 $15.00 $5.00 $15.00 $15.00
B1107 $15.00 $10.00 $15.00 $15.00
B1108 $15.00 $5.00 $10.00 $10.00
B1109 $15.00 $8.00 $12.00 $15.00
B1110 $15.00 $8.00 $12.00 $15.00
B1111 $15.00 $5.00 $10.00 $10.00
B1112 $15.00 $5.00 $10.00 $10.00
B1113 $15.00 $5.00 $15.00 $15.00
B1114 $15.00 $10.00 $15.00 $15.00
B1115 $15.00 $8.00 $12.00 $15.00
B1116 $15.00 $8.00 $12.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
57
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1117 N/C $8.00 $12.00 $15.00
B1118 $15.00 $10.00 $15.00 $15.00
B1119 $15.00 $5.00 $10.00 $10.00
B1120 $15.00 $5.00 $15.00 $15.00
B1121 $15.00 $8.00 $12.00 $15.00
B1122 $15.00 $10.00 $15.00 $15.00
B1123 $15.00 $10.00 $15.00 $15.00
B1124 $15.00 $5.00 $15.00 $15.00
B1125 $15.00 $5.00 $10.00 $10.00
B1126 $15.00 $10.00 $15.00 $15.00
B1127 $15.00 $10.00 $15.00 $15.00
B1128 $15.00 $10.00 $15.00 $15.00
B1129 $15.00 $5.00 $15.00 $15.00
B1130 $15.00 $10.00 $15.00 $15.00
B1131 $15.00 $10.00 $15.00 $15.00
B1132 $15.00 $10.00 $15.00 $15.00
B1133 $15.00 $10.00 $15.00 $15.00
B1134 $15.00 $10.00 $15.00 $15.00
B1135 $15.00 $10.00 $15.00 $15.00
B1136 $15.00 $10.00 $15.00 $15.00
B1137 $15.00 $10.00 $15.00 $15.00
B1138 $15.00 $5.00 $10.00 $10.00
B1139 $15.00 $5.00 $10.00 $10.00
B1140 $15.00 $5.00 $10.00 $10.00
B1141 $15.00 $5.00 $10.00 $10.00
B1142 $15.00 $5.00 $10.00 $10.00
B1143 $15.00 $8.00 $12.00 $15.00
B1144 $15.00 $6.00 $8.00 $8.00
B1145 $15.00 $5.00 $10.00 $10.00
B1146 $15.00 $5.00 $15.00 $15.00
B1147 $15.00 $5.00 $15.00 $15.00
B1148 $15.00 $5.00 $15.00 $15.00
B1149 $15.00 $10.00 $15.00 $15.00
B1150 $15.00 $10.00 $15.00 $15.00
B1151 $15.00 $6.00 $8.00 $8.00
B1152 $15.00 $5.00 $15.00 $15.00
B1153 $15.00 $10.00 $15.00 $15.00
B1154 $15.00 $8.00 $12.00 $15.00
B1155 $15.00 $5.00 $15.00 $15.00
B1156 $15.00 $5.00 $15.00 $15.00
B1157 $15.00 $10.00 $15.00 $15.00
B1158 $15.00 $6.00 $8.00 $8.00
B1159 $15.00 $5.00 $15.00 $15.00
B1160 $15.00 $10.00 $15.00 $15.00
B1161 $15.00 $5.00 $10.00 $10.00
B1162 $15.00 $5.00 $15.00 $15.00
B1163 $15.00 $5.00 $15.00 $15.00
B1164 $15.00 $5.00 $10.00 $10.00
B1165 $15.00 $5.00 $15.00 $15.00
B1166 $15.00 $5.00 $10.00 $10.00
B1167 $15.00 $5.00 $15.00 $15.00
B1168 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
58
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1169 $15.00 $5.00 $15.00 $15.00
B1170 $15.00 $10.00 $15.00 $15.00
B1171 $15.00 $5.00 $10.00 $10.00
B1172 $15.00 $8.00 $12.00 $15.00
B1173 $15.00 $5.00 $15.00 $15.00
B1174 $15.00 $5.00 $15.00 $15.00
B1175 $15.00 $10.00 $15.00 $15.00
B1176 $15.00 $5.00 $15.00 $15.00
B1177 $15.00 $10.00 $15.00 $15.00
B1178 $15.00 $6.00 $8.00 $8.00
B1179 $15.00 $6.00 $8.00 $8.00
B1180 $15.00 $5.00 $10.00 $10.00
B1181 $15.00 $5.00 $10.00 $10.00
B1182 $15.00 $8.00 $12.00 $15.00
B1183 $15.00 $8.00 $12.00 $15.00
B1184 $15.00 $5.00 $15.00 $15.00
B1185 $15.00 $6.00 $8.00 $8.00
B1186 $15.00 $5.00 $10.00 $10.00
B1187 $15.00 $8.00 $12.00 $15.00
B1188 $15.00 $10.00 $15.00 $15.00
B1189 $15.00 $5.00 $10.00 $10.00
B1190 $15.00 $5.00 $10.00 $10.00
B1191 $15.00 $10.00 $15.00 $15.00
B1192 $15.00 $10.00 $15.00 $15.00
B1193 $15.00 $6.00 $8.00 $8.00
B1194 $15.00 $5.00 $10.00 $10.00
B1195 $15.00 $8.00 $12.00 $15.00
B1196 $15.00 $5.00 $15.00 $15.00
B1197 $15.00 $10.00 $15.00 $15.00
B1198 $15.00 $10.00 $15.00 $15.00
B1199 $15.00 $10.00 $15.00 $15.00
B1200 $15.00 $6.00 $8.00 $8.00
B1201 $15.00 $5.00 $10.00 $10.00
B1202 $15.00 $5.00 $15.00 $15.00
B1203 $15.00 $5.00 $10.00 $10.00
B1204 $15.00 $5.00 $15.00 $15.00
B1205 $15.00 $5.00 $15.00 $15.00
B1206 $15.00 $5.00 $15.00 $15.00
B1207 $15.00 $5.00 $15.00 $15.00
B1208 $15.00 $10.00 $15.00 $15.00
B1209 $15.00 $10.00 $15.00 $15.00
B1210 $15.00 $5.00 $15.00 $15.00
B1211 $15.00 $5.00 $15.00 $15.00
B1212 $15.00 $5.00 $15.00 $15.00
B1213 $15.00 $10.00 $15.00 $15.00
B1214 $15.00 $10.00 $15.00 $15.00
B1215 $15.00 $8.00 $12.00 $15.00
B1216 $15.00 $10.00 $15.00 $15.00
B1217 $15.00 $5.00 $15.00 $15.00
B1218 $15.00 $5.00 $15.00 $15.00
B1219 $15.00 $5.00 $15.00 $15.00
B1220 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
59
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1221 $15.00 $5.00 $15.00 $15.00
B1222 $15.00 $10.00 $15.00 $15.00
B1223 $15.00 $5.00 $15.00 $15.00
B1224 $15.00 $5.00 $15.00 $15.00
B1225 $15.00 $5.00 $15.00 $15.00
B1226 $15.00 $5.00 $15.00 $15.00
B1227 $15.00 $5.00 $15.00 $15.00
B1228 $15.00 $10.00 $15.00 $15.00
B1229 $15.00 $6.00 $8.00 $8.00
B1230 $15.00 $5.00 $10.00 $10.00
B1231 $15.00 $5.00 $15.00 $15.00
B1232 $15.00 $10.00 $15.00 $15.00
B1233 $15.00 $5.00 $15.00 $15.00
B1234 $15.00 $10.00 $15.00 $15.00
B1235 $15.00 $5.00 $15.00 $15.00
B1236 $15.00 $5.00 $15.00 $15.00
B1237 $15.00 $5.00 $15.00 $15.00
B1238 $15.00 $8.00 $12.00 $15.00
B1239 $15.00 $5.00 $15.00 $15.00
B1240 $15.00 $8.00 $12.00 $15.00
B1241 $15.00 $5.00 $15.00 $15.00
B1242 $15.00 $5.00 $15.00 $15.00
B1243 $15.00 $8.00 $12.00 $15.00
B1244 $15.00 $6.00 $8.00 $8.00
B1245 $15.00 $5.00 $15.00 $15.00
B1246 $15.00 $5.00 $15.00 $15.00
B1247 $15.00 $10.00 $15.00 $15.00
B1248 $15.00 $5.00 $15.00 $15.00
B1249 $15.00 $10.00 $15.00 $15.00
B1250 $15.00 $5.00 $10.00 $10.00
B1251 $15.00 $8.00 $12.00 $15.00
B1252 $15.00 $10.00 $15.00 $15.00
B1253 $15.00 $5.00 $10.00 $10.00
B1254 $15.00 $8.00 $12.00 $15.00
B1255 $15.00 $10.00 $15.00 $15.00
B1256 $15.00 $10.00 $15.00 $15.00
B1257 $15.00 $8.00 $12.00 $15.00
B1258 $15.00 $10.00 $15.00 $15.00
B1259 $15.00 $10.00 $15.00 $15.00
B1260 $15.00 $5.00 $10.00 $10.00
B1261 $15.00 $5.00 $15.00 $15.00
B1262 $15.00 $5.00 $10.00 $10.00
B1263 $15.00 $10.00 $15.00 $15.00
B1264 $15.00 $5.00 $10.00 $10.00
B1265 $15.00 $8.00 $12.00 $15.00
B1266 $15.00 $5.00 $15.00 $15.00
B1267 $15.00 $10.00 $15.00 $15.00
B1268 $15.00 $8.00 $12.00 $15.00
B1269 $15.00 $8.00 $12.00 $15.00
B1270 $15.00 $6.00 $8.00 $8.00
B1271 $15.00 $5.00 $10.00 $10.00
B1272 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
60
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1273 $15.00 $8.00 $12.00 $15.00
B1274 $15.00 $5.00 $15.00 $15.00
B1275 $15.00 $5.00 $15.00 $15.00
B1276 $15.00 $5.00 $10.00 $10.00
B1277 $15.00 $5.00 $15.00 $15.00
B1278 $15.00 $10.00 $15.00 $15.00
B1279 $15.00 $10.00 $15.00 $15.00
B1280 $15.00 $10.00 $15.00 $15.00
B1281 $15.00 $10.00 $15.00 $15.00
B1282 $15.00 $10.00 $15.00 $15.00
B1283 $15.00 $8.00 $12.00 $15.00
B1284 $15.00 $10.00 $15.00 $15.00
B1285 $15.00 $5.00 $15.00 $15.00
B1286 $15.00 $5.00 $10.00 $10.00
B1287 $15.00 $5.00 $10.00 $10.00
B1288 $15.00 $8.00 $12.00 $15.00
B1289 $15.00 $4.00 $15.00 $20.00
B1290 $15.00 $4.00 $15.00 $20.00
B1291 $15.00 $4.00 $15.00 $20.00
B1292 $15.00 $10.00 $15.00 $15.00
B1293 $15.00 $5.00 $10.00 $10.00
B1294 $15.00 $10.00 $15.00 $15.00
B1295 $15.00 $5.00 $10.00 $10.00
B1296 $15.00 $10.00 $15.00 $15.00
B1297 $15.00 $5.00 $15.00 $15.00
B1298 $15.00 $5.00 $10.00 $10.00
B1299 $15.00 $5.00 $15.00 $15.00
B1300 $15.00 $5.00 $10.00 $10.00
B1301 $15.00 $10.00 $15.00 $15.00
B1302 $15.00 $10.00 $15.00 $15.00
B1303 $15.00 $5.00 $10.00 $10.00
B1304 $15.00 $5.00 $10.00 $10.00
B1305 $15.00 $8.00 $12.00 $15.00
B1306 $15.00 $5.00 $10.00 $10.00
B1307 $15.00 $5.00 $15.00 $15.00
B1308 $15.00 $5.00 $10.00 $10.00
B1309 $15.00 $5.00 $10.00 $10.00
B1310 $15.00 $5.00 $15.00 $15.00
B1311 $15.00 $10.00 $15.00 $15.00
B1312 $15.00 $5.00 $15.00 $15.00
B1313 $15.00 $5.00 $15.00 $15.00
B1314 $15.00 $10.00 $15.00 $15.00
B1315 $15.00 $5.00 $15.00 $15.00
B1316 $15.00 $8.00 $12.00 $15.00
B1317 $15.00 $8.00 $12.00 $15.00
B1318 $15.00 $10.00 $15.00 $15.00
B1319 $15.00 $5.00 $15.00 $15.00
B1320 $15.00 $10.00 $15.00 $15.00
B1321 $15.00 $5.00 $15.00 $15.00
B1322 $15.00 $10.00 $15.00 $15.00
B1323 $15.00 $5.00 $15.00 $15.00
B1324 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
61
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1325 $15.00 $10.00 $15.00 $15.00
B1326 $15.00 $10.00 $15.00 $15.00
B1327 $15.00 $5.00 $15.00 $15.00
B1328 $15.00 $10.00 $15.00 $15.00
B1329 $15.00 $5.00 $15.00 $15.00
B1330 $15.00 $10.00 $15.00 $15.00
B1331 $15.00 $5.00 $15.00 $15.00
B1332 $15.00 $5.00 $15.00 $15.00
B1333 $15.00 $10.00 $15.00 $15.00
B1334 $15.00 $5.00 $15.00 $15.00
B1335 $15.00 $5.00 $15.00 $15.00
B1336 $15.00 $10.00 $15.00 $15.00
B1337 $15.00 $8.00 $12.00 $15.00
B1338 $15.00 $8.00 $12.00 $15.00
B1339 $15.00 $10.00 $15.00 $15.00
B1340 $15.00 $5.00 $15.00 $15.00
B1341 $15.00 $10.00 $15.00 $15.00
B1342 $15.00 $5.00 $10.00 $10.00
B1343 $15.00 $5.00 $10.00 $10.00
B1344 $15.00 $5.00 $15.00 $15.00
B1345 $15.00 $5.00 $15.00 $15.00
B1346 $15.00 $5.00 $15.00 $15.00
B1347 $15.00 $10.00 $15.00 $15.00
B1348 $15.00 $8.00 $12.00 $15.00
B1349 $15.00 $5.00 $15.00 $15.00
B1350 $15.00 $10.00 $15.00 $15.00
B1351 $15.00 $5.00 $15.00 $15.00
B1352 $15.00 $10.00 $15.00 $15.00
B1353 $15.00 $10.00 $15.00 $15.00
B1354 $15.00 $10.00 $15.00 $15.00
B1355 $15.00 $8.00 $12.00 $15.00
B1356 $15.00 $5.00 $15.00 $15.00
B1357 $15.00 $5.00 $15.00 $15.00
B1358 $15.00 $10.00 $15.00 $15.00
B1359 $15.00 $10.00 $15.00 $15.00
B1360 $15.00 $8.00 $12.00 $15.00
B1361 $15.00 $5.00 $15.00 $15.00
B1362 $15.00 $10.00 $15.00 $15.00
B1363 $15.00 $8.00 $12.00 $15.00
B1364 $15.00 $10.00 $15.00 $15.00
B1365 $15.00 $10.00 $15.00 $15.00
B1366 $15.00 $5.00 $15.00 $15.00
B1367 $15.00 $5.00 $15.00 $15.00
B1368 $15.00 $10.00 $15.00 $15.00
B1369 $15.00 $5.00 $15.00 $15.00
B1370 $15.00 $5.00 $10.00 $10.00
B1371 $15.00 $10.00 $15.00 $15.00
B1372 $15.00 $5.00 $15.00 $15.00
B1373 $15.00 $5.00 $15.00 $15.00
B1374 $15.00 $5.00 $15.00 $15.00
B1375 $15.00 $10.00 $15.00 $15.00
B1376 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
62
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1377 $15.00 $10.00 $15.00 $15.00
B1378 $15.00 $5.00 $15.00 $15.00
B1379 $15.00 $8.00 $12.00 $15.00
B1380 $15.00 $5.00 $10.00 $10.00
B1381 $15.00 $10.00 $15.00 $15.00
B1382 $15.00 $5.00 $10.00 $10.00
B1383 $15.00 $10.00 $15.00 $15.00
B1384 $15.00 $10.00 $15.00 $15.00
B1385 $15.00 $10.00 $15.00 $15.00
B1386 $15.00 $10.00 $15.00 $15.00
B1387 $15.00 $10.00 $15.00 $15.00
B1388 $15.00 $10.00 $15.00 $15.00
B1389 $15.00 $10.00 $15.00 $15.00
B1390 $15.00 $5.00 $10.00 $10.00
B1391 $15.00 $10.00 $15.00 $15.00
B1392 $15.00 $10.00 $15.00 $15.00
B1393 $15.00 $10.00 $15.00 $15.00
B1394 $15.00 $5.00 $15.00 $15.00
B1395 $15.00 $10.00 $15.00 $15.00
B1396 $15.00 $10.00 $15.00 $15.00
B1397 $15.00 $5.00 $10.00 $10.00
B1398 $15.00 $10.00 $15.00 $15.00
B1399 $15.00 $5.00 $15.00 $15.00
B1400 $15.00 $8.00 $12.00 $15.00
B1401 $15.00 $5.00 $15.00 $15.00
B1402 $15.00 $10.00 $15.00 $15.00
B1403 $15.00 $10.00 $15.00 $15.00
B1404 $15.00 $10.00 $15.00 $15.00
B1405 $15.00 $5.00 $10.00 $10.00
B1406 $15.00 $10.00 $15.00 $15.00
B1407 $15.00 $5.00 $15.00 $15.00
B1408 $15.00 $5.00 $10.00 $10.00
B1409 $15.00 $5.00 $15.00 $15.00
B1410 $15.00 $5.00 $15.00 $15.00
B1411 $15.00 $10.00 $15.00 $15.00
B1412 $15.00 $8.00 $12.00 $15.00
B1413 $15.00 $5.00 $10.00 $10.00
B1414 $15.00 $10.00 $15.00 $15.00
B1415 $15.00 $10.00 $15.00 $15.00
B1416 $15.00 $8.00 $12.00 $15.00
B1417 $15.00 $10.00 $15.00 $15.00
B1418 $15.00 $5.00 $10.00 $10.00
B1419 $15.00 $10.00 $15.00 $15.00
B1420 $15.00 $5.00 $10.00 $10.00
B1421 $15.00 $5.00 $15.00 $15.00
B1422 $15.00 $10.00 $15.00 $15.00
B1423 $15.00 $10.00 $15.00 $15.00
B1424 $15.00 $8.00 $12.00 $15.00
B1425 $15.00 $5.00 $10.00 $10.00
B1426 $15.00 $10.00 $15.00 $15.00
B1427 $15.00 $5.00 $10.00 $10.00
B1428 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
63
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1429 $15.00 $10.00 $15.00 $15.00
B1430 $15.00 $5.00 $15.00 $15.00
B1431 $15.00 $5.00 $15.00 $15.00
B1432 $15.00 $10.00 $15.00 $15.00
B1433 $15.00 $5.00 $15.00 $15.00
B1434 $15.00 $10.00 $15.00 $15.00
B1435 $15.00 $5.00 $10.00 $10.00
B1436 $15.00 $5.00 $15.00 $15.00
B1437 $15.00 $10.00 $15.00 $15.00
B1438 $15.00 $5.00 $15.00 $15.00
B1439 $15.00 $5.00 $10.00 $10.00
B1440 $15.00 $10.00 $15.00 $15.00
B1441 $15.00 $5.00 $15.00 $15.00
B1442 $15.00 $10.00 $15.00 $15.00
B1443 $15.00 $5.00 $15.00 $15.00
B1444 $15.00 $10.00 $15.00 $15.00
B1445 $15.00 $5.00 $15.00 $15.00
B1446 $15.00 $10.00 $15.00 $15.00
B1447 $15.00 $10.00 $15.00 $15.00
B1448 $15.00 $10.00 $15.00 $15.00
B1449 $15.00 $10.00 $15.00 $15.00
B1450 $15.00 $10.00 $15.00 $15.00
B1451 $15.00 $8.00 $12.00 $15.00
B1452 $15.00 $5.00 $15.00 $15.00
B1453 $15.00 $10.00 $15.00 $15.00
B1454 $15.00 $5.00 $15.00 $15.00
B1455 $15.00 $10.00 $15.00 $15.00
B1456 $15.00 $8.00 $12.00 $15.00
B1457 $15.00 $10.00 $15.00 $15.00
B1458 $15.00 $10.00 $15.00 $15.00
B1459 $15.00 $10.00 $15.00 $15.00
B1460 $15.00 $10.00 $15.00 $15.00
B1461 $15.00 $10.00 $15.00 $15.00
B1462 $15.00 $10.00 $15.00 $15.00
B1463 $15.00 $5.00 $10.00 $10.00
B1464 $15.00 $5.00 $15.00 $15.00
B1465 $15.00 $5.00 $10.00 $10.00
B1466 $15.00 $5.00 $15.00 $15.00
B1467 $15.00 $10.00 $15.00 $15.00
B1468 $15.00 $5.00 $10.00 $10.00
B1469 $15.00 $10.00 $15.00 $15.00
B1470 $15.00 $10.00 $15.00 $15.00
B1471 $15.00 $5.00 $15.00 $15.00
B1472 $15.00 $10.00 $15.00 $15.00
B1473 $15.00 $10.00 $15.00 $15.00
B1474 $15.00 $10.00 $15.00 $15.00
B1475 $15.00 $10.00 $15.00 $15.00
B1476 $15.00 $10.00 $15.00 $15.00
B1477 $15.00 $10.00 $15.00 $15.00
B1478 $15.00 $10.00 $15.00 $15.00
B1479 $15.00 $5.00 $15.00 $15.00
B1480 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
64
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1481 $15.00 $8.00 $12.00 $15.00
B1482 $15.00 $5.00 $15.00 $15.00
B1483 $15.00 $10.00 $15.00 $15.00
B1484 $15.00 $5.00 $10.00 $10.00
B1485 $15.00 $5.00 $15.00 $15.00
B1486 $15.00 $10.00 $15.00 $15.00
B1487 $15.00 $5.00 $15.00 $15.00
B1488 $15.00 $10.00 $15.00 $15.00
B1489 $15.00 $10.00 $15.00 $15.00
B1490 $15.00 $10.00 $15.00 $15.00
B1491 $15.00 $10.00 $15.00 $15.00
B1492 $15.00 $5.00 $10.00 $10.00
B1493 $15.00 $5.00 $15.00 $15.00
B1494 $15.00 $5.00 $10.00 $10.00
B1495 $15.00 $10.00 $15.00 $15.00
B1496 $15.00 $8.00 $12.00 $15.00
B1497 $15.00 $5.00 $15.00 $15.00
B1498 $15.00 $5.00 $15.00 $15.00
B1499 $15.00 $10.00 $15.00 $15.00
B1500 $15.00 $10.00 $15.00 $15.00
B1501 $15.00 $5.00 $15.00 $15.00
B1502 $15.00 $5.00 $15.00 $15.00
B1503 $15.00 $10.00 $15.00 $15.00
B1504 $15.00 $5.00 $15.00 $15.00
B1505 $15.00 $5.00 $15.00 $15.00
B1506 $15.00 $10.00 $15.00 $15.00
B1507 $15.00 $5.00 $15.00 $15.00
B1508 $15.00 $10.00 $15.00 $15.00
B1509 $15.00 $10.00 $15.00 $15.00
B1510 $15.00 $10.00 $15.00 $15.00
B1511 $15.00 $10.00 $15.00 $15.00
B1512 $15.00 $5.00 $10.00 $10.00
B1513 $15.00 $10.00 $15.00 $15.00
B1514 $15.00 $5.00 $10.00 $10.00
B1515 $15.00 $10.00 $15.00 $15.00
B1516 $15.00 $5.00 $15.00 $15.00
B1517 $15.00 $10.00 $15.00 $15.00
B1518 $15.00 $10.00 $15.00 $15.00
B1519 $15.00 $10.00 $15.00 $15.00
B1520 $15.00 $5.00 $15.00 $15.00
B1521 $15.00 $10.00 $15.00 $15.00
B1522 $15.00 $5.00 $15.00 $15.00
B1523 $15.00 $10.00 $15.00 $15.00
B1524 $15.00 $5.00 $10.00 $10.00
B1525 $15.00 $10.00 $15.00 $15.00
B1526 $15.00 $10.00 $15.00 $15.00
B1527 $15.00 $5.00 $15.00 $15.00
B1528 $15.00 $10.00 $15.00 $15.00
B1529 $15.00 $5.00 $15.00 $15.00
B1530 $15.00 $8.00 $12.00 $15.00
B1531 $15.00 $10.00 $15.00 $15.00
B1532 $15.00 $6.00 $8.00 $8.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
65
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1533 $15.00 $10.00 $15.00 $15.00
B1534 $15.00 $10.00 $15.00 $15.00
B1535 $15.00 $5.00 $15.00 $15.00
B1536 $15.00 $10.00 $15.00 $15.00
B1537 $15.00 $10.00 $15.00 $15.00
B1538 $15.00 $6.00 $8.00 $8.00
B1539 $15.00 $10.00 $15.00 $15.00
B1540 $15.00 $5.00 $10.00 $10.00
B1541 $15.00 $10.00 $15.00 $15.00
B1542 $15.00 $10.00 $15.00 $15.00
B1543 $15.00 $10.00 $15.00 $15.00
B1544 $15.00 $5.00 $15.00 $15.00
B1545 $15.00 $5.00 $15.00 $15.00
B1546 $15.00 $10.00 $15.00 $15.00
B1547 $15.00 $10.00 $15.00 $15.00
B1548 $15.00 $10.00 $15.00 $15.00
B1549 $15.00 $10.00 $15.00 $15.00
B1550 $15.00 $10.00 $15.00 $15.00
B1551 $15.00 $10.00 $15.00 $15.00
B1552 $15.00 $5.00 $15.00 $15.00
B1553 $15.00 $10.00 $15.00 $15.00
B1554 $15.00 $10.00 $15.00 $15.00
B1555 $15.00 $10.00 $15.00 $15.00
B1556 $15.00 $5.00 $15.00 $15.00
B1557 $15.00 $10.00 $15.00 $15.00
B1558 $15.00 $10.00 $15.00 $15.00
B1559 $15.00 $10.00 $15.00 $15.00
B1560 $15.00 $10.00 $15.00 $15.00
B1561 $15.00 $10.00 $15.00 $15.00
B1562 $15.00 $10.00 $15.00 $15.00
B1563 $15.00 $5.00 $10.00 $10.00
B1564 $15.00 $5.00 $15.00 $15.00
B1565 $15.00 $5.00 $10.00 $10.00
B1566 $15.00 $10.00 $15.00 $15.00
B1567 $15.00 $10.00 $15.00 $15.00
B1568 $15.00 $10.00 $15.00 $15.00
B1569 $15.00 $10.00 $15.00 $15.00
B1570 $15.00 $10.00 $15.00 $15.00
B1571 $15.00 $10.00 $15.00 $15.00
B1572 $15.00 $10.00 $15.00 $15.00
B1573 $15.00 $10.00 $15.00 $15.00
B1574 $15.00 $4.00 $15.00 $20.00
B1575 $15.00 $4.00 $15.00 $20.00
B1576 $15.00 $4.00 $15.00 $20.00
B1577 $15.00 $5.00 $10.00 $10.00
B1578 $15.00 $8.00 $12.00 $15.00
B1579 $15.00 $5.00 $15.00 $15.00
B1580 $15.00 $10.00 $15.00 $15.00
B1581 $15.00 $5.00 $15.00 $15.00
B1582 $15.00 $5.00 $10.00 $10.00
B1583 $15.00 $8.00 $12.00 $15.00
B1584 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
66
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1585 $15.00 $10.00 $15.00 $15.00
B1586 $15.00 $5.00 $10.00 $10.00
B1587 $15.00 $5.00 $10.00 $10.00
B1588 $15.00 $5.00 $15.00 $15.00
B1589 $15.00 $10.00 $15.00 $15.00
B1590 $15.00 $5.00 $10.00 $10.00
B1591 $15.00 $5.00 $10.00 $10.00
B1592 $15.00 $5.00 $15.00 $15.00
B1593 $15.00 $5.00 $15.00 $15.00
B1594 $15.00 $5.00 $15.00 $15.00
B1595 $15.00 $5.00 $15.00 $15.00
B1596 $15.00 $10.00 $15.00 $15.00
B1597 $15.00 $5.00 $15.00 $15.00
B1598 $15.00 $5.00 $10.00 $10.00
B1599 $15.00 $5.00 $15.00 $15.00
B1600 $15.00 $10.00 $15.00 $15.00
B1601 $15.00 $10.00 $15.00 $15.00
B1602 $15.00 $5.00 $15.00 $15.00
B1603 $15.00 $5.00 $15.00 $15.00
B1604 $15.00 $10.00 $15.00 $15.00
B1605 $15.00 $10.00 $15.00 $15.00
B1606 N/C $5.00 $10.00 $10.00
B1607 $15.00 $5.00 $15.00 $15.00
B1608 $15.00 $5.00 $15.00 $15.00
B1609 $15.00 $5.00 $15.00 $15.00
B1610 N/C $5.00 $10.00 $15.00
B1611 N/C $5.00 $10.00 $15.00
B1612 N/C $5.00 $10.00 $15.00
B1613 N/C $5.00 $10.00 $15.00
B1614 N/C $5.00 $10.00 $15.00
B1615 N/C $5.00 $10.00 $15.00
B1616 N/C $5.00 $10.00 $15.00
B1617 N/C $5.00 $10.00 $15.00
B1618 N/C $5.00 $10.00 $15.00
B1619 N/C $5.00 $10.00 $15.00
B1620 N/C $5.00 $10.00 $15.00
B1621 N/C $5.00 $10.00 $15.00
B1622 N/C $5.00 $10.00 $15.00
B1623 N/C $5.00 $10.00 $15.00
B1624 N/C $5.00 $10.00 $15.00
B1625 N/C $5.00 $10.00 $15.00
B1626 N/C $5.00 $10.00 $15.00
B1627 N/C $5.00 $10.00 $15.00
B1628 N/C $5.00 $10.00 $15.00
B1629 N/C $5.00 $10.00 $15.00
B1630 N/C $5.00 $10.00 $15.00
B1631 N/C $5.00 $10.00 $15.00
B1632 N/C $5.00 $10.00 $15.00
B1633 N/C $5.00 $10.00 $15.00
B1634 N/C $5.00 $10.00 $15.00
B1635 N/C $5.00 $10.00 $15.00
B1636 N/C $5.00 $10.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
67
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1637 N/C $5.00 $10.00 $15.00
B1638 N/C $5.00 $10.00 $15.00
B1639 N/C $5.00 $10.00 $15.00
B1640 N/C $5.00 $10.00 $15.00
B1641 N/C $5.00 $10.00 $15.00
B1642 N/C $5.00 $10.00 $15.00
B1643 N/C $5.00 $10.00 $15.00
B1644 N/C $5.00 $10.00 $15.00
B1645 N/C $5.00 $10.00 $15.00
B1646 N/C $5.00 $10.00 $15.00
B1647 N/C $5.00 $10.00 $15.00
B1648 N/C $5.00 $10.00 $15.00
B1649 N/C $10.00 $15.00 $20.00
B1650 N/C $10.00 $15.00 $20.00
B1651 N/C $10.00 $15.00 $20.00
B1652 N/C $10.00 $15.00 $20.00
B1653 N/C $10.00 $15.00 $20.00
B1654 N/C $10.00 $15.00 $20.00
B1655 N/C $10.00 $15.00 $20.00
B1656 N/C $10.00 $15.00 $20.00
B1657 N/C $10.00 $15.00 $20.00
B1658 N/C $10.00 $15.00 $20.00
B1659 N/C $10.00 $15.00 $20.00
B1660 N/C $10.00 $15.00 $20.00
B1661 N/C $10.00 $15.00 $20.00
B1662 N/C $10.00 $15.00 $20.00
B1663 N/C $10.00 $15.00 $20.00
B1664 N/C $10.00 $15.00 $20.00
B1665 N/C $10.00 $15.00 $20.00
B1666 N/C $10.00 $15.00 $20.00
B1667 N/C $10.00 $15.00 $20.00
B1668 N/C $10.00 $15.00 $20.00
B1669 N/C $10.00 $15.00 $20.00
B1670 N/C $10.00 $15.00 $20.00
B1671 N/C $10.00 $15.00 $20.00
B1672 N/C $10.00 $15.00 $20.00
B1673 N/C $10.00 $15.00 $20.00
B1674 N/C $10.00 $15.00 $20.00
B1675 N/C $10.00 $15.00 $20.00
B1676 N/C $10.00 $15.00 $20.00
B1677 N/C $10.00 $15.00 $20.00
B1678 N/C $10.00 $15.00 $20.00
B1679 N/C $10.00 $15.00 $20.00
B1680 N/C $10.00 $15.00 $20.00
B1681 N/C $10.00 $15.00 $20.00
B1682 N/C $10.00 $15.00 $20.00
B1683 N/C $10.00 $15.00 $20.00
B1684 N/C $10.00 $15.00 $20.00
B1685 N/C $10.00 $15.00 $20.00
B1686 N/C $10.00 $15.00 $20.00
B1687 N/C $10.00 $15.00 $20.00
B1688 N/C $10.00 $15.00 $20.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
68
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1689 N/C $10.00 $15.00 $20.00
B1690 N/C $10.00 $15.00 $20.00
B1691 N/C $5.00 $10.00 $15.00
B1692 N/C $5.00 $10.00 $15.00
B1693 N/C $5.00 $10.00 $15.00
B1694 N/C $5.00 $10.00 $15.00
B1695 N/C $5.00 $10.00 $15.00
B1696 N/C $5.00 $10.00 $15.00
B1697 N/C $5.00 $10.00 $15.00
B1698 N/C $5.00 $10.00 $15.00
B1699 N/C $5.00 $10.00 $15.00
B1700 N/C $5.00 $10.00 $15.00
B1701 N/C $5.00 $10.00 $15.00
B1702 N/C $5.00 $10.00 $15.00
B1703 N/C $5.00 $10.00 $15.00
B1704 N/C $5.00 $10.00 $15.00
B1705 $15.00 $5.00 $15.00 $15.00
B1706 $15.00 $10.00 $15.00 $15.00
B1707 $15.00 $5.00 $10.00 $10.00
B1708 $15.00 $5.00 $10.00 $10.00
B1709 $15.00 $10.00 $15.00 $15.00
B1710 $15.00 $10.00 $15.00 N/C
B1711 $15.00 $10.00 $20.00 $20.00
B1712 $15.00 $10.00 $18.00 $18.00
B1713 $15.00 $5.00 $15.00 $15.00
B1714 $15.00 $10.00 $15.00 $15.00
B1715 $15.00 $5.00 $15.00 $15.00
B1716 $15.00 $5.00 $15.00 $15.00
B1717 $15.00 $5.00 $15.00 $15.00
B1718 $15.00 $10.00 $15.00 $15.00
B1719 $15.00 $3.00 $7.00 $11.00
B1720 $15.00 $10.00 $15.00 $15.00
B1721 $15.00 $5.00 $15.00 $15.00
B1722 $15.00 $5.00 $15.00 $15.00
B1723 $15.00 $5.00 $15.00 $15.00
B1724 $15.00 $10.00 $15.00 $15.00
B1725 $15.00 $5.00 $15.00 $15.00
B1726 $15.00 $5.00 $15.00 $15.00
B1727 $15.00 $5.00 $15.00 $15.00
B1728 $15.00 $5.00 $10.00 $10.00
B1729 $15.00 $10.00 $15.00 $15.00
B1730 $15.00 $10.00 $15.00 $15.00
B1731 $15.00 $5.00 $10.00 $10.00
B1732 $15.00 $5.00 $10.00 $10.00
B1733 $15.00 $5.00 $15.00 $15.00
B1734 $15.00 $5.00 $15.00 $15.00
B1735 $15.00 $10.00 $15.00 $15.00
B1736 $15.00 $8.00 $12.00 $15.00
B1737 $15.00 $5.00 $15.00 $15.00
B1738 $15.00 $10.00 $15.00 $15.00
B1739 $15.00 $5.00 $15.00 $15.00
B1740 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
69
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1741 $15.00 $10.00 $15.00 $15.00
B1742 $15.00 $10.00 $15.00 $15.00
B1743 $15.00 $10.00 $15.00 $15.00
B1744 $15.00 $10.00 $15.00 $15.00
B1745 $15.00 $10.00 $15.00 $15.00
B1746 $15.00 $10.00 $15.00 $15.00
B1747 $15.00 $5.00 $10.00 $10.00
B1748 $15.00 $8.00 $12.00 $15.00
B1749 $15.00 $10.00 $15.00 $15.00
B1750 $15.00 $5.00 $10.00 $10.00
B1751 $15.00 $5.00 $15.00 $15.00
B1752 $15.00 $10.00 $15.00 $15.00
B1753 $15.00 $5.00 $15.00 $15.00
B1754 $15.00 $10.00 $15.00 $15.00
B1755 $15.00 $10.00 $15.00 $15.00
B1756 $15.00 $5.00 $15.00 $15.00
B1757 $15.00 $5.00 $15.00 $15.00
B1758 $15.00 $10.00 $15.00 $15.00
B1759 $15.00 $10.00 $15.00 $15.00
B1760 $15.00 $10.00 $15.00 $15.00
B1761 $15.00 $5.00 $10.00 $10.00
B1762 N/C $10.00 $15.00 $20.00
B1763 N/C $10.00 $15.00 $20.00
B1764 N/C $10.00 $15.00 $20.00
B1765 N/C $10.00 $15.00 $20.00
B1766 N/C $10.00 $15.00 $20.00
B1767 N/C $10.00 $15.00 $20.00
B1768 N/C $10.00 $15.00 $20.00
B1769 N/C $10.00 $15.00 $20.00
B1770 N/C $10.00 $15.00 $20.00
B1771 N/C $10.00 $15.00 $20.00
B1772 N/C $10.00 $15.00 $20.00
B1773 N/C $10.00 $15.00 $20.00
B1774 N/C $10.00 $15.00 $20.00
B1775 N/C $10.00 $15.00 $20.00
B1776 N/C $10.00 $15.00 $20.00
B1777 N/C $10.00 $15.00 $20.00
B1778 N/C $10.00 $15.00 $20.00
B1779 N/C $10.00 $15.00 $20.00
B1780 N/C $10.00 $15.00 $20.00
B1781 N/C $10.00 $15.00 $20.00
B1782 N/C $5.00 $10.00 $15.00
B1783 N/C $5.00 $10.00 $15.00
B1784 N/C $5.00 $10.00 $15.00
B1785 N/C $5.00 $10.00 $15.00
B1786 N/C $5.00 $10.00 $15.00
B1787 N/C $5.00 $10.00 $15.00
B1788 N/C $5.00 $10.00 $15.00
B1789 N/C $5.00 $10.00 $15.00
B1790 N/C $5.00 $10.00 $15.00
B1791 N/C $5.00 $10.00 $15.00
B1792 N/C $5.00 $10.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
70
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1793 N/C $5.00 $10.00 $15.00
B1794 N/C $5.00 $10.00 $15.00
B1795 N/C $5.00 $10.00 $15.00
B1796 N/C $5.00 $10.00 $15.00
B1797 N/C $5.00 $10.00 $15.00
B1798 N/C $5.00 $10.00 $15.00
B1799 N/C $5.00 $10.00 $15.00
B1800 N/C $5.00 $10.00 $15.00
B1801 N/C $5.00 $10.00 $15.00
B1802 N/C $5.00 $10.00 $15.00
B1803 N/C $5.00 $10.00 $15.00
B1804 N/C $5.00 $10.00 $15.00
B1805 N/C $5.00 $10.00 $15.00
B1806 N/C $5.00 $10.00 $15.00
B1807 N/C $5.00 $10.00 $15.00
B1808 N/C $5.00 $10.00 $15.00
B1809 N/C $5.00 $10.00 $15.00
B1810 N/C $5.00 $10.00 $15.00
B1811 N/C $5.00 $10.00 $15.00
B1812 N/C $5.00 $10.00 $15.00
B1813 N/C $5.00 $10.00 $15.00
B1814 $15.00 $8.00 $12.00 $15.00
B1815 $15.00 $10.00 $15.00 $15.00
B1816 $15.00 $5.00 $15.00 $15.00
B1817 $15.00 $5.00 $10.00 $10.00
B1818 $15.00 $10.00 $15.00 $15.00
B1819 $15.00 $10.00 $15.00 $15.00
B1820 $15.00 $8.00 $12.00 $15.00
B1821 $15.00 $8.00 $12.00 $15.00
B1822 $15.00 $5.00 $15.00 $15.00
B1823 $15.00 $5.00 $15.00 $15.00
B1824 $15.00 $10.00 $15.00 $15.00
B1825 $15.00 $5.00 $10.00 $10.00
B1826 $15.00 $5.00 $15.00 $15.00
B1827 $15.00 $4.00 $15.00 $20.00
B1828 $15.00 $10.00 $15.00 $15.00
B1829 $15.00 $5.00 $15.00 $15.00
B1830 $15.00 $10.00 $15.00 $15.00
B1831 $15.00 $5.00 $15.00 $15.00
B1832 $15.00 $10.00 $15.00 $15.00
B1833 $15.00 $5.00 $15.00 $15.00
B1834 $15.00 $10.00 $15.00 $15.00
B1835 $15.00 $5.00 $10.00 $10.00
B1836 $15.00 $10.00 $15.00 $15.00
B1837 $15.00 $10.00 $15.00 $15.00
B1838 N/C $5.00 $15.00 $15.00
B1839 $15.00 $5.00 $15.00 $15.00
B1840 $15.00 $10.00 $15.00 $15.00
B1841 $15.00 $8.00 $12.00 $15.00
B1842 $15.00 $10.00 $15.00 $15.00
B1843 $15.00 $5.00 $10.00 $10.00
B1844 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
71
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1845 $15.00 $10.00 $15.00 $15.00
B1846 $15.00 $10.00 $15.00 $15.00
B1847 $15.00 $10.00 $15.00 $15.00
B1848 $15.00 $5.00 $10.00 $10.00
B1849 $15.00 $10.00 $15.00 $15.00
B1850 $15.00 $10.00 $15.00 $15.00
B1851 $15.00 $10.00 $15.00 $15.00
B1852 $15.00 $5.00 $15.00 $15.00
B1853 $15.00 $5.00 $15.00 $15.00
B1854 $15.00 $5.00 $15.00 $15.00
B1855 N/C $5.00 $10.00 $15.00
B1856 $15.00 $10.00 $15.00 $15.00
B1857 $15.00 $5.00 $15.00 $15.00
B1858 $15.00 $10.00 $15.00 $15.00
B1859 $15.00 $10.00 $15.00 $15.00
B1860 $15.00 $10.00 $15.00 $15.00
B1861 $15.00 $5.00 $15.00 $15.00
B1862 $15.00 $10.00 $15.00 $15.00
B1863 $15.00 $10.00 $15.00 $15.00
B1864 $15.00 $10.00 $15.00 $15.00
B1865 $15.00 $5.00 $15.00 $15.00
B1866 $15.00 $10.00 $15.00 $15.00
B1867 $15.00 $5.00 $15.00 $15.00
B1868 $15.00 $10.00 $15.00 $15.00
B1869 $15.00 $10.00 $15.00 $15.00
B1870 $15.00 $10.00 $15.00 $15.00
B1871 $15.00 $10.00 $15.00 $15.00
B1872 $15.00 $10.00 $15.00 $15.00
B1873 $15.00 $10.00 $15.00 $15.00
B1874 $15.00 $10.00 $15.00 $15.00
B1875 $15.00 $5.00 $10.00 $10.00
B1876 $15.00 $5.00 $10.00 $10.00
B1877 $15.00 $5.00 $15.00 $15.00
B1878 $15.00 $5.00 $15.00 $15.00
B1879 $15.00 $8.00 $12.00 $15.00
B1880 $15.00 $8.00 $12.00 $15.00
B1881 $15.00 $5.00 $10.00 $10.00
B1882 $15.00 $7.50 $10.00 $10.00
B1883 $15.00 $10.00 $15.00 $15.00
B1884 $15.00 $5.00 $15.00 $15.00
B1885 $15.00 $5.00 $15.00 $15.00
B1886 $15.00 $10.00 $15.00 $15.00
B1887 $15.00 $5.00 $10.00 $10.00
B1888 $15.00 $10.00 $15.00 $15.00
B1889 $15.00 $8.00 $12.00 $15.00
B1890 $15.00 $8.00 $12.00 $15.00
B1891 $15.00 $5.00 $15.00 $15.00
B1892 $15.00 $5.00 $15.00 $15.00
B1893 $15.00 $5.00 $15.00 $15.00
B1894 $15.00 $5.00 $15.00 $15.00
B1895 $15.00 $10.00 $15.00 $15.00
B1896 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
72
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1897 $15.00 $10.00 $15.00 $15.00
B1898 $15.00 $5.00 $10.00 $10.00
B1899 $15.00 $5.00 $15.00 $15.00
B1900 $15.00 $5.00 $15.00 $15.00
B1901 $15.00 $5.00 $15.00 $15.00
B1902 $15.00 $5.00 $15.00 $15.00
B1903 $15.00 $5.00 $10.00 $10.00
B1904 $15.00 $5.00 $15.00 $15.00
B1905 $15.00 $10.00 $15.00 $15.00
B1906 $15.00 $10.00 $15.00 $15.00
B1907 $15.00 $8.00 $12.00 $15.00
B1908 $15.00 $10.00 $15.00 $15.00
B1909 $15.00 $10.00 $15.00 $15.00
B1910 $15.00 $5.00 $10.00 $10.00
B1911 $15.00 $5.00 $15.00 $15.00
B1912 $15.00 $5.00 $15.00 $15.00
B1913 $15.00 $8.00 $12.00 $15.00
B1914 $15.00 $5.00 $15.00 $15.00
B1915 $15.00 $5.00 $10.00 $10.00
B1916 $15.00 $10.00 $15.00 $15.00
B1917 $15.00 $10.00 $15.00 $15.00
B1918 $15.00 $10.00 $15.00 $15.00
B1919 $15.00 $10.00 $15.00 $15.00
B1920 $15.00 $8.00 $12.00 $15.00
B1921 $15.00 $10.00 $15.00 $15.00
B1922 $15.00 $10.00 $15.00 $15.00
B1923 $15.00 $10.00 $15.00 $15.00
B1924 $15.00 $5.00 $15.00 $15.00
B1925 $15.00 $5.00 $15.00 $15.00
B1926 $15.00 $4.00 $15.00 $20.00
B1927 $15.00 $10.00 $15.00 $15.00
B1928 N/C $10.00 $10.00 $10.00
B1929 $15.00 $10.00 $15.00 $15.00
B1930 $15.00 $10.00 $15.00 $15.00
B1931 $15.00 $10.00 $15.00 $15.00
B1932 $15.00 $10.00 $15.00 $15.00
B1933 $15.00 $5.00 $10.00 $10.00
B1934 $15.00 $10.00 $15.00 $15.00
B1935 $15.00 $5.00 $10.00 $10.00
B1936 $15.00 $5.00 $15.00 $15.00
B1937 $15.00 $8.00 $12.00 $15.00
B1938 $15.00 $5.00 $10.00 $10.00
B1939 $15.00 $4.00 $15.00 $20.00
B1940 $15.00 $10.00 $15.00 $15.00
B1941 $15.00 $5.00 $15.00 $15.00
B1942 $15.00 $8.00 $12.00 $15.00
B1943 $15.00 $5.00 $10.00 $10.00
B1944 $15.00 $10.00 $15.00 $15.00
B1945 $15.00 $8.00 $12.00 $15.00
B1946 $15.00 $8.00 $12.00 $15.00
B1947 $15.00 $5.00 $15.00 $15.00
B1948 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
73
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B1949 $15.00 $5.00 $15.00 $15.00
B1950 $15.00 $10.00 $15.00 $15.00
B1951 $15.00 $10.00 $15.00 $15.00
B1952 $15.00 $5.00 $10.00 $10.00
B1953 $15.00 $5.00 $10.00 $10.00
B1954 $15.00 $5.00 $15.00 $15.00
B1955 $15.00 $4.00 $15.00 $20.00
B1956 $15.00 $5.00 $15.00 $15.00
B1957 $15.00 $8.00 $12.00 $15.00
B1958 $15.00 $8.00 $12.00 $15.00
B1959 $15.00 $10.00 $15.00 $15.00
B1960 $15.00 $5.00 $15.00 $15.00
B1961 $15.00 $10.00 $15.00 $15.00
B1962 $15.00 $10.00 $15.00 $15.00
B1963 $15.00 $10.00 $15.00 $15.00
B1964 $15.00 $5.00 $10.00 $10.00
B1965 $15.00 $5.00 $15.00 $15.00
B1966 $15.00 $10.00 $15.00 $15.00
B1967 $15.00 $5.00 $15.00 $15.00
B1968 $15.00 $10.00 $15.00 $15.00
B1969 $15.00 $10.00 $15.00 $15.00
B1970 $15.00 $10.00 $15.00 $15.00
B1971 $15.00 $8.00 $12.00 $15.00
B1972 $15.00 $5.00 $15.00 $15.00
B1973 $15.00 $8.00 $12.00 $15.00
B1974 $15.00 $8.00 $12.00 $15.00
B1975 $15.00 $5.00 $10.00 $10.00
B1976 $15.00 $10.00 $15.00 $15.00
B1977 $15.00 $10.00 $15.00 $15.00
B1978 $15.00 $8.00 $12.00 $15.00
B1979 $15.00 $10.00 $15.00 $15.00
B1980 $15.00 $5.00 $10.00 $10.00
B1981 $15.00 $10.00 $15.00 $15.00
B1982 $15.00 $5.00 $15.00 $15.00
B1983 $15.00 $5.00 $15.00 $15.00
B1984 $15.00 $10.00 $15.00 $15.00
B1985 $15.00 $5.00 $10.00 $10.00
B1986 $15.00 $10.00 $15.00 $15.00
B1987 $15.00 $5.00 $10.00 $10.00
B1988 $15.00 $10.00 $15.00 $15.00
B1989 $15.00 $5.00 $10.00 $10.00
B1990 $15.00 $10.00 $15.00 $15.00
B1991 $15.00 $5.00 $15.00 $15.00
B1992 $15.00 $5.00 $15.00 $15.00
B1993 $15.00 $5.00 $15.00 $15.00
B1994 $15.00 $10.00 $15.00 $15.00
B1995 $15.00 $8.00 $12.00 $15.00
B1996 $15.00 $5.00 $15.00 $15.00
B1997 $15.00 $8.00 $12.00 $15.00
B1998 $15.00 $10.00 $15.00 $15.00
B1999 $15.00 $5.00 $10.00 $10.00
B2000 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
74
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2001 $15.00 $5.00 $15.00 $15.00
B2002 $15.00 $10.00 $15.00 $15.00
B2003 $15.00 $5.00 $10.00 $10.00
B2004 $15.00 $5.00 $15.00 $15.00
B2005 $15.00 $10.00 $15.00 $15.00
B2006 $15.00 $5.00 $10.00 $10.00
B2007 $15.00 $10.00 $15.00 $15.00
B2008 $15.00 $5.00 $10.00 $10.00
B2009 $15.00 $5.00 $10.00 $10.00
B2010 $15.00 $8.00 $12.00 $15.00
B2011 $15.00 $10.00 $15.00 $15.00
B2012 $15.00 $5.00 $10.00 $10.00
B2013 $15.00 $10.00 $20.00 $20.00
B2014 $15.00 $10.00 $15.00 $15.00
B2015 $15.00 $5.00 $10.00 $10.00
B2016 $15.00 $10.00 $15.00 $15.00
B2017 $15.00 $10.00 $15.00 $15.00
B2018 $15.00 $5.00 $15.00 $15.00
B2019 $15.00 $8.00 $12.00 $15.00
B2020 $15.00 $10.00 $15.00 $15.00
B2021 $15.00 $10.00 $15.00 $15.00
B2022 $15.00 $5.00 $15.00 $15.00
B2023 $15.00 $10.00 $15.00 $15.00
B2024 $15.00 $10.00 $15.00 $15.00
B2025 $15.00 $5.00 $15.00 $15.00
B2026 $15.00 $5.00 $15.00 $15.00
B2027 $15.00 $5.00 $15.00 $15.00
B2028 $15.00 $8.00 $12.00 $15.00
B2029 $15.00 $10.00 $15.00 $15.00
B2030 $15.00 $8.00 $12.00 $15.00
B2031 $15.00 $10.00 $15.00 $15.00
B2032 $15.00 $5.00 $15.00 $15.00
B2033 $15.00 $5.00 $15.00 $15.00
B2034 $15.00 $10.00 $15.00 $15.00
B2035 $15.00 $10.00 $15.00 $15.00
B2036 $15.00 $5.00 $15.00 $15.00
B2037 $15.00 $5.00 $15.00 $15.00
B2038 $15.00 $8.00 $12.00 $15.00
B2039 $15.00 $8.00 $12.00 $15.00
B2040 $15.00 $5.00 $15.00 $15.00
B2041 $15.00 $10.00 $15.00 $15.00
B2042 $15.00 $10.00 $15.00 $15.00
B2043 $15.00 $5.00 $15.00 $15.00
B2044 $15.00 $5.00 $15.00 $15.00
B2045 $15.00 $5.00 $15.00 $15.00
B2046 $15.00 $8.00 $12.00 $15.00
B2047 $15.00 $5.00 $15.00 $15.00
B2048 $15.00 $10.00 $15.00 $15.00
B2049 $15.00 $10.00 $15.00 $15.00
B2050 $15.00 $5.00 $15.00 $15.00
B2051 $15.00 $10.00 $15.00 $15.00
B2052 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
75
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2053 $15.00 $5.00 $15.00 $15.00
B2054 $15.00 $8.00 $12.00 $15.00
B2055 $15.00 $10.00 $15.00 $15.00
B2056 $15.00 $5.00 $15.00 $15.00
B2057 $15.00 $5.00 $10.00 $10.00
B2058 $15.00 $10.00 $15.00 $15.00
B2059 $15.00 $10.00 $15.00 $15.00
B2060 $15.00 $10.00 $15.00 $15.00
B2061 $15.00 $4.00 $15.00 $20.00
B2062 $15.00 $5.00 $10.00 $10.00
B2063 $15.00 $10.00 $15.00 $20.00
B2064 $15.00 $10.00 $15.00 $20.00
B2065 $15.00 $5.00 $15.00 $15.00
B2066 $15.00 $5.00 $20.00 $20.00
B2067 $15.00 $10.00 $15.00 $18.00
B2068 $15.00 $6.00 $8.00 $8.00
B2069 $15.00 $12.00 $15.00 $18.00
B2070 $15.00 $10.00 $10.00 $10.00
B2071 $15.00 $5.00 $10.00 $10.00
B2072 $15.00 $5.00 $15.00 $15.00
B2073 $15.00 $10.00 $20.00 $20.00
B2074 $15.00 $5.00 $10.00 $10.00
B2075 $15.00 $5.00 $15.00 $15.00
B2076 $15.00 $5.00 $15.00 $15.00
B2077 $15.00 $10.00 $15.00 $15.00
B2078 N/C $10.00 $15.00 $15.00
B2079 $15.00 $5.00 $15.00 $15.00
B2080 $15.00 $5.00 $15.00 $15.00
B2081 $15.00 $5.00 $15.00 $15.00
B2082 $15.00 $5.00 $18.00 $20.00
B2083 $15.00 $6.00 $8.00 $8.00
B2084 $15.00 $8.00 $12.00 $15.00
B2085 $15.00 $8.00 $12.00 $15.00
B2086 $15.00 $10.00 $20.00 $20.00
B2087 $15.00 $3.00 $7.00 $11.00
B2088 $15.00 $8.00 $15.00 $15.00
B2089 $15.00 $5.00 $15.00 $15.00
B2090 $15.00 $10.00 $15.00 $15.00
B2091 $15.00 $5.00 $15.00 $15.00
B2092 $15.00 $5.00 $10.00 $10.00
B2093 $15.00 $7.00 $18.00 $20.00
B2094 $15.00 $10.00 $15.00 $15.00
B2095 $15.00 $10.00 $15.00 $15.00
B2096 $15.00 $5.00 $15.00 $15.00
B2097 $15.00 $10.00 $15.00 $15.00
B2098 $15.00 $4.00 $15.00 $20.00
B2099 $15.00 $4.00 $15.00 $20.00
B2100 $15.00 $5.00 $15.00 $15.00
B2101 $15.00 $10.00 $12.00 $15.00
B2102 $15.00 $5.00 $15.00 $15.00
B2103 $15.00 $10.00 $15.00 $18.00
B2104 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
76
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2105 $15.00 $10.00 $18.00 $20.00
B2106 $15.00 $10.00 $18.00 $20.00
B2107 $15.00 $10.00 $15.00 $15.00
B2108 $15.00 $7.00 $12.00 $15.00
B2109 $15.00 $10.00 $20.00 $20.00
B2110 $15.00 $5.00 $15.00 $15.00
B2111 $15.00 $3.00 $7.00 $11.00
B2112 $15.00 $5.00 $15.00 $15.00
B2113 $15.00 $5.00 $15.00 $15.00
B2114 $15.00 $7.00 $15.00 $20.00
B2115 $15.00 $5.00 $12.00 $15.00
B2116 N/C $10.00 $15.00 $15.00
B2117 $15.00 $5.00 $20.00 $20.00
B2118 $15.00 $5.00 $15.00 $15.00
B2119 $15.00 $5.00 $15.00 $15.00
B2120 $15.00 $5.00 $15.00 $15.00
B2121 $15.00 $5.00 $15.00 $15.00
B2122 $15.00 $10.00 $15.00 $15.00
B2123 $15.00 $5.00 $10.00 $10.00
B2124 $15.00 $10.00 $15.00 $15.00
B2125 $15.00 $5.00 $10.00 $10.00
B2126 $15.00 $5.00 $15.00 $15.00
B2127 $15.00 $10.00 $15.00 $15.00
B2128 $15.00 $10.00 $20.00 $20.00
B2129 $15.00 $10.00 $15.00 $15.00
B2130 $15.00 $35.00 $35.00 $50.00
B2131 $15.00 $10.00 $18.00 $18.00
B2132 $15.00 $3.00 $7.00 $11.00
B2133 $15.00 $10.00 $15.00 $15.00
B2134 $15.00 $12.00 $12.00 $12.00
B2135 $15.00 $12.00 $12.00 $12.00
B2136 $15.00 $10.00 $15.00 $15.00
B2137 $15.00 $7.00 $18.00 $18.00
B2138 $15.00 $10.00 $15.00 $15.00
B2139 $15.00 $15.00 $15.00 $20.00
B2140 $15.00 $10.00 $15.00 $15.00
B2141 $15.00 $10.00 $10.00 $20.00
B2142 $15.00 $10.00 $10.00 $20.00
B2143 $15.00 $10.00 $10.00 $20.00
B2144 $15.00 $10.00 $10.00 $20.00
B2145 $15.00 $10.00 $10.00 $20.00
B2146 $15.00 $10.00 $10.00 $20.00
B2147 $15.00 $10.00 $15.00 $15.00
B2148 $15.00 $5.00 $15.00 $15.00
B2149 $15.00 $5.00 $15.00 $15.00
B2150 $15.00 $10.00 $15.00 $15.00
B2151 $15.00 $5.00 $15.00 $15.00
B2152 $15.00 $5.00 $15.00 $15.00
B2153 $15.00 $15.00 $20.00 $20.00
B2154 $15.00 $10.00 $12.00 $15.00
B2155 $15.00 $5.00 $10.00 $10.00
B2156 $15.00 $6.00 $8.00 $8.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
77
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2157 $15.00 $5.00 $15.00 $15.00
B2158 $15.00 $7.00 $18.00 $20.00
B2159 $15.00 $7.00 $18.00 $20.00
B2160 $15.00 $10.00 $15.00 $15.00
B2161 $15.00 $15.00 $20.00 $20.00
B2162 $15.00 $7.00 $15.00 $20.00
B2163 $15.00 $10.00 $15.00 $15.00
B2164 $15.00 $10.00 $18.00 $18.00
B2165 $15.00 $5.00 $10.00 $10.00
B2166 $15.00 $10.00 $15.00 $15.00
B2167 $15.00 $8.00 $12.00 $15.00
B2168 $15.00 $10.00 $15.00 $15.00
B2169 $15.00 $10.00 $15.00 $15.00
B2170 $15.00 $5.00 $15.00 $15.00
B2171 $15.00 $5.00 $15.00 $15.00
B2172 $15.00 $5.00 $10.00 $10.00
B2173 $15.00 $5.00 $15.00 $15.00
B2174 N/C $8.00 $12.00 $15.00
B2175 $15.00 $8.00 $12.00 $15.00
B2176 $15.00 $5.00 $10.00 $10.00
B2177 $15.00 $5.00 $15.00 $15.00
B2178 $15.00 $10.00 $15.00 $15.00
B2179 $15.00 $5.00 $15.00 $15.00
B2180 $15.00 $5.00 $10.00 $10.00
B2181 $15.00 $10.00 $15.00 $15.00
B2182 $15.00 $5.00 $15.00 $15.00
B2183 $15.00 $10.00 $15.00 $15.00
B2184 $15.00 $10.00 $15.00 $15.00
B2185 $15.00 $10.00 $15.00 $15.00
B2186 $15.00 $10.00 $15.00 $15.00
B2187 $15.00 $10.00 $15.00 $15.00
B2188 $15.00 $10.00 $15.00 $15.00
B2189 $15.00 $10.00 $15.00 $15.00
B2190 $15.00 $10.00 $15.00 $15.00
B2191 $15.00 $5.00 $15.00 $15.00
B2192 $15.00 $5.00 $10.00 $10.00
B2193 $15.00 $5.00 $15.00 $15.00
B2194 $15.00 $10.00 $15.00 $15.00
B2195 $15.00 $8.00 $12.00 $15.00
B2196 $15.00 $4.00 $15.00 $20.00
B2197 $15.00 $5.00 $15.00 $15.00
B2198 $15.00 $10.00 $15.00 $15.00
B2199 $15.00 $5.00 $15.00 $15.00
B2200 $15.00 $10.00 $15.00 $15.00
B2201 $15.00 $5.00 $10.00 $10.00
B2202 $15.00 $5.00 $15.00 $15.00
B2203 $15.00 $7.00 $12.00 $15.00
B2204 $15.00 $8.00 $12.00 $15.00
B2205 $15.00 $10.00 $10.00 $20.00
B2206 N/C $5.00 $10.00 $15.00
B2207 $15.00 $10.00 $15.00 $15.00
B2208 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
78
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2209 $15.00 $8.00 $12.00 $15.00
B2210 $15.00 $5.00 $15.00 $15.00
B2211 $15.00 $5.00 $10.00 $10.00
B2212 $15.00 $5.00 $15.00 $15.00
B2213 $15.00 $10.00 $15.00 $15.00
B2214 $15.00 $10.00 $15.00 $15.00
B2215 $15.00 $8.00 $12.00 $15.00
B2216 $15.00 $5.00 $15.00 $15.00
B2217 $15.00 $5.00 $10.00 $10.00
B2218 $15.00 $5.00 $10.00 $10.00
B2219 $15.00 $5.00 $15.00 $15.00
B2220 $15.00 $5.00 $10.00 $10.00
B2221 $15.00 $5.00 $15.00 $15.00
B2222 $15.00 $10.00 $15.00 $15.00
B2223 $15.00 $10.00 $15.00 $15.00
B2224 $15.00 $10.00 $15.00 $15.00
B2225 $15.00 $5.00 $15.00 $15.00
B2226 $15.00 $10.00 $15.00 $15.00
B2227 $15.00 $10.00 $15.00 $15.00
B2228 $15.00 $10.00 $15.00 $15.00
B2229 $15.00 $10.00 $15.00 $15.00
B2230 $15.00 $10.00 $15.00 $15.00
B2231 $10.00 $15.00 $15.00
B2232 $15.00 $5.00 $15.00 $15.00
B2233 $15.00 $5.00 $15.00 $15.00
B2234 $15.00 $10.00 $15.00 $15.00
B2235 $15.00 $8.00 $12.00 $15.00
B2236 $15.00 $5.00 $10.00 $10.00
B2237 $15.00 $5.00 $10.00 $10.00
B2238 $15.00 $10.00 $15.00 $15.00
B2239 $15.00 $4.00 $15.00 $20.00
B2240 $15.00 $4.00 $15.00 $20.00
B2241 $15.00 $5.00 $15.00 $15.00
B2242 $15.00 $5.00 $15.00 $15.00
B2243 $15.00 $10.00 $15.00 $15.00
B2244 $15.00 $10.00 $15.00 $15.00
B2245 $15.00 $5.00 $10.00 $10.00
B2246 $15.00 $10.00 $15.00 $15.00
B2247 $15.00 $10.00 $20.00 $20.00
B2248 $15.00 $5.00 $15.00 $15.00
B2249 $15.00 $8.00 $12.00 $15.00
B2250 $15.00 $10.00 $15.00 $20.00
B2251 $15.00 $5.00 $15.00 $15.00
B2252 $15.00 $5.00 $15.00 $15.00
B2253 $15.00 $5.00 $10.00 $10.00
B2254 $15.00 $10.00 $15.00 $15.00
B2255 $15.00 $8.00 $12.00 $15.00
B2256 $15.00 $8.00 $12.00 $15.00
B2257 $15.00 $5.00 $15.00 $15.00
B2258 $15.00 $6.00 $8.00 $8.00
B2259 $15.00 $3.00 $5.00 $7.00
B2260 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
79
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2261 $15.00 $10.00 $15.00 $15.00
B2262 $15.00 $10.00 $18.00 $18.00
B2263 $15.00 $10.00 $18.00 $20.00
B2264 $15.00 $15.00 $15.00 $18.00
B2265 $15.00 $5.00 $15.00 $18.00
B2266 $15.00 $5.00 $15.00 $18.00
B2267 $15.00 $5.00 $15.00 $15.00
B2268 $15.00 $5.00 $10.00 $10.00
B2269 $15.00 $10.00 $15.00 $15.00
B2270 $15.00 $10.00 $15.00 $15.00
B2271 $15.00 $6.00 $10.00 $12.00
B2272 $15.00 $5.00 $15.00 $15.00
B2273 $15.00 $6.00 $10.00 $12.00
B2274 $15.00 $10.00 $15.00 $15.00
B2275 $15.00 $10.00 $20.00 $20.00
B2276 $15.00 $10.00 $20.00 $20.00
B2277 $15.00 $7.00 $20.00 $20.00
B2278 $15.00 $7.00 $20.00 $20.00
B2279 $15.00 $10.00 $15.00 $20.00
B2280 $15.00 $5.00 $15.00 $15.00
B2281 $15.00 $5.00 $15.00 $15.00
B2282 $15.00 $8.00 $12.00 $15.00
B2283 $15.00 $5.00 $15.00 $15.00
B2284 $15.00 $8.00 $12.00 $15.00
B2285 $15.00 $10.00 $18.00 $20.00
B2286 $15.00 $5.00 $15.00 $15.00
B2287 $15.00 $10.00 $18.00 $20.00
B2288 $15.00 $5.00 $15.00 $15.00
B2289 $15.00 $15.00 $15.00 $15.00
B2290 $15.00 $10.00 $17.00 $20.00
B2291 $15.00 $10.00 $15.00 $15.00
B2292 $15.00 $10.00 $15.00 $15.00
B2293 $15.00 $5.00 $10.00 $10.00
B2294 $15.00 $10.00 $18.00 $20.00
B2295 $15.00 $5.00 $10.00 $12.00
B2296 $15.00 $15.00 $20.00 $20.00
B2297 $10.00 $10.00 $12.00 $15.00
B2298 $10.00 $10.00 $12.00 $15.00
B2299 $15.00 $15.00 $18.00 $20.00
B2300 $15.00 $10.00 $20.00 $20.00
B2301 $15.00 $10.00 $15.00 $15.00
B2302 $15.00 $5.00 $10.00 $10.00
B2303 $15.00 $5.00 $10.00 $10.00
B2304 $15.00 $10.00 $15.00 $15.00
B2305 $15.00 $4.00 $15.00 $20.00
B2306 $15.00 $5.00 $15.00 $15.00
B2307 $20.00 $10.00 $15.00 $15.00
B2308 $15.00 $5.00 $15.00 $15.00
B2309 $15.00 $10.00 $15.00 $15.00
B2310 $15.00 $10.00 $15.00 $15.00
B2311 $15.00 $10.00 $12.00 $15.00
B2312 $15.00 $10.00 $12.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
80
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2313 $15.00 $7.00 $18.00 $18.00
B2315 $15.00 $10.00 $15.00 $15.00
B2316 $15.00 $10.00 $15.00 $15.00
B2317 $15.00 $10.00 $15.00 $15.00
B2318 $15.00 $5.00 $15.00 $15.00
B2319 $15.00 $8.00 $15.00 $15.00
B2320 $15.00 $10.00 $15.00 $15.00
B2321 $15.00 $5.00 $15.00 $15.00
B2322 $15.00 $5.00 $12.00 $20.00
B2323 $15.00 $10.00 $15.00 $15.00
B2324 $15.00 $7.00 $10.00 $15.00
B2325 $15.00 $7.00 $10.00 $15.00
B2326 $15.00 $5.00 $15.00 $15.00
B2327 $15.00 $5.00 $10.00 $12.00
B2328 $15.00 $10.00 $12.00 $15.00
B2329 $15.00 $10.00 $15.00 $15.00
B2330 $15.00 $12.00 $18.00 $20.00
B2331 $15.00 $5.00 $15.00 $20.00
B2332 $15.00 $5.00 $15.00 $15.00
B2333 $15.00 $10.00 $12.00 $15.00
B2334 $15.00 $12.00 $12.00 $12.00
B2335 $15.00 $12.00 $12.00 $12.00
B2336 $15.00 $10.00 $15.00 $15.00
B2337 $15.00 $15.00 $15.00 $15.00
B2338 $15.00 $15.00 $15.00 $15.00
B2339 $15.00 $10.00 $12.00 $12.00
B2340 $15.00 $10.00 $15.00 $15.00
B2341 $15.00 $10.00 $12.00 $15.00
B2342 $15.00 $5.00 $15.00 $15.00
B2343 $15.00 $8.00 $12.00 $15.00
B2344 $15.00 $5.00 $15.00 $15.00
B2345 $15.00 $10.00 $12.00 $15.00
B2346 $15.00 $5.00 $15.00 $15.00
B2347 $15.00 $5.00 $15.00 $15.00
B2348 $15.00 $5.00 $15.00 $18.00
B2349 $15.00 $5.00 $10.00 $10.00
B2350 $15.00 $10.00 $18.00 $20.00
B2351 $15.00 $10.00 $12.00 $12.00
B2352 $15.00 $12.00 $15.00 $15.00
B2353 $15.00 $10.00 $15.00 $15.00
B2354 $15.00 $15.00 $15.00 $18.00
B2355 $15.00 $4.00 $15.00 $20.00
B2356 $15.00 $4.00 $15.00 $20.00
B2357 $15.00 $10.00 $15.00 $15.00
B2358 $15.00 $8.00 $12.00 $15.00
B2359 $15.00 $10.00 $15.00 $15.00
B2360 $15.00 $10.00 $10.00 $10.00
B2361 $15.00 $5.00 $15.00 $15.00
B2362 $15.00 $10.00 $15.00 $15.00
B2363 N/C $3.00 $6.00 $6.00
B2364 $15.00 $10.00 $15.00 $20.00
B2365 $15.00 $8.00 $10.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
81
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2366 $15.00 $8.00 $10.00 $15.00
B2367 $15.00 $10.00 $12.00 $15.00
B2368 $15.00 $10.00 $15.00 $15.00
B2369 $15.00 $5.00 $15.00 $15.00
B2370 $15.00 $15.00 $20.00 $20.00
B2371 $15.00 $8.00 $12.00 $15.00
B2372 $15.00 $15.00 $15.00 $15.00
B2373 $15.00 $5.00 $20.00 $20.00
B2374 $15.00 $5.00 $20.00 $20.00
B2375 $15.00 $10.00 $12.00 $15.00
B2376 $15.00 $10.00 $15.00 $20.00
B2377 $15.00 $8.00 $18.00 $18.00
B2378 $15.00 $5.00 $15.00 $15.00
B2379 $15.00 $5.00 $15.00 $15.00
B2380 $15.00 $5.00 $15.00 $15.00
B2381 $15.00 $10.00 $15.00 $15.00
B2382 $15.00 $8.00 $12.00 $15.00
B2383 $15.00 $8.00 $12.00 $15.00
B2384 $15.00 $12.00 $15.00 $18.00
B2385 $15.00 $5.00 $15.00 $15.00
B2386 $15.00 $5.00 $15.00 $15.00
B2387 $15.00 $8.00 $12.00 $15.00
B2388 $15.00 $8.00 $12.00 $15.00
B2389 $15.00 $10.00 $20.00 $20.00
B2390 $15.00 $10.00 $15.00 $15.00
B2391 $15.00 $10.00 $15.00 $15.00
B2392 $15.00 $10.00 $10.00 $10.00
B2393 $15.00 $7.00 $10.00 $15.00
B2394 $15.00 $10.00 $20.00 $25.00
B2395 $15.00 $10.00 $20.00 $25.00
B2396 $15.00 $8.00 $10.00 $12.00
B2397 $15.00 $15.00 $15.00 $15.00
B2398 $15.00 $10.00 $15.00 $15.00
B2399 $15.00 $8.00 $12.00 $15.00
B2400 $15.00 $5.00 $10.00 $10.00
B2401 $15.00 $8.00 $12.00 $15.00
B2402 $15.00 $15.00 $18.00 $20.00
B2403 $15.00 $10.00 $15.00 $18.00
B2404 $15.00 $5.00 $15.00 $15.00
B2405 $15.00 $15.00 $20.00 $25.00
B2406 $15.00 $10.00 $15.00 $15.00
B2407 $15.00 $10.00 $10.00 $10.00
B2408 N/C $5.00 $15.00 $20.00
B2409 N/C $5.00 $15.00 $20.00
B2410 $15.00 $4.00 $15.00 $20.00
B2411 $15.00 $8.00 $10.00 $15.00
B2412 $15.00 $15.00 $15.00 $15.00
B2413 $15.00 $10.00 $15.00 $20.00
B2414 $15.00 $10.00 $15.00 $20.00
B2415 $15.00 $10.00 $15.00 $15.00
B2416 $15.00 $5.00 $15.00 $15.00
B2417 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
82
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2418 $15.00 $10.00 $12.00 $15.00
B2419 $15.00 $5.00 $10.00 $10.00
B2420 $15.00 $10.00 $15.00 $15.00
B2421 $15.00 $30.00 $40.00 $40.00
B2422 N/C $5.00 $15.00 $20.00
B2423 N/C $5.00 $15.00 $20.00
B2424 $15.00 $10.00 $15.00 $15.00
B2425 $15.00 $5.00 $12.00 $15.00
B2426 $15.00 $10.00 $15.00 $15.00
B2427 $15.00 $10.00 $15.00 $15.00
B2428 $15.00 $5.00 $18.00 $18.00
B2429 $15.00 $5.00 $18.00 $18.00
B2430 $15.00 $5.00 $18.00 $18.00
B2431 $15.00 $5.00 $18.00 $18.00
B2432 $15.00 $5.00 $18.00 $18.00
B2433 $15.00 $5.00 $18.00 $18.00
B2434 $15.00 $5.00 $18.00 $18.00
B2435 $15.00 $5.00 $18.00 $18.00
B2436 $15.00 $5.00 $18.00 $18.00
B2437 $15.00 $5.00 $18.00 $18.00
B2438 $15.00 $5.00 $18.00 $18.00
B2439 $15.00 $5.00 $18.00 $18.00
B2440 $15.00 $5.00 $18.00 $18.00
B2441 $15.00 $5.00 $18.00 $18.00
B2442 $15.00 $5.00 $18.00 $18.00
B2443 $15.00 $5.00 $18.00 $18.00
B2444 $15.00 $10.00 $10.00 $10.00
B2445 $15.00 $5.00 $10.00 $10.00
B2446 $15.00 $10.00 $15.00 $15.00
B2447 $15.00 $10.00 $15.00 $20.00
B2448 $15.00 $10.00 $12.00 $15.00
B2449 $15.00 $10.00 $12.00 $15.00
B2450 $15.00 $10.00 $15.00 $20.00
B2451 $15.00 $5.00 $10.00 $10.00
B2452 $15.00 $5.00 $10.00 $15.00
B2453 $15.00 $5.00 $10.00 $12.00
B2454 $15.00 $5.00 $10.00 $10.00
B2455 $15.00 $15.00 $20.00 $20.00
B2456 $15.00 $8.00 $15.00 $18.00
B2457 $15.00 $8.00 $15.00 $18.00
B2458 $15.00 $8.00 $15.00 $18.00
B2459 $15.00 $8.00 $15.00 $18.00
B2460 $15.00 $5.00 $10.00 $15.00
B2461 $15.00 $10.00 $18.00 $20.00
B2462 $15.00 $10.00 $18.00 $18.00
B2463 $15.00 $5.00 $15.00 $15.00
B2464 $15.00 $10.00 $18.00 $20.00
B2465 $15.00 $10.00 $18.00 $18.00
B2466 $15.00 $5.00 $15.00 $15.00
B2467 $15.00 $5.00 $15.00 $15.00
B2468 $15.00 $10.00 $18.00 $20.00
B2469 $15.00 $10.00 $20.00 $20.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
83
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2470 $15.00 $10.00 $15.00 $18.00
B2471 $15.00 $5.00 $15.00 $15.00
B2472 $15.00 $5.00 $15.00 $15.00
B2473 $15.00 $15.00 $15.00 $15.00
B2474 $15.00 $10.00 $10.00 $10.00
B2475 $15.00 $10.00 $10.00 $10.00
B2476 $15.00 $15.00 $20.00 $20.00
B2477 $15.00 $10.00 $10.00 $10.00
B2478 $15.00 $15.00 $15.00 $15.00
B2479 N/C $3.00 $6.00 $6.00
B2480 N/C $3.00 $6.00 $6.00
B2481 $15.00 $4.00 $15.00 $20.00
B2482 $15.00 $5.00 $10.00 $12.00
B2483 $15.00 $10.00 $15.00 $20.00
B2484 $15.00 $5.00 $7.00 $10.00
B2485 $15.00 $5.00 $15.00 $15.00
B2486 $15.00 $7.00 $18.00 $20.00
B2487 $15.00 $7.00 $18.00 $20.00
B2488 $15.00 $7.00 $18.00 $20.00
B2489 $15.00 $7.00 $18.00 $20.00
B2490 $15.00 $5.00 $18.00 $20.00
B2491 $15.00 $5.00 $10.00 $10.00
B2492 $15.00 $7.00 $18.00 $20.00
B2493 $15.00 $7.00 $18.00 $20.00
B2494 $15.00 $7.00 $18.00 $20.00
B2495 $15.00 $7.00 $12.00 $15.00
B2496 $15.00 $5.00 $8.00 $10.00
B2497 $15.00 $5.00 $18.00 $18.00
B2498 $15.00 $5.00 $15.00 $15.00
B2499 $15.00 $8.00 $12.00 $15.00
B2500 $15.00 $10.00 $12.00 $15.00
B2501 $15.00 $10.00 $15.00 $15.00
B2502 $15.00 $5.00 $18.00 $18.00
B2503 $15.00 $15.00 $20.00 $20.00
B2504 $15.00 $10.00 $15.00 $17.00
B2505 $15.00 $5.00 $10.00 $10.00
B2506 $15.00 $10.00 $15.00 $15.00
B2507 $15.00 $5.00 $15.00 $15.00
B2508 $15.00 $5.00 $10.00 $10.00
B2509 $15.00 $5.00 $10.00 $10.00
B2510 $15.00 $5.00 $15.00 $15.00
B2511 $15.00 $8.00 $15.00 $15.00
B2512 $15.00 $5.00 $10.00 $15.00
B2513 $15.00 $5.00 $15.00 $15.00
B2514 $15.00 $10.00 $20.00 $20.00
B2515 $15.00 $10.00 $15.00 $20.00
B2516 $15.00 $10.00 $15.00 $20.00
B2517 $15.00 $5.00 $15.00 $15.00
B2518 $15.00 $10.00 $15.00 $15.00
B2519 N/C $10.00 $15.00 $15.00
B2520 $15.00 $7.00 $15.00 $15.00
B2521 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
84
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2522 $15.00 $10.00 $15.00 $15.00
B2523 $15.00 $6.00 $10.00 $12.00
B2524 $15.00 $15.00 $20.00 $20.00
B2525 $15.00 $10.00 $15.00 $15.00
B2526 $15.00 $5.00 $15.00 $15.00
B2527 $15.00 $5.00 $15.00 $15.00
B2528 $15.00 $8.00 $12.00 $15.00
B2529 $15.00 $10.00 $12.00 $15.00
B2530 $15.00 $10.00 $15.00 $18.00
B2531 $15.00 $10.00 $15.00 $15.00
B2532 $15.00 $5.00 $10.00 $15.00
B2533 $15.00 $10.00 $15.00 $20.00
B2534 $15.00 $10.00 $15.00 $20.00
B2535 $15.00 $5.00 $15.00 $15.00
B2536 $15.00 $10.00 $15.00 $15.00
B2537 $15.00 $8.00 $12.00 $15.00
B2538 $15.00 $10.00 $15.00 $15.00
B2539 $15.00 $5.00 $10.00 $10.00
B2540 $15.00 $10.00 $15.00 $15.00
B2541 $15.00 $10.00 $20.00 $20.00
B2542 $15.00 $10.00 $15.00 $15.00
B2543 N/C $10.00 $15.00 $15.00
B2544 $15.00 $5.00 $15.00 $15.00
B2545 $15.00 $10.00 $15.00 $15.00
B2546 $15.00 $10.00 $15.00 $15.00
B2547 $15.00 $10.00 $15.00 $18.00
B2548 $15.00 $15.00 $20.00 $25.00
B2549 $15.00 $10.00 $20.00 $20.00
B2550 $15.00 $7.00 $18.00 $20.00
B2551 $15.00 $10.00 $15.00 $20.00
B2552 $15.00 $10.00 $15.00 $20.00
B2553 $15.00 $3.00 $7.00 $11.00
B2554 $15.00 $10.00 $20.00 $20.00
B2555 $15.00 $5.00 $15.00 $15.00
B2556 $15.00 $8.00 $12.00 $15.00
B2557 $15.00 $10.00 $15.00 $15.00
B2558 $15.00 $10.00 $18.00 $18.00
B2559 $15.00 $10.00 $15.00 $15.00
B2560 $15.00 $10.00 $15.00 $15.00
B2561 $15.00 $10.00 $15.00 $15.00
B2562 $15.00 $4.00 $15.00 $20.00
B2563 $15.00 $10.00 $15.00 $20.00
B2564 $15.00 $10.00 $15.00 $20.00
B2565 $15.00 $10.00 $17.00 $20.00
B2566 $15.00 $10.00 $20.00 $20.00
B2567 $15.00 $10.00 $15.00 $15.00
B2568 $15.00 $4.00 $15.00 $20.00
B2569 $15.00 $5.00 $10.00 $10.00
B2570 $15.00 $10.00 $15.00 $15.00
B2571 N/C $5.00 $15.00 $15.00
B2572 $15.00 $5.00 $10.00 $10.00
B2573 $15.00 $8.00 $12.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
85
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2574 $15.00 $10.00 $15.00 $15.00
B2575 $15.00 $5.00 $15.00 $15.00
B2576 $15.00 $5.00 $20.00 $20.00
B2577 $15.00 $10.00 $15.00 $18.00
B2578 $15.00 $10.00 $15.00 $18.00
B2579 $15.00 $10.00 $15.00 $15.00
B2580 $15.00 $5.00 $10.00 $10.00
B2581 $15.00 $10.00 $15.00 $15.00
B2582 $15.00 $10.00 $15.00 $15.00
B2583 $15.00 $10.00 $15.00 $15.00
B2584 $15.00 $10.00 $20.00 $20.00
B2585 $15.00 $10.00 $15.00 $15.00
B2586 $15.00 $10.00 $15.00 $15.00
B2587 $15.00 $6.00 $8.00 $8.00
B2588 $15.00 $6.00 $8.00 $8.00
B2589 $15.00 $10.00 $15.00 $15.00
B2590 $15.00 $5.00 $15.00 $15.00
B2591 $15.00 $4.00 $15.00 $20.00
B2592 $15.00 $10.00 $15.00 $15.00
B2593 $15.00 $15.00 $15.00 $18.00
B2594 $15.00 $10.00 $15.00 $15.00
B2595 $15.00 $5.00 $10.00 $10.00
B2596 $15.00 $5.00 $10.00 $10.00
B2597 $15.00 $10.00 $15.00 $15.00
B2598 $15.00 $5.00 $10.00 $10.00
B2599 $15.00 $10.00 $15.00 $15.00
B2600 $15.00 $10.00 $15.00 $15.00
B2601 $15.00 $5.00 $15.00 $15.00
B2602 $15.00 $10.00 $15.00 $15.00
B2603 $15.00 $5.00 $10.00 $10.00
B2604 $15.00 $10.00 $15.00 $15.00
B2605 $15.00 $8.00 $15.00 $15.00
B2606 $15.00 $5.00 $15.00 $15.00
B2607 $15.00 $5.00 $15.00 $15.00
B2608 $15.00 $10.00 $15.00 $15.00
B2609 $15.00 $10.00 $15.00 $15.00
B2610 $15.00 $10.00 $15.00 $15.00
B2611 $15.00 $10.00 $15.00 $15.00
B2612 $15.00 $10.00 $15.00 $15.00
B2613 $15.00 $5.00 $15.00 $15.00
B2614 $15.00 $5.00 $15.00 $15.00
B2615 $15.00 $10.00 $15.00 $18.00
B2616 $15.00 $5.00 $15.00 $15.00
B2617 $15.00 $5.00 $15.00 $15.00
B2618 $15.00 $10.00 $15.00 $15.00
B2619 $15.00 $10.00 $15.00 $15.00
B2620 $15.00 $5.00 $15.00 $15.00
B2621 $15.00 $5.00 $15.00 $15.00
B2622 $15.00 $7.00 $18.00 $20.00
B2623 $15.00 $5.00 $15.00 $15.00
B2624 $15.00 $5.00 $15.00 $15.00
B2625 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
86
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2626 $15.00 $10.00 $15.00 $15.00
B2627 $15.00 $5.00 $15.00 $15.00
B2628 $15.00 $5.00 $15.00 $15.00
B2629 $15.00 $12.00 $15.00 $18.00
B2630 $15.00 $10.00 $10.00 $10.00
B2631 $15.00 $5.00 $10.00 $10.00
B2632 N/C $8.00 $12.00 $15.00
B2633 $15.00 $10.00 $15.00 $15.00
B2634 $15.00 $5.00 $15.00 $15.00
B2635 $15.00 $8.00 $12.00 $15.00
B2636 $15.00 $10.00 $20.00 $20.00
B2637 $15.00 $5.00 $15.00 $15.00
B2638 $15.00 $10.00 $15.00 $18.00
B2639 $15.00 $10.00 $15.00 $15.00
B2640 $15.00 $3.00 $7.00 $11.00
B2641 $15.00 $10.00 $15.00 $15.00
B2642 $15.00 $3.00 $7.00 $11.00
B2643 $15.00 $5.00 $15.00 $15.00
B2644 $15.00 $5.00 $15.00 $15.00
B2645 $15.00 $10.00 $15.00 $15.00
B2646 $15.00 $7.00 $15.00 $20.00
B2647 $15.00 $5.00 $15.00 $15.00
B2648 $15.00 $5.00 $15.00 $15.00
B2649 $15.00 $8.00 $12.00 $15.00
B2650 $15.00 $10.00 $15.00 $20.00
B2651 $15.00 $10.00 $15.00 $15.00
B2652 $15.00 $5.00 $15.00 $15.00
B2653 $15.00 $7.00 $15.00 $20.00
B2654 $15.00 $10.00 $20.00 $20.00
B2655 $15.00 $7.00 $15.00 $20.00
B2656 $15.00 $10.00 $15.00 $15.00
B2657 $15.00 $5.00 $15.00 $15.00
B2658 $15.00 $5.00 $10.00 $10.00
B2659 $15.00 $10.00 $15.00 $15.00
B2660 $15.00 $10.00 $12.00 $15.00
B2661 $15.00 $10.00 $15.00 $15.00
B2662 $15.00 $5.00 $10.00 $10.00
B2663 $15.00 $6.00 $12.00 $12.00
B2664 $15.00 $8.00 $12.00 $15.00
B2665 $15.00 $10.00 $15.00 $15.00
B2666 $15.00 $5.00 $15.00 $15.00
B2667 $15.00 $10.00 $15.00 $15.00
B2668 $15.00 $10.00 $15.00 $15.00
B2669 $15.00 $5.00 $15.00 $15.00
B2670 $15.00 $5.00 $10.00 $15.00
B2671 $15.00 $5.00 $10.00 $15.00
B2672 $15.00 $5.00 $10.00 $15.00
B2673 $15.00 $10.00 $15.00 $20.00
B2674 $15.00 $10.00 $15.00 $20.00
B2675 $15.00 $5.00 $15.00 $15.00
B2676 $15.00 $10.00 $15.00 $15.00
B2677 $15.00 $10.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
87
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2678 $15.00 $8.00 $12.00 $15.00
B2679 $15.00 $3.00 $3.00 $3.00
B2680 $15.00 $15.00 $20.00 $20.00
B2681 $15.00 $10.00 $15.00 $15.00
B2682 $15.00 $10.00 $15.00 $18.00
B2683 $15.00 $10.00 $18.00 $20.00
B2684 $15.00 $10.00 $15.00 $15.00
B2685 $15.00 $10.00 $15.00 $18.00
B2686 $15.00 $10.00 $15.00 $18.00
B2687 $15.00 $8.00 $15.00 $15.00
B2688 $15.00 $10.00 $15.00 $15.00
B2689 $15.00 $10.00 $12.00 $15.00
B2690 $15.00 $12.00 $16.00 $16.00
B2691 $15.00 $10.00 $15.00 $15.00
B2692 $15.00 $8.00 $10.00 $12.00
B2693 $15.00 $7.00 $15.00 $18.00
B2694 $15.00 $10.00 $15.00 $18.00
B2695 $15.00 $10.00 $15.00 $18.00
B2696 $15.00 $15.00 $20.00 $20.00
B2697 $15.00 $10.00 $17.00 $20.00
B2698 $15.00 $10.00 $20.00 $20.00
B2699 $15.00 $5.00 $15.00 $15.00
B2700 $15.00 $5.00 $15.00 $15.00
B2701 $15.00 $10.00 $15.00 $20.00
B2702 $15.00 $10.00 $15.00 $20.00
B2703 $15.00 $10.00 $15.00 $18.00
B2704 $15.00 $4.00 $15.00 $20.00
B2705 $15.00 $5.00 $15.00 $15.00
B2706 $15.00 $5.00 $10.00 $12.00
B2707 $15.00 $10.00 $15.00 $20.00
B2708 $15.00 $10.00 $15.00 $20.00
B2709 $15.00 $12.00 $18.00 $22.00
B2710 $15.00 $10.00 $15.00 $20.00
B2711 $15.00 $12.00 $18.00 $20.00
B2712 $15.00 $10.00 $15.00 $20.00
B2713 N/C NADA NADA NADA
B2714 $15.00 $10.00 $15.00 $15.00
B2715 $15.00 $10.00 $15.00 $20.00
B2716 $15.00 $15.00 $20.00 $25.00
B2717 $15.00 $8.00 $12.00 $15.00
B2718 $15.00 $15.00 $20.00 $25.00
B2719 $15.00 $10.00 $20.00 $20.00
B2720 $15.00 $10.00 $15.00 $18.00
B2721 $15.00 $10.00 $15.00 $18.00
B2722 $18.00 $12.00 $18.00 $20.00
B2723 $15.00 $10.00 $15.00 $18.00
B2724 $15.00 $10.00 $15.00 $18.00
B2725 $15.00 $5.00 $12.00 $15.00
B2726 $15.00 $10.00 $15.00 $15.00
B2727 $15.00 $7.00 $18.00 $18.00
B2728 $15.00 $10.00 $18.00 $18.00
B2729 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
88
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2730 $15.00 $10.00 $15.00 $15.00
B2731 $15.00 $10.00 $10.00 $10.00
B2732 $15.00 $10.00 $15.00 $20.00
B2733 N/C NADA NADA NADA
B2734 $15.00 $10.00 $20.00 $20.00
B2735 $15.00 $10.00 $15.00 $15.00
B2736 $15.00 $15.00 $15.00 $18.00
B2737 $15.00 $5.00 $15.00 $15.00
B2738 $15.00 $10.00 $15.00 $15.00
B2739 $15.00 $10.00 $15.00 $15.00
B2740 $15.00 $7.00 $15.00 $15.00
B2741 $15.00 $7.00 $15.00 $15.00
B2742 $15.00 $10.00 $15.00 $15.00
B2743 $15.00 $10.00 $15.00 $15.00
B2744 $15.00 $10.00 $15.00 $15.00
B2745 $15.00 $10.00 $15.00 $15.00
B2746 $15.00 $10.00 $15.00 $15.00
B2747 N/C $10.00 $15.00 $15.00
B2748 N/C $10.00 $15.00 $15.00
B2749 $15.00 $6.00 $12.00 $12.00
B2750 $15.00 $10.00 $12.00 $12.00
B2751 $15.00 $10.00 $15.00 $15.00
B2752 $15.00 $12.00 $12.00 $12.00
B2753 $15.00 $12.00 $15.00 $15.00
B2754 $15.00 $10.00 $15.00 $18.00
B2755 $15.00 $7.00 $10.00 $12.00
B2756 $15.00 $5.00 $10.00 $12.00
B2757 $15.00 $5.00 $10.00 $12.00
B2758 $15.00 $5.00 $15.00 $15.00
B2759 $15.00 $5.00 $15.00 $15.00
B2760 $15.00 $10.00 $15.00 $20.00
B2761 $15.00 $10.00 $15.00 $15.00
B2762 $15.00 $5.00 $15.00 $15.00
B2763 $15.00 $10.00 $15.00 $15.00
B2764 $15.00 $6.00 $10.00 $12.00
B2765 $15.00 $15.00 $15.00 $18.00
B2766 $15.00 $4.00 $15.00 $20.00
B2767 $15.00 $4.00 $15.00 $20.00
B2768 $15.00 $5.00 $12.00 $15.00
B2769 $15.00 $4.00 $15.00 $20.00
B2770 $15.00 $4.00 $15.00 $20.00
B2771 $15.00 $4.00 $15.00 $20.00
B2772 $15.00 $4.00 $15.00 $20.00
B2773 $15.00 $15.00 $20.00 $25.00
B2774 $15.00 $10.00 $15.00 $15.00
B2775 N/C $10.00 $15.00 $15.00
B2776 N/C $10.00 $15.00 $15.00
B2777 N/C $10.00 $15.00 $15.00
B2778 N/C $10.00 $15.00 $15.00
B2779 $15.00 $5.00 $15.00 $15.00
B2780 $15.00 $5.00 $15.00 $15.00
B2781 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
89
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2782 $15.00 $5.00 $15.00 $15.00
B2783 N/C $7.00 $15.00 $15.00
B2784 N/C $7.00 $15.00 $15.00
B2785 N/C $7.00 $15.00 $15.00
B2786 $15.00 $8.00 $12.00 $15.00
B2787 $15.00 $5.00 $15.00 $15.00
B2788 $15.00 $8.00 $12.00 $15.00
B2789 $15.00 $5.00 $15.00 $15.00
B2790 $15.00 $5.00 $10.00 $10.00
B2791 $15.00 $5.00 $10.00 $12.00
B2792 $15.00 $5.00 $10.00 $12.00
B2793 $15.00 $10.00 $15.00 $15.00
B2794 $15.00 $5.00 $10.00 $10.00
B2795 $15.00 $4.00 $15.00 $20.00
B2796 $15.00 $5.00 $10.00 $10.00
B2797 $15.00 $35.00 $35.00 $50.00
B2798 $15.00 $8.00 $12.00 $15.00
B2799 $15.00 $4.00 $15.00 $20.00
B2800 $15.00 $4.00 $15.00 $20.00
B2801 $15.00 $4.00 $15.00 $20.00
B2802 $15.00 $4.00 $15.00 $20.00
B2803 $15.00 $10.00 $15.00 $20.00
B2804 $15.00 $5.00 $15.00 $15.00
B2805 $15.00 $5.00 $15.00 $15.00
B2806 $15.00 $10.00 $15.00 $15.00
B2807 $15.00 $6.00 $12.00 $15.00
B2808 $15.00 $4.00 $15.00 $20.00
B2809 $15.00 $10.00 $15.00 $15.00
B2810 $15.00 $10.00 $15.00 $15.00
B2811 $15.00 $10.00 $15.00 $15.00
B2812 $15.00 $5.00 $15.00 $15.00
B2813 $15.00 $5.00 $15.00 $15.00
B2814 $15.00 $10.00 $15.00 $15.00
B2815 $15.00 $7.00 $15.00 $15.00
B2816 $15.00 $7.00 $15.00 $15.00
B2817 $15.00 $7.00 $15.00 $15.00
B2818 $15.00 $10.00 $15.00 $15.00
B2819 $15.00 $10.00 $15.00 $15.00
B2820 $15.00 $10.00 $20.00 $20.00
B2821 $15.00 $10.00 $20.00 $20.00
B2822 $15.00 $10.00 $20.00 $20.00
B2823 $15.00 $5.00 $10.00 $10.00
B2824 $15.00 $10.00 $15.00 $15.00
B2825 $15.00 $10.00 $18.00 $20.00
B2826 $15.00 $10.00 $15.00 $15.00
B2827 $15.00 $5.00 $15.00 $15.00
B2828 $15.00 $10.00 $15.00 $18.00
B2829 $15.00 $10.00 $15.00 $15.00
B2830 $15.00 $5.00 $15.00 $15.00
B2831 $15.00 $5.00 $12.00 $20.00
B2832 $15.00 $8.00 $12.00 $15.00
B2833 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
90
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2834 $15.00 $5.00 $15.00 $15.00
B2835 $15.00 $5.00 $15.00 $15.00
B2836 $15.00 $8.00 $10.00 $12.00
B2837 $15.00 $5.00 $10.00 $10.00
B2838 $15.00 $4.00 $15.00 $20.00
B2839 $15.00 $8.00 $12.00 $15.00
B2840 $15.00 $10.00 $15.00 $15.00
B2841 $15.00 $10.00 $15.00 $15.00
B2842 $15.00 $5.00 $10.00 $10.00
B2843 $15.00 $5.00 $15.00 $15.00
B2844 $15.00 $8.00 $12.00 $15.00
B2845 $15.00 $10.00 $15.00 $15.00
B2846 $15.00 $8.00 $12.00 $15.00
B2847 $15.00 $10.00 $15.00 $15.00
B2848 $15.00 $5.00 $10.00 $10.00
B2849 $15.00 $5.00 $15.00 $15.00
B2850 $15.00 $5.00 $15.00 $15.00
B2851 $15.00 $4.00 $15.00 $20.00
B2852 $15.00 $10.00 $15.00 $15.00
B2853 $15.00 $10.00 $15.00 $20.00
B2854 $15.00 $10.00 $15.00 $20.00
B2855 $15.00 $8.00 $10.00 $12.00
B2856 $15.00 $12.00 $18.00 $22.00
B2857 $15.00 $15.00 $20.00 $25.00
B2858 $15.00 $10.00 $15.00 $15.00
B2859 $15.00 $7.00 $10.00 $15.00
B2860 $15.00 $7.00 $10.00 $15.00
B2861 $15.00 $5.00 $15.00 $15.00
B2862 $15.00 $10.00 $15.00 $15.00
B2863 $15.00 $10.00 $18.00 $20.00
B2864 $15.00 $10.00 $18.00 $20.00
B2865 $15.00 $10.00 $18.00 $20.00
B2866 $15.00 $5.00 $15.00 $15.00
B2867 $15.00 $5.00 $10.00 $10.00
B2868 $15.00 $15.00 $20.00 $25.00
B2869 $15.00 $15.00 $18.00 $20.00
B2870 $15.00 $8.00 $12.00 $15.00
B2871 $15.00 $10.00 $15.00 $15.00
B2872 $15.00 $10.00 $15.00 $15.00
B2873 $15.00 $10.00 $15.00 $15.00
B2874 $15.00 $5.00 $15.00 $15.00
B2875 $15.00 $15.00 $20.00 $25.00
B2876 $15.00 $2.00 $3.00 $5.00
B2877 $15.00 $2.00 $3.00 $5.00
B2878 $15.00 $10.00 $15.00 $15.00
B2879 $15.00 $8.00 $12.00 $15.00
B2880 $15.00 $8.00 $15.00 $18.00
B2881 $15.00 $8.00 $12.00 $15.00
B2882 $15.00 $8.00 $10.00 $12.00
B2883 $15.00 $8.00 $10.00 $12.00
B2884 $15.00 $8.00 $12.00 $15.00
B2885 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
91
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2886 $15.00 $5.00 $10.00 $10.00
B2887 $15.00 $5.00 $15.00 $15.00
B2888 $15.00 $10.00 $15.00 $15.00
B2889 $15.00 $5.00 $15.00 $15.00
B2890 $15.00 $10.00 $15.00 $15.00
B2891 $15.00 $5.00 $10.00 $10.00
B2892 $15.00 $5.00 $10.00 $10.00
B2893 $15.00 $5.00 $10.00 $10.00
B2894 $15.00 $5.00 $15.00 $15.00
B2895 $15.00 $5.00 $15.00 $15.00
B2896 $15.00 $10.00 $15.00 $15.00
B2897 $15.00 $5.00 $15.00 $15.00
B2898 $15.00 $5.00 $10.00 $10.00
B2899 $15.00 $4.00 $15.00 $20.00
B2900 $15.00 $5.00 $10.00 $10.00
B2901 $15.00 $10.00 $15.00 $18.00
B2902 $15.00 $10.00 $15.00 $18.00
B2903 $15.00 $10.00 $15.00 $15.00
B2904 $15.00 $5.00 $15.00 $15.00
B2905 $15.00 $10.00 $15.00 $15.00
B2906 $15.00 $15.00 $15.00 $15.00
B2907 $15.00 $8.00 $12.00 $15.00
B2908 $15.00 $5.00 $10.00 $10.00
B2909 $15.00 $7.00 $18.00 $18.00
B2910 $15.00 $10.00 $15.00 $15.00
B2911 $15.00 $10.00 $15.00 $15.00
B2912 $15.00 $10.00 $15.00 $15.00
B2913 $15.00 $5.00 $15.00 $15.00
B2914 $15.00 $5.00 $18.00 $20.00
B2915 $15.00 $10.00 $15.00 $15.00
B2916 $15.00 $5.00 $10.00 $10.00
B2917 $15.00 $10.00 $15.00 $15.00
B2918 $15.00 $5.00 $10.00 $10.00
B2919 $15.00 $5.00 $15.00 $15.00
B2920 $15.00 $5.00 $10.00 $12.00
B2921 $15.00 $10.00 $15.00 $15.00
B2922 $15.00 $10.00 $15.00 $15.00
B2923 $15.00 $10.00 $15.00 $15.00
B2924 $15.00 $5.00 $15.00 $15.00
B2925 $15.00 $5.00 $15.00 $15.00
B2926 $15.00 $4.00 $15.00 $20.00
B2927 $15.00 $10.00 $15.00 $15.00
B2928 $15.00 $5.00 $15.00 $15.00
B2929 $15.00 $10.00 $15.00 $15.00
B2930 $15.00 $8.00 $12.00 $15.00
B2931 $15.00 $10.00 $15.00 $15.00
B2932 $15.00 $10.00 $15.00 $15.00
B2933 $15.00 $10.00 $15.00 $15.00
B2934 $15.00 $5.00 $15.00 $15.00
B2935 $15.00 $10.00 $15.00 $15.00
B2936 $15.00 $5.00 $15.00 $15.00
B2937 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
92
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2938 $15.00 $8.00 $12.00 $15.00
B2939 $15.00 $5.00 $10.00 $10.00
B2940 $15.00 $10.00 $15.00 $15.00
B2941 $15.00 $10.00 $15.00 $15.00
B2942 $15.00 $10.00 $15.00 $15.00
B2943 $15.00 $10.00 $15.00 $15.00
B2944 $15.00 $5.00 $15.00 $15.00
B2945 $15.00 $5.00 $15.00 $15.00
B2946 $15.00 $10.00 $15.00 $18.00
B2947 $15.00 $5.00 $15.00 $15.00
B2948 $15.00 $10.00 $15.00 $15.00
B2949 $15.00 $5.00 $15.00 $15.00
B2950 $15.00 $8.00 $12.00 $15.00
B2951 $15.00 $5.00 $15.00 $15.00
B2952 $15.00 $5.00 $15.00 $15.00
B2953 $15.00 $5.00 $15.00 $15.00
B2954 $15.00 $10.00 $15.00 $15.00
B2955 $15.00 $5.00 $10.00 $10.00
B2956 $15.00 $10.00 $15.00 $15.00
B2957 $15.00 $10.00 $15.00 $15.00
B2958 $15.00 $8.00 $12.00 $15.00
B2959 $15.00 $8.00 $12.00 $15.00
B2960 $15.00 $8.00 $12.00 $15.00
B2961 $15.00 $5.00 $10.00 $10.00
B2962 $15.00 $10.00 $15.00 $15.00
B2963 $15.00 $10.00 $15.00 $15.00
B2964 $15.00 $10.00 $15.00 $15.00
B2965 $15.00 $8.00 $12.00 $15.00
B2966 $15.00 $10.00 $15.00 $15.00
B2967 $15.00 $10.00 $15.00 $15.00
B2968 $15.00 $10.00 $15.00 $15.00
B2969 $15.00 $10.00 $15.00 $15.00
B2970 $15.00 $8.00 $12.00 $15.00
B2971 $15.00 $5.00 $10.00 $10.00
B2972 $15.00 $10.00 $15.00 $15.00
B2973 $15.00 $15.00 $20.00 $20.00
B2974 $15.00 $5.00 $15.00 $15.00
B2975 $15.00 $5.00 $15.00 $15.00
B2976 $15.00 $5.00 $15.00 $15.00
B2977 $15.00 $5.00 $15.00 $15.00
B2978 $15.00 $5.00 $10.00 $12.00
B2979 $15.00 $10.00 $15.00 $18.00
B2980 $15.00 $10.00 $15.00 $15.00
B2981 $15.00 $8.00 $12.00 $15.00
B2982 $15.00 $10.00 $12.00 $15.00
B2983 $15.00 $5.00 $12.00 $18.00
B2984 $15.00 $10.00 $10.00 $10.00
B2985 $15.00 $10.00 $15.00 $15.00
B2986 $15.00 $10.00 $15.00 $15.00
B2987 $15.00 $10.00 $15.00 $15.00
B2988 $15.00 $10.00 $15.00 $15.00
B2989 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
93
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B2990 $15.00 $10.00 $15.00 $15.00
B2991 $15.00 $8.00 $12.00 $15.00
B2992 $15.00 $10.00 $12.00 $15.00
B2993 $15.00 $5.00 $8.00 $10.00
B2994 $15.00 $10.00 $18.00 $18.00
B2995 $15.00 $7.00 $15.00 $18.00
B2996 $15.00 $12.00 $15.00 $18.00
B2997 $15.00 $15.00 $15.00 $20.00
B2998 $15.00 $4.00 $15.00 $20.00
B2999 $15.00 $4.00 $15.00 $20.00
B3000 $15.00 $10.00 $15.00 $15.00
B3001 $15.00 $5.00 $15.00 $15.00
B3002 $15.00 $10.00 $15.00 $15.00
B3003 $15.00 $10.00 $15.00 $15.00
B3004 $15.00 $10.00 $15.00 $18.00
B3005 $15.00 $10.00 $18.00 $20.00
B3006 $15.00 $10.00 $18.00 $20.00
B3007 $15.00 $10.00 $15.00 $18.00
B3008 $15.00 $10.00 $15.00 $18.00
B3009 $15.00 $8.00 $12.00 $15.00
B3010 $15.00 $5.00 $8.00 $8.00
B3011 $15.00 $6.00 $10.00 $12.00
B3012 $15.00 $8.00 $12.00 $15.00
B3013 $15.00 $8.00 $12.00 $15.00
B3014 $15.00 $10.00 $15.00 $15.00
B3015 N/C NADA NADA NADA
B3016 $15.00 $4.00 $15.00 $20.00
B3017 $15.00 $12.00 $15.00 $18.00
B3018 $15.00 $12.00 $15.00 $18.00
B3019 $15.00 $8.00 $12.00 $15.00
B3020 $15.00 $10.00 $12.00 $15.00
B3021 $15.00 $8.00 $12.00 $15.00
B3022 $15.00 $8.00 $12.00 $15.00
B3023 $15.00 $10.00 $12.00 $15.00
B3024 $15.00 $8.00 $12.00 $15.00
B3025 $15.00 $12.00 $15.00 $18.00
B3026 $15.00 $12.00 $15.00 $18.00
B3027 $15.00 $8.00 $15.00 $15.00
B3028 $15.00 $8.00 $15.00 $15.00
B3029 $15.00 $10.00 $20.00 $20.00
B3030 $15.00 $10.00 $15.00 $18.00
B3031 $15.00 $8.00 $15.00 $18.00
B3032 $15.00 $8.00 $15.00 $18.00
B3033 $15.00 $4.00 $15.00 $20.00
B3034 $15.00 $5.00 $10.00 $10.00
B3035 $15.00 $5.00 $10.00 $10.00
B3036 $15.00 $15.00 $20.00 $20.00
B3037 $15.00 $15.00 $20.00 $20.00
B3038 $15.00 $10.00 $15.00 $15.00
B3039 $15.00 $5.00 $10.00 $10.00
B3040 $15.00 $5.00 $10.00 $10.00
B3041 $15.00 $8.00 $12.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
94
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3042 $15.00 $8.00 $12.00 $15.00
B3043 $15.00 $5.00 $10.00 $10.00
B3044 $15.00 $5.00 $10.00 $10.00
B3045 $15.00 $10.00 $15.00 $15.00
B3046 $15.00 $10.00 $15.00 $15.00
B3047 $15.00 $10.00 $15.00 $15.00
B3048 $15.00 $10.00 $15.00 $15.00
B3049 $15.00 $5.00 $10.00 $10.00
B3050 $15.00 $5.00 $15.00 $15.00
B3051 $15.00 $10.00 $15.00 $15.00
B3052 $15.00 $10.00 $15.00 $15.00
B3053 $15.00 $10.00 $12.00 $15.00
B3054 $15.00 $10.00 $15.00 $15.00
B3055 $15.00 $5.00 $15.00 $15.00
B3056 $15.00 $5.00 $15.00 $15.00
B3057 $15.00 $5.00 $15.00 $15.00
B3058 $15.00 $5.00 $10.00 $10.00
B3059 $15.00 $8.00 $12.00 $15.00
B3060 $15.00 $10.00 $15.00 $15.00
B3061 $15.00 $10.00 $15.00 $15.00
B3062 $15.00 $15.00 $15.00 $20.00
B3063 $15.00 $4.00 $7.00 $10.00
B3064 $15.00 $4.00 $7.00 $10.00
B3065 $15.00 $6.00 $12.00 $15.00
B3066 $15.00 $6.00 $12.00 $15.00
B3067 $15.00 $6.00 $12.00 $15.00
B3068 $15.00 $6.00 $12.00 $15.00
B3069 $15.00 $6.00 $10.00 $15.00
B3070 $15.00 $6.00 $10.00 $15.00
B3071 $15.00 $6.00 $10.00 $15.00
B3072 $15.00 $5.00 $10.00 $15.00
B3073 $15.00 $5.00 $10.00 $15.00
B3074 $15.00 $5.00 $15.00 $15.00
B3075 $15.00 $12.00 $15.00 $18.00
B3076 $15.00 $7.00 $12.00 $15.00
B3077 $15.00 $7.00 $12.00 $15.00
B3078 $15.00 $8.00 $10.00 $12.00
B3079 $15.00 $7.00 $12.00 $15.00
B3080 $15.00 $12.00 $17.00 $20.00
B3081 $15.00 $5.00 $10.00 $15.00
B3082 $15.00 $5.00 $7.00 $10.00
B3083 $15.00 $3.00 $7.00 $11.00
B3084 $15.00 $10.00 $15.00 $18.00
B3085 $15.00 $5.00 $10.00 $15.00
B3086 $15.00 $3.00 $4.00 $6.00
B3087 $15.00 $8.00 $12.00 $15.00
B3088 $15.00 $8.00 $13.00 $15.00
B3089 $15.00 $8.00 $13.00 $15.00
B3090 $15.00 $10.00 $15.00 $15.00
B3091 $15.00 $15.00 $15.00 $20.00
B3092 $15.00 $12.00 $15.00 $15.00
B3093 $15.00 $3.00 $7.00 $11.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
95
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3094 $15.00 $7.00 $7.00 $7.00
B3095 N/C $5.00 $10.00 $15.00
B3096 N/C $5.00 $10.00 $15.00
B3097 $15.00 $5.00 $10.00 $15.00
B3098 N/C $5.00 $10.00 $15.00
B3099 $10.00 $10.00 $12.00 $15.00
B3100 $12.00 $12.00 $15.00 $15.00
B3101 $15.00 $5.00 $10.00 $15.00
B3102 $15.00 $5.00 $10.00 $15.00
B3103 $10.00 $10.00 $10.00 $10.00
B3104 $15.00 $5.00 $15.00 $15.00
B3105 $15.00 $8.00 $15.00 $15.00
B3106 $15.00 $10.00 $15.00 $15.00
B3107 $15.00 $7.00 $12.00 $15.00
B3108 $15.00 $5.00 $7.00 $12.00
B3109 $15.00 $5.00 $10.00 $12.00
B3110 $15.00 $7.00 $15.00 $15.00
B3111 $15.00 $10.00 $20.00 $20.00
B3112 $15.00 $10.00 $20.00 $20.00
B3113 $15.00 $3.00 $10.00 $15.00
B3114 $15.00 $10.00 $12.00 $15.00
B3115 $15.00 $7.00 $10.00 $12.00
B3116 $15.00 $10.00 $15.00 $15.00
B3117 $15.00 $5.00 $10.00 $10.00
B3118 $10.00 $10.00 $10.00 $10.00
B3119 $15.00 $5.00 $10.00 $10.00
B3120 $15.00 $10.00 $15.00 $15.00
B3121 N/C $5.00 $15.00 $15.00
B3122 $15.00 $8.00 $10.00 $15.00
B3123 $15.00 $3.00 $7.00 $11.00
B3124 $15.00 $3.00 $7.00 $11.00
B3125 $15.00 $15.00 $20.00 $25.00
B3126 $15.00 $8.00 $12.00 $15.00
B3127 $15.00 $12.00 $15.00 $18.00
B3128 $15.00 $10.00 $15.00 $15.00
B3129 $15.00 $5.00 $10.00 $12.00
B3130 $15.00 $5.00 $10.00 $15.00
B3131 $15.00 $10.00 $15.00 $15.00
B3132 $15.00 $10.00 $15.00 $15.00
B3133 $15.00 $5.00 $10.00 $12.00
B3134 $15.00 $6.50 $12.00 $12.00
B3135 $15.00 $6.50 $12.00 $12.00
B3136 N/C $8.00 $10.00 $12.00
B3137 $15.00 $5.00 $7.00 $10.00
B3138 $15.00 $10.00 $12.00 $15.00
B3139 $20.00 $6.00 $6.00 $6.00
B3140 $20.00 $6.00 $6.00 $6.00
B3141 N/C $2.00 $3.00 $5.00
B3142 N/C $2.00 $3.00 $5.00
B3143 NADA $2.00 $3.00 $5.00
B3144 $15.00 $10.00 $15.00 $15.00
B3145 N/C $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
96
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3146 $15.00 $10.00 $10.00 $10.00
B3147 $15.00 $10.00 $15.00 $15.00
B3148 $15.00 $7.00 $10.00 $12.00
B3149 $15.00 $8.00 $10.00 $12.00
B3150 $15.00 $10.00 $12.00 $15.00
B3151 $15.00 $10.00 $12.00 $15.00
B3152 $15.00 $7.00 $15.00 $15.00
B3153 $15.00 $7.00 $15.00 $20.00
B3154 $15.00 $5.00 $7.00 $10.00
B3155 $15.00 $15.00 $18.00 $20.00
B3156 $15.00 $15.00 $20.00 $25.00
B3157 $15.00 $10.00 $15.00 $18.00
B3158 $15.00 $10.00 $15.00 $15.00
B3159 $15.00 $7.00 $15.00 $15.00
B3160 $15.00 $10.00 $15.00 $15.00
B3161 $15.00 $5.00 $8.00 $12.00
B3162 $15.00 $5.00 $10.00 $10.00
B3163 $15.00 $10.00 $15.00 $15.00
B3164 $15.00 $10.00 $15.00 $15.00
B3165 $15.00 $10.00 $15.00 $15.00
B3166 $15.00 $5.00 $10.00 $10.00
B3167 $15.00 $10.00 $15.00 $15.00
B3168 $15.00 $5.00 $10.00 $10.00
B3169 $15.00 $10.00 $15.00 $15.00
B3170 $15.00 $10.00 $15.00 $15.00
B3171 $15.00 $5.00 $10.00 $10.00
B3172 $15.00 $10.00 $15.00 $15.00
B3173 $15.00 $10.00 $15.00 $15.00
B3174 $15.00 $8.00 $12.00 $15.00
B3175 $15.00 $5.00 $10.00 $10.00
B3176 $15.00 $10.00 $15.00 $15.00
B3177 $15.00 $5.00 $10.00 $10.00
B3178 $15.00 $5.00 $10.00 $10.00
B3179 $15.00 $8.00 $12.00 $15.00
B3180 $15.00 $5.00 $10.00 $10.00
B3181 $15.00 $10.00 $15.00 $15.00
B3182 $15.00 $5.00 $10.00 $10.00
B3183 $15.00 $5.00 $10.00 $10.00
B3184 $15.00 $8.00 $12.00 $15.00
B3185 $15.00 $5.00 $10.00 $10.00
B3186 $15.00 $8.00 $12.00 $15.00
B3187 $15.00 $5.00 $10.00 $10.00
B3188 $15.00 $5.00 $10.00 $10.00
B3189 $15.00 $8.00 $12.00 $15.00
B3190 $15.00 $8.00 $12.00 $15.00
B3191 $15.00 $8.00 $12.00 $15.00
B3192 $15.00 $5.00 $10.00 $10.00
B3193 $15.00 $5.00 $15.00 $15.00
B3194 $15.00 $10.00 $15.00 $15.00
B3195 $15.00 $5.00 $10.00 $10.00
B3196 $15.00 $10.00 $15.00 $15.00
B3197 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
97
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3198 $15.00 $5.00 $10.00 $10.00
B3199 $15.00 $8.00 $12.00 $15.00
B3200 $15.00 $8.00 $13.00 $15.00
B3201 $15.00 $8.00 $13.00 $15.00
B3202 $15.00 $10.00 $15.00 $15.00
B3203 $15.00 $5.00 $7.00 $10.00
B3204 $15.00 $6.00 $12.00 $15.00
B3205 $15.00 $10.00 $18.00 $18.00
B3206 $15.00 $10.00 $15.00 $15.00
B3207 $15.00 $6.00 $10.00 $12.00
B3208 $15.00 $6.00 $12.00 $15.00
B3209 $15.00 $5.00 $10.00 $10.00
B3210 $15.00 $10.00 $20.00 $20.00
B3211 $15.00 $10.00 $15.00 $15.00
B3212 $15.00 $10.00 $15.00 $15.00
B3213 $15.00 $8.00 $12.00 $15.00
B3214 $15.00 $6.00 $12.00 $15.00
B3215 $15.00 $4.00 $15.00 $20.00
B3216 $15.00 $18.00 $22.00 $25.00
B3217 $15.00 $10.00 $10.00 $10.00
B3218 $15.00 $4.00 $15.00 $20.00
B3219 $15.00 $8.00 $12.00 $15.00
B3220 $15.00 $8.00 $12.00 $15.00
B3221 $15.00 $4.00 $15.00 $20.00
B3222 $15.00 $10.00 $20.00 $20.00
B3223 $15.00 $5.00 $15.00 $15.00
B3224 $15.00 $5.00 $10.00 $10.00
B3225 $15.00 $5.00 $10.00 $10.00
B3226 $15.00 $5.00 $10.00 $10.00
B3227 $15.00 $8.00 $12.00 $15.00
B3228 $15.00 $3.00 $3.00 $3.00
B3229 $15.00 $8.00 $12.00 $15.00
B3230 $15.00 $10.00 $12.00 $15.00
B3231 $15.00 $10.00 $12.00 $15.00
B3232 $15.00 $10.00 $12.00 $15.00
B3233 $15.00 $15.00 $18.00 $18.00
B3234 $15.00 $10.00 $12.00 $15.00
B3235 $15.00 $15.00 $20.00 $20.00
B3236 $15.00 $15.00 $20.00 $20.00
B3237 $15.00 $10.00 $15.00 $18.00
B3238 $15.00 $10.00 $15.00 $15.00
B3239 $15.00 $10.00 $15.00 $15.00
B3240 $15.00 $10.00 $15.00 $15.00
B3241 $15.00 $5.00 $10.00 $10.00
B3242 $15.00 $12.00 $15.00 $18.00
B3243 $15.00 $15.00 $20.00 $20.00
B3244 $15.00 $8.00 $12.00 $15.00
B3245 $15.00 $12.00 $15.00 $18.00
B3246 $15.00 $7.00 $15.00 $15.00
B3247 $15.00 $7.00 $15.00 $15.00
B3248 $15.00 $10.00 $15.00 $18.00
B3249 $20.00 $6.00 $6.00 $6.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3250 $15.00 $10.00 $12.00 $15.00
B3251 $15.00 $10.00 $12.00 $15.00
B3252 $15.00 $7.00 $15.00 $15.00
B3253 $15.00 $7.00 $15.00 $15.00
B3254 $15.00 $10.00 $15.00 $15.00
B3255 $15.00 $10.00 $15.00 $15.00
B3256 $15.00 $8.00 $12.00 $15.00
B3257 $15.00 $10.00 $12.00 $15.00
B3258 $15.00 $5.00 $15.00 $15.00
B3259 $15.00 $5.00 $15.00 $15.00
B3260 $15.00 $10.00 $15.00 $15.00
B3261 $15.00 $10.00 $15.00 $15.00
B3262 $15.00 $12.00 $15.00 $18.00
B3263 $15.00 $12.00 $15.00 $18.00
B3264 $15.00 $10.00 $15.00 $15.00
B3265 $15.00 $10.00 $15.00 $15.00
B3266 $15.00 $10.00 $12.00 $15.00
B3267 $15.00 $10.00 $12.00 $15.00
B3268 $20.00 $6.00 $6.00 $6.00
B3269 $15.00 $10.00 $15.00 $15.00
B3270 $15.00 $10.00 $15.00 $18.00
B3271 $15.00 $8.00 $12.00 $15.00
B3272 $15.00 $5.00 $15.00 $15.00
B3273 $15.00 $5.00 $15.00 $15.00
B3274 $15.00 $8.00 $18.00 $18.00
B3275 $15.00 $10.00 $15.00 $15.00
B3276 $15.00 $8.00 $10.00 $12.00
B3277 $15.00 $5.00 $15.00 $15.00
B3278 $15.00 $10.00 $15.00 $15.00
B3279 $15.00 $10.00 $15.00 $15.00
B3280 $15.00 $10.00 $15.00 $15.00
B3281 $15.00 $10.00 $15.00 $15.00
B3282 $15.00 $5.00 $10.00 $10.00
B3283 $15.00 $5.00 $10.00 $10.00
B3284 $15.00 $10.00 $15.00 $15.00
B3285 $15.00 $5.00 $10.00 $10.00
B3286 $15.00 $15.00 $20.00 $20.00
B3287 $15.00 $5.00 $15.00 $15.00
B3288 $15.00 $5.00 $15.00 $15.00
B3289 $15.00 $5.00 $15.00 $15.00
B3290 $15.00 $8.00 $12.00 $15.00
B3291 $15.00 $4.00 $15.00 $20.00
B3292 $15.00 $8.00 $12.00 $15.00
B3293 $15.00 $5.00 $10.00 $10.00
B3294 $15.00 $5.00 $10.00 $10.00
B3295 $15.00 $10.00 $15.00 $15.00
B3296 $15.00 $10.00 $12.00 $15.00
B3297 $15.00 $5.00 $10.00 $10.00
B3298 NADA NADA NADA NADA
B3299 $15.00 $5.00 $10.00 $10.00
B3300 $15.00 $5.00 $10.00 $10.00
B3301 $15.00 $5.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3302 $15.00 $8.00 $12.00 $15.00
B3303 $15.00 $8.00 $12.00 $15.00
B3304 $15.00 $5.00 $10.00 $10.00
B3305 $15.00 $10.00 $15.00 $15.00
B3306 $15.00 $5.00 $10.00 $10.00
B3307 $15.00 $8.00 $12.00 $15.00
B3308 $15.00 $10.00 $12.00 $15.00
B3309 $15.00 $5.00 $15.00 $15.00
B3310 $15.00 $4.00 $7.00 $10.00
B3311 $15.00 $5.00 $15.00 $15.00
B3312 $15.00 $5.00 $15.00 $15.00
B3313 $15.00 $8.00 $12.00 $15.00
B3314 $15.00 $8.00 $15.00 $18.00
B3315 $15.00 $8.00 $15.00 $18.00
B3316 $15.00 $8.00 $12.00 $15.00
B3317 $15.00 $5.00 $10.00 $10.00
B3318 $15.00 $5.00 $10.00 $10.00
B3319 $15.00 $10.00 $15.00 $15.00
B3320 $15.00 $5.00 $15.00 $15.00
B3321 $15.00 $10.00 $15.00 $20.00
B3322 $15.00 $12.00 $18.00 $22.00
B3323 $15.00 $4.00 $15.00 $20.00
B3324 $15.00 $10.00 $15.00 $15.00
B3325 $15.00 $5.00 $10.00 $10.00
B3326 $15.00 $5.00 $7.00 $10.00
B3327 N/C $5.00 $15.00 $20.00
B3328 $15.00 $10.00 $15.00 $15.00
B3329 $15.00 $5.00 $15.00 $15.00
B3330 $15.00 $5.00 $15.00 $15.00
B3331 $15.00 $5.00 $10.00 $10.00
B3332 $15.00 $10.00 $15.00 $15.00
B3333 $15.00 $5.00 $10.00 $10.00
B3334 $15.00 $5.00 $15.00 $15.00
B3335 $15.00 $10.00 $15.00 $15.00
B3336 $15.00 $10.00 $15.00 $15.00
B3337 $15.00 $5.00 $10.00 $10.00
B3338 $15.00 $5.00 $15.00 $15.00
B3339 $15.00 $5.00 $10.00 $10.00
B3340 $15.00 $5.00 $10.00 $10.00
B3341 $15.00 $5.00 $15.00 $15.00
B3342 $15.00 $5.00 $10.00 $10.00
B3343 $15.00 $5.00 $15.00 $15.00
B3344 $15.00 $10.00 $15.00 $15.00
B3345 $15.00 $10.00 $15.00 $15.00
B3346 $15.00 $10.00 $15.00 $15.00
B3347 $15.00 $12.00 $15.00 $18.00
B3348 $15.00 $10.00 $15.00 $15.00
B3349 $15.00 $10.00 $15.00 $15.00
B3350 $15.00 $10.00 $15.00 $15.00
B3351 $15.00 $7.00 $10.00 $15.00
B3352 $15.00 $10.00 $15.00 $15.00
B3353 $15.00 $5.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3354 $15.00 $5.00 $10.00 $10.00
B3355 $15.00 $8.00 $12.00 $15.00
B3356 $15.00 $5.00 $15.00 $15.00
B3357 $15.00 $10.00 $15.00 $18.00
B3358 $15.00 $10.00 $15.00 $18.00
B3359 $15.00 $10.00 $15.00 $15.00
B3360 $15.00 $10.00 $15.00 $18.00
B3361 $15.00 $6.00 $8.00 $8.00
B3362 $15.00 $10.00 $15.00 $15.00
B3363 $15.00 $10.00 $15.00 $15.00
B3364 $15.00 $10.00 $15.00 $18.00
B3365 NADA $5.00 $15.00 $20.00
B3366 NADA $5.00 $15.00 $20.00
B3367 $15.00 $10.00 $15.00 $15.00
B3368 $15.00 $8.00 $12.00 $15.00
B3369 $15.00 $8.00 $12.00 $15.00
B3370 $15.00 $3.00 $7.00 $11.00
B3371 $15.00 $10.00 $15.00 $15.00
B3372 $15.00 $8.00 $12.00 $15.00
B3373 $15.00 $12.00 $15.00 $18.00
B3374 $15.00 $10.00 $15.00 $15.00
B3375 $15.00 $5.00 $18.00 $20.00
B3376 $15.00 $5.00 $15.00 $15.00
B3377 $15.00 $5.00 $10.00 $10.00
B3378 $15.00 $5.00 $20.00 $20.00
B3379 $15.00 $5.00 $15.00 $15.00
B3380 $15.00 $5.00 $15.00 $15.00
B3381 $15.00 $10.00 $15.00 $20.00
B3382 $15.00 $5.00 $10.00 $10.00
B3383 $15.00 $5.00 $10.00 $10.00
B3384 $15.00 $5.00 $10.00 $10.00
B3385 $15.00 $10.00 $15.00 $15.00
B3386 $15.00 $7.00 $10.00 $15.00
B3387 $15.00 $5.00 $10.00 $12.00
B3388 $15.00 $10.00 $12.00 $15.00
B3389 $15.00 $5.00 $10.00 $12.00
B3390 $15.00 $5.00 $15.00 $15.00
B3391 $15.00 $10.00 $15.00 $15.00
B3392 $15.00 $10.00 $15.00 $20.00
B3393 $15.00 $5.00 $10.00 $10.00
B3394 $15.00 $10.00 $15.00 $15.00
B3395 $15.00 $5.00 $10.00 $10.00
B3396 $15.00 $5.00 $15.00 $15.00
B3397 $15.00 $5.00 $15.00 $15.00
B3398 $15.00 $5.00 $15.00 $15.00
B3399 $15.00 $10.00 $18.00 $18.00
B3400 $15.00 $5.00 $10.00 $10.00
B3401 $15.00 $5.00 $10.00 $12.00
B3402 $15.00 $10.00 $18.00 $20.00
B3403 $15.00 $10.00 $18.00 $18.00
B3404 $15.00 $10.00 $15.00 $15.00
B3405 $15.00 $5.00 $10.00 $10.00
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3406 NADA $10.00 $15.00 $20.00
B3407 $15.00 $10.00 $15.00 $18.00
B3408 $15.00 $10.00 $15.00 $15.00
B3409 $15.00 $10.00 $18.00 $20.00
B3410 $15.00 $5.00 $15.00 $15.00
B3411 NADA $5.00 $10.00 $15.00
B3412 NADA $5.00 $8.00 $10.00
B3413 NADA $5.00 $8.00 $10.00
B3414 $15.00 $5.00 $10.00 $10.00
B3415 $15.00 $5.00 $15.00 $15.00
B3416 $15.00 $10.00 $20.00 $20.00
B3417 $15.00 $8.00 $12.00 $15.00
B3418 $15.00 $10.00 $15.00 $18.00
B3419 $15.00 $10.00 $15.00 $18.00
B3420 $15.00 $10.00 $15.00 $15.00
B3421 $15.00 $9.00 $13.00 $15.00
B3422 $15.00 $10.00 $15.00 $15.00
B3423 $15.00 $10.00 $15.00 $15.00
B3424 $15.00 $10.00 $15.00 $15.00
B3425 $15.00 $5.00 $10.00 $15.00
B3426 $15.00 $5.00 $10.00 $10.00
B3427 $15.00 $12.00 $15.00 $18.00
B3428 $15.00 $12.00 $15.00 $18.00
B3429 $15.00 $12.00 $15.00 $18.00
B3430 $15.00 $5.00 $10.00 $10.00
B3431 $15.00 $12.00 $15.00 $18.00
B3432 $15.00 $5.00 $15.00 $15.00
B3433 $15.00 $10.00 $18.00 $20.00
B3434 $15.00 $15.00 $18.00 $20.00
B3435 $15.00 $10.00 $15.00 $18.00
B3436 $15.00 $10.00 $18.00 $20.00
B3437 $15.00 $12.00 $12.00 $12.00
B3438 $15.00 $12.00 $12.00 $12.00
B3439 $15.00 $10.00 $15.00 $15.00
B3440 $15.00 $10.00 $15.00 $15.00
B3441 $15.00 $10.00 $20.00 $20.00
B3442 NADA $10.00 $15.00 $20.00
B3443 $15.00 $10.00 $20.00 $20.00
B3444 $15.00 $10.00 $20.00 $20.00
B3445 $15.00 $10.00 $15.00 $15.00
B3446 $15.00 $5.00 $15.00 $15.00
B3447 $15.00 $8.00 $12.00 $15.00
B3448 $15.00 $8.00 $12.00 $15.00
B3449 $15.00 $5.00 $15.00 $15.00
B3450 NADA $5.00 $10.00 $15.00
B3451 NADA $10.00 $15.00 $20.00
B3452 $15.00 $8.00 $12.00 $15.00
B3453 $15.00 $4.00 $15.00 $20.00
B3454 NADA $5.00 $10.00 $15.00
B3455 NADA $5.00 $10.00 $15.00
B3456 $15.00 $5.00 $15.00 $15.00
B3457 $15.00 $15.00 $15.00 $18.00
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3458 NADA $10.00 $15.00 $20.00
B3459 NADA $5.00 $10.00 $15.00
B3460 $15.00 $8.00 $12.00 $15.00
B3461 $15.00 $8.00 $12.00 $15.00
B3462 $15.00 $10.00 $15.00 $15.00
B3463 NADA $0.00 $0.00 $0.00
B3464 $15.00 $8.00 $12.00 $15.00
B3465 $15.00 $5.00 $10.00 $15.00
B3466 $15.00 $12.00 $18.00 $20.00
B3467 $15.00 $10.00 $15.00 $20.00
B3468 $15.00 $10.00 $15.00 $15.00
B3469 NADA $10.00 $15.00 $20.00
B3470 $15.00 $5.00 $10.00 $10.00
B3471 $15.00 $15.00 $15.00 $18.00
B3472 $15.00 $4.00 $15.00 $20.00
B3473 $15.00 $10.00 $12.00 $15.00
B3474 $15.00 $12.00 $18.00 $20.00
B3475 $15.00 $10.00 $15.00 $15.00
B3476 $15.00 $10.00 $12.00 $15.00
B3477 $15.00 $5.00 $10.00 $10.00
B3478 $15.00 $8.00 $15.00 $15.00
B3479 $15.00 $7.00 $12.00 $15.00
B3480 $15.00 $10.00 $15.00 $15.00
B3481 $15.00 $5.00 $15.00 $15.00
B3482 $15.00 $10.00 $20.00 $25.00
B3483 $15.00 $10.00 $20.00 $25.00
B3484 $15.00 $10.00 $20.00 $25.00
B3485 $15.00 $10.00 $20.00 $25.00
B3486 $15.00 $10.00 $20.00 $25.00
B3487 $15.00 $10.00 $20.00 $25.00
B3488 $15.00 $10.00 $15.00 $15.00
B3489 $15.00 $10.00 $15.00 $15.00
B3490 $15.00 $10.00 $15.00 $20.00
B3491 $15.00 $5.00 $15.00 $15.00
B3492 $15.00 $5.00 $15.00 $15.00
B3493 $15.00 $6.00 $10.00 $15.00
B3494 $15.00 $5.00 $15.00 $15.00
B3495 $15.00 $10.00 $15.00 $15.00
B3496 NADA $5.00 $10.00 $15.00
B3497 $15.00 $5.00 $15.00 $15.00
B3498 $15.00 $6.00 $10.00 $15.00
B3499 $15.00 $12.00 $15.00 $18.00
B3500 $15.00 $4.00 $15.00 $18.00
B3501 $15.00 $10.00 $15.00 $15.00
B3502 $15.00 $5.00 $15.00 $15.00
B3503 $15.00 $5.00 $10.00 $10.00
B3504 $15.00 $10.00 $15.00 $15.00
B3505 NADA $5.00 $10.00 $15.00
B3506 NADA $10.00 $15.00 $20.00
B3507 $15.00 $10.00 $15.00 $15.00
B3508 $15.00 $10.00 $20.00 $20.00
B3509 $15.00 $4.00 $15.00 $20.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3510 $15.00 $10.00 $15.00 $15.00
B3511 $15.00 $10.00 $15.00 $15.00
B3512 $15.00 $8.00 $12.00 $15.00
B3513 $15.00 $5.00 $15.00 $15.00
B3514 NADA $5.00 $10.00 $15.00
B3515 $15.00 $10.00 $20.00 $20.00
B3516 $15.00 $5.00 $10.00 $10.00
B3517 NADA $5.00 $10.00 $15.00
B3518 NADA $5.00 $10.00 $15.00
B3519 NADA $5.00 $10.00 $12.00
B3520 NADA $5.00 $10.00 $12.00
B3521 $15.00 $5.00 $15.00 $15.00
B3522 $15.00 $10.00 $12.00 $15.00
B3523 $15.00 $5.00 $7.00 $10.00
B3524 $15.00 $5.00 $15.00 $15.00
B3525 $15.00 $5.00 $15.00 $15.00
B3526 $15.00 $8.00 $10.00 $12.00
B3527 $15.00 $5.00 $15.00 $15.00
B3528 $15.00 $8.00 $12.00 $15.00
B3529 $15.00 $4.00 $15.00 $20.00
B3530 $15.00 $10.00 $15.00 $15.00
B3531 $15.00 $8.00 $12.00 $15.00
B3532 $15.00 $7.00 $18.00 $18.00
B3533 $15.00 $5.00 $12.00 $15.00
B3534 $15.00 $10.00 $15.00 $18.00
B3535 $15.00 $10.00 $15.00 $18.00
B3536 $15.00 $5.00 $15.00 $15.00
B3537 $15.00 $5.00 $12.00 $15.00
B3538 $15.00 $5.00 $15.00 $15.00
B3539 $10.00 $10.00 $10.00 $10.00
B3540 $10.00 $10.00 $10.00 $10.00
B3541 $10.00 $10.00 $10.00 $10.00
B3542 $15.00 $7.00 $7.00 $7.00
B3543 $15.00 $10.00 $20.00 $20.00
B3544 $15.00 $10.00 $10.00 $10.00
B3545 $15.00 $7.00 $7.00 $7.00
B3546 $15.00 $8.00 $12.00 $12.00
B3547 $15.00 $10.00 $10.00 $10.00
B3548 NADA $8.00 $15.00 $20.00
B3549 $15.00 $7.00 $10.00 $15.00
B3550 $15.00 $7.00 $10.00 $15.00
B3551 $15.00 $8.00 $10.00 $12.00
B3552 $15.00 $8.00 $10.00 $12.00
B3553 $15.00 $8.00 $10.00 $12.00
B3554 $15.00 $8.00 $10.00 $12.00
B3555 $15.00 $8.00 $10.00 $12.00
B3556 $15.00 $10.00 $15.00 $20.00
B3557 $15.00 $10.00 $15.00 $15.00
B3558 $15.00 $15.00 $20.00 $20.00
B3559 $15.00 $10.00 $15.00 $20.00
B3560 $15.00 $10.00 $10.00 $20.00
B3561 $15.00 $10.00 $10.00 $20.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3562 $15.00 $10.00 $15.00 $15.00
B3563 $15.00 $10.00 $15.00 $15.00
B3564 $15.00 $8.00 $12.00 $15.00
B3565 $15.00 $10.00 $15.00 $15.00
B3566 $15.00 $10.00 $15.00 $15.00
B3567 $15.00 $5.00 $10.00 $10.00
B3568 $15.00 $5.00 $15.00 $15.00
B3569 $15.00 $5.00 $10.00 $10.00
B3570 $15.00 $5.00 $12.00 $15.00
B3571 $15.00 $5.00 $15.00 $18.00
B3572 $15.00 $5.00 $15.00 $18.00
B3573 $15.00 $18.00 $21.00 $25.00
B3574 $15.00 $10.00 $15.00 $15.00
B3575 $15.00 $8.00 $10.00 $12.00
B3576 $15.00 $8.00 $10.00 $12.00
B3577 $15.00 $8.00 $10.00 $12.00
B3578 $15.00 $12.00 $15.00 $18.00
B3579 $15.00 $10.00 $10.00 $10.00
B3580 $15.00 $8.00 $12.00 $12.00
B3581 $15.00 $5.00 $5.00 $5.00
B3582 $15.00 $10.00 $10.00 $10.00
B3583 $15.00 $7.00 $7.00 $7.00
B3584 $10.00 $10.00 $10.00 $10.00
B3585 $10.00 $10.00 $10.00 $10.00
B3586 $10.00 $10.00 $10.00 $10.00
B3587 NADA $5.00 $15.00 $15.00
B3588 $15.00 $6.00 $10.00 $12.00
B3589 $15.00 $8.00 $12.00 $15.00
B3590 $15.00 $10.00 $12.00 $15.00
B3591 $15.00 $10.00 $15.00 $15.00
B3592 $15.00 $5.00 $10.00 $10.00
B3593 $15.00 $10.00 $12.00 $15.00
B3594 $15.00 $3.00 $7.00 $9.00
B3595 $15.00 $8.00 $12.00 $15.00
B3596 $15.00 $6.00 $10.00 $12.00
B3597 $15.00 $10.00 $18.00 $20.00
B3598 $15.00 $10.00 $15.00 $15.00
B3599 $15.00 $5.00 $10.00 $10.00
B3600 $15.00 $5.00 $10.00 $10.00
B3601 $15.00 $5.00 $10.00 $10.00
B3602 $15.00 $5.00 $10.00 $10.00
B3603 $15.00 $10.00 $15.00 $15.00
B3604 $15.00 $7.00 $12.00 $12.00
B3605 $15.00 $18.00 $21.00 $25.00
B3606 $15.00 $5.00 $10.00 $10.00
B3607 $15.00 $8.00 $10.00 $15.00
B3609 $15.00 $5.00 $10.00 $10.00
B3610 $15.00 $10.00 $15.00 $18.00
B3611 $15.00 $8.00 $12.00 $15.00
B3612 $15.00 $5.00 $15.00 $15.00
B3613 $15.00 $5.00 $15.00 $15.00
B3614 $15.00 $5.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3615 $15.00 $8.00 $12.00 $15.00
B3616 $15.00 $8.00 $15.00 $18.00
B3617 $15.00 $5.00 $15.00 $15.00
B3618 $15.00 $8.00 $12.00 $18.00
B3619 $15.00 $5.00 $15.00 $15.00
B3620 $15.00 $10.00 $15.00 $15.00
B3621 $15.00 $3.00 $6.00 $8.00
B3622 $15.00 $10.00 $12.00 $12.00
B3623 $15.00 $10.00 $15.00 $15.00
B3624 $15.00 $5.00 $15.00 $15.00
B3625 $15.00 $5.00 $15.00 $15.00
B3626 $15.00 $5.00 $15.00 $15.00
B3627 $15.00 $10.00 $15.00 $15.00
B3628 $15.00 $5.00 $15.00 $15.00
B3629 $15.00 $10.00 $15.00 $15.00
B3630 $15.00 $10.00 $15.00 $15.00
B3631 $15.00 $10.00 $15.00 $18.00
B3632 $15.00 $8.00 $12.00 $15.00
B3633 $15.00 $10.00 $15.00 $18.00
B3634 $15.00 $8.00 $12.00 $15.00
B3635 $15.00 $5.00 $15.00 $15.00
B3636 $15.00 $5.00 $10.00 $10.00
B3637 $15.00 $6.00 $8.00 $8.00
B3638 $15.00 $10.00 $15.00 $15.00
B3639 $15.00 $5.00 $15.00 $15.00
B3640 $15.00 $5.00 $15.00 $15.00
B3641 $15.00 $10.00 $15.00 $15.00
B3642 $15.00 $5.00 $15.00 $15.00
B3643 $15.00 $10.00 $15.00 $15.00
B3644 $15.00 $5.00 $10.00 $10.00
B3645 $15.00 $5.00 $10.00 $10.00
B3646 $15.00 $10.00 $15.00 $15.00
B3647 $15.00 $10.00 $15.00 $15.00
B3648 $15.00 $10.00 $15.00 $15.00
B3649 $15.00 $5.00 $8.00 $10.00
B3650 $15.00 $10.00 $20.00 $20.00
B3651 $15.00 $10.00 $15.00 $15.00
B3652 $15.00 $10.00 $15.00 $15.00
B3653 $15.00 $10.00 $15.00 $15.00
B3654 $15.00 $5.00 $10.00 $10.00
B3655 $15.00 $10.00 $15.00 $15.00
B3656 $15.00 $8.00 $12.00 $15.00
B3657 $15.00 $5.00 $10.00 $10.00
B3658 $15.00 $10.00 $15.00 $15.00
B3659 $15.00 $10.00 $15.00 $15.00
B3660 $15.00 $10.00 $15.00 $15.00
B3661 $15.00 $5.00 $10.00 $10.00
B3662 $15.00 $5.00 $10.00 $10.00
B3663 $15.00 $5.00 $10.00 $10.00
B3664 $15.00 $5.00 $10.00 $10.00
B3665 $15.00 $5.00 $15.00 $15.00
B3666 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3667 $15.00 $8.00 $15.00 $18.00
B3668 $15.00 $10.00 $15.00 $20.00
B3669 $15.00 $10.00 $15.00 $20.00
B3670 $15.00 $10.00 $15.00 $20.00
B3671 $15.00 $5.00 $15.00 $15.00
B3672 NADA $8.00 $12.00 $15.00
B3673 $15.00 $5.00 $10.00 $10.00
B3674 $15.00 $10.00 $10.00 $10.00
B3675 $15.00 $7.00 $7.00 $7.00
B3676 $15.00 $10.00 $15.00 $15.00
B3677 $15.00 $10.00 $15.00 $15.00
B3678 $15.00 $10.00 $12.00 $15.00
B3679 $15.00 $5.00 $10.00 $10.00
B3680 $15.00 $10.00 $15.00 $15.00
B3681 $15.00 $10.00 $15.00 $15.00
B3682 $15.00 $5.00 $15.00 $15.00
B3683 NADA $10.00 $18.00 $20.00
B3684 $15.00 $4.00 $15.00 $20.00
B3685 $15.00 $10.00 $15.00 $15.00
B3686 $15.00 $5.00 $15.00 $15.00
B3687 $15.00 $10.00 $20.00 $20.00
B3688 $15.00 $10.00 $20.00 $20.00
B3689 $15.00 $8.00 $15.00 $15.00
B3690 $15.00 $5.00 $10.00 $10.00
B3691 $15.00 $10.00 $15.00 $15.00
B3692 $15.00 $10.00 $10.00 $10.00
B3693 $15.00 $8.00 $12.00 $15.00
B3694 $15.00 $5.00 $15.00 $15.00
B3695 $15.00 $10.00 $15.00 $15.00
B3696 $15.00 $10.00 $15.00 $15.00
B3697 $15.00 $10.00 $15.00 $15.00
B3698 $15.00 $10.00 $15.00 $15.00
B3699 $15.00 $5.00 $10.00 $10.00
B3700 $15.00 $5.00 $10.00 $10.00
B3701 $15.00 $8.00 $10.00 $12.00
B3702 $15.00 $8.00 $10.00 $12.00
B3703 $15.00 $10.00 $15.00 $15.00
B3704 $15.00 $10.00 $15.00 $15.00
B3705 $15.00 $10.00 $15.00 $15.00
B3706 $15.00 $5.00 $15.00 $15.00
B3707 $15.00 $5.00 $15.00 $15.00
B3708 $15.00 $7.00 $12.00 $12.00
B3709 $15.00 $5.00 $15.00 $15.00
B3710 $15.00 $5.00 $10.00 $12.00
B3711 $15.00 $5.00 $15.00 $15.00
B3712 $15.00 $10.00 $15.00 $15.00
B3713 $15.00 $10.00 $15.00 $15.00
B3714 $15.00 $12.00 $15.00 $18.00
B3715 $15.00 $10.00 $15.00 $18.00
B3716 $15.00 $10.00 $15.00 $15.00
B3717 $15.00 $10.00 $15.00 $15.00
B3718 $15.00 $8.00 $12.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3719 $15.00 $10.00 $15.00 $15.00
B3720 $15.00 $10.00 $15.00 $15.00
B3721 $15.00 $8.00 $12.00 $15.00
B3722 $15.00 $15.00 $20.00 $20.00
B3723 $15.00 $10.00 $15.00 $15.00
B3724 $15.00 $18.00 $22.00 $25.00
B3725 $15.00 $15.00 $20.00 $20.00
B3726 $15.00 $5.00 $18.00 $18.00
B3727 $15.00 $8.00 $12.00 $15.00
B3728 $15.00 $8.00 $12.00 $15.00
B3729 $15.00 $5.00 $15.00 $15.00
B3730 $15.00 $10.00 $15.00 $15.00
B3731 $15.00 $5.00 $15.00 $15.00
B3732 $15.00 $10.00 $15.00 $15.00
B3733 NADA $15.00 $15.00 $15.00
B3734 $15.00 $10.00 $15.00 $15.00
B3735 $15.00 $10.00 $15.00 $15.00
B3736 $15.00 $8.00 $12.00 $15.00
B3737 $15.00 $7.00 $12.00 $15.00
B3738 $15.00 $8.00 $12.00 $15.00
B3739 $15.00 $8.00 $12.00 $15.00
B3740 $15.00 $8.00 $12.00 $15.00
B3741 $15.00 $8.00 $12.00 $15.00
B3742 $15.00 $10.00 $15.00 $15.00
B3743 $15.00 $5.00 $15.00 $15.00
B3744 $15.00 $4.00 $15.00 $20.00
B3745 $15.00 $8.00 $12.00 $15.00
B3746 $15.00 $5.00 $10.00 $10.00
B3747 $15.00 $10.00 $15.00 $15.00
B3748 $15.00 $5.00 $15.00 $15.00
B3749 $15.00 $5.00 $15.00 $15.00
B3750 $15.00 $10.00 $15.00 $15.00
B3751 $15.00 $5.00 $15.00 $15.00
B3752 $15.00 $5.00 $15.00 $15.00
B3753 $15.00 $8.00 $12.00 $15.00
B3754 $15.00 $10.00 $15.00 $15.00
B3755 $15.00 $10.00 $15.00 $15.00
B3756 $15.00 $10.00 $15.00 $15.00
B3757 $15.00 $10.00 $15.00 $15.00
B3758 $15.00 $4.00 $15.00 $20.00
B3759 $15.00 $10.00 $15.00 $15.00
B3760 $15.00 $10.00 $15.00 $15.00
B3761 $15.00 $5.00 $15.00 $15.00
B3762 $15.00 $10.00 $15.00 $15.00
B3763 $15.00 $10.00 $15.00 $15.00
B3764 $15.00 $10.00 $15.00 $15.00
B3765 $15.00 $5.00 $15.00 $15.00
B3766 $15.00 $10.00 $15.00 $15.00
B3767 $15.00 $5.00 $15.00 $15.00
B3768 $15.00 $10.00 $15.00 $15.00
B3769 NADA $8.00 $12.00 $15.00
B3770 $15.00 $10.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3771 $15.00 $10.00 $15.00 $15.00
B3772 $15.00 $4.00 $15.00 $20.00
B3773 $15.00 $5.00 $10.00 $10.00
B3774 $15.00 $5.00 $10.00 $10.00
B3775 $15.00 $10.00 $15.00 $15.00
B3776 $15.00 $8.00 $12.00 $15.00
B3777 $15.00 $10.00 $15.00 $15.00
B3778 $15.00 $5.00 $15.00 $15.00
B3779 $15.00 $10.00 $15.00 $15.00
B3780 $15.00 $5.00 $10.00 $10.00
B3781 $15.00 $8.00 $12.00 $15.00
B3782 $15.00 $10.00 $15.00 $15.00
B3783 $15.00 $10.00 $15.00 $15.00
B3784 $15.00 $10.00 $15.00 $15.00
B3785 $15.00 $5.00 $15.00 $15.00
B3786 $15.00 $5.00 $10.00 $10.00
B3787 $15.00 $10.00 $15.00 $15.00
B3788 $15.00 $5.00 $10.00 $10.00
B3789 $15.00 $5.00 $15.00 $15.00
B3790 $15.00 $5.00 $15.00 $15.00
B3791 $15.00 $8.00 $12.00 $15.00
B3792 $15.00 $5.00 $10.00 $10.00
B3793 $15.00 $5.00 $15.00 $15.00
B3794 $15.00 $5.00 $15.00 $15.00
B3795 $15.00 $5.00 $10.00 $10.00
B3796 $15.00 $10.00 $15.00 $15.00
B3797 $15.00 $8.00 $12.00 $15.00
B3798 $15.00 $5.00 $15.00 $15.00
B3799 $15.00 $10.00 $15.00 $15.00
B3800 $15.00 $10.00 $15.00 $15.00
B3801 $15.00 $5.00 $10.00 $10.00
B3802 $15.00 $10.00 $15.00 $15.00
B3803 $15.00 $10.00 $15.00 $15.00
B3804 $15.00 $8.00 $12.00 $15.00
B3805 $15.00 $10.00 $15.00 $15.00
B3806 $15.00 $5.00 $15.00 $15.00
B3807 $15.00 $10.00 $15.00 $15.00
B3808 $15.00 $5.00 $15.00 $15.00
B3809 $15.00 $10.00 $15.00 $15.00
B3810 $15.00 $10.00 $15.00 $15.00
B3811 $15.00 $8.00 $12.00 $15.00
B3812 $15.00 $5.00 $15.00 $15.00
B3813 $15.00 $10.00 $15.00 $15.00
B3814 $15.00 $5.00 $10.00 $10.00
B3815 $15.00 $10.00 $15.00 $15.00
B3816 $15.00 $5.00 $15.00 $15.00
B3817 $15.00 $10.00 $15.00 $15.00
B3818 $15.00 $10.00 $15.00 $15.00
B3819 $15.00 $5.00 $15.00 $15.00
B3820 $15.00 $5.00 $15.00 $15.00
B3821 $15.00 $10.00 $15.00 $15.00
B3822 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3823 $15.00 $10.00 $15.00 $15.00
B3824 $15.00 $10.00 $15.00 $15.00
B3825 $15.00 $5.00 $15.00 $15.00
B3826 $15.00 $5.00 $10.00 $10.00
B3827 $15.00 $10.00 $15.00 $15.00
B3828 $15.00 $10.00 $15.00 $15.00
B3829 $15.00 $10.00 $15.00 $15.00
B3830 $15.00 $5.00 $15.00 $15.00
B3831 $15.00 $10.00 $15.00 $15.00
B3832 $15.00 $5.00 $15.00 $15.00
B3833 $15.00 $10.00 $15.00 $15.00
B3834 $15.00 $8.00 $12.00 $15.00
B3835 $15.00 $5.00 $15.00 $15.00
B3836 $15.00 $10.00 $15.00 $15.00
B3837 $15.00 $5.00 $15.00 $15.00
B3838 $15.00 $5.00 $15.00 $15.00
B3839 $15.00 $5.00 $15.00 $15.00
B3840 $15.00 $10.00 $15.00 $15.00
B3841 $15.00 $5.00 $15.00 $15.00
B3842 $15.00 $5.00 $15.00 $15.00
B3843 $15.00 $5.00 $15.00 $15.00
B3844 $15.00 $10.00 $15.00 $15.00
B3845 $15.00 $5.00 $15.00 $15.00
B3846 $15.00 $5.00 $15.00 $15.00
B3847 $15.00 $5.00 $15.00 $15.00
B3848 $15.00 $5.00 $15.00 $15.00
B3849 $15.00 $5.00 $15.00 $15.00
B3850 $15.00 $5.00 $10.00 $10.00
B3851 $15.00 $5.00 $10.00 $10.00
B3852 $15.00 $5.00 $15.00 $15.00
B3853 $15.00 $5.00 $10.00 $10.00
B3854 $15.00 $8.00 $12.00 $15.00
B3855 $15.00 $10.00 $15.00 $15.00
B3856 $15.00 $10.00 $15.00 $15.00
B3857 $15.00 $10.00 $15.00 $15.00
B3858 $15.00 $10.00 $15.00 $15.00
B3859 $15.00 $10.00 $15.00 $15.00
B3860 $15.00 $5.00 $10.00 $10.00
B3861 $15.00 $10.00 $15.00 $15.00
B3862 $15.00 $10.00 $15.00 $15.00
B3863 $15.00 $10.00 $15.00 $15.00
B3864 $15.00 $10.00 $15.00 $15.00
B3865 $15.00 $12.00 $15.00 $18.00
B3866 $15.00 $5.00 $15.00 $15.00
B3867 $15.00 $8.00 $12.00 $15.00
B3868 $15.00 $8.00 $12.00 $15.00
B3869 $15.00 $8.00 $12.00 $15.00
B3870 $15.00 $5.00 $15.00 $15.00
B3871 $15.00 $10.00 $15.00 $15.00
B3872 $15.00 $8.00 $12.00 $15.00
B3873 $15.00 $10.00 $15.00 $15.00
B3874 $15.00 $10.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3875 $15.00 $10.00 $15.00 $15.00
B3876 $15.00 $5.00 $15.00 $15.00
B3877 $15.00 $8.00 $12.00 $15.00
B3878 $15.00 $10.00 $15.00 $15.00
B3879 $15.00 $10.00 $15.00 $15.00
B3880 $15.00 $5.00 $15.00 $15.00
B3881 $15.00 $10.00 $15.00 $15.00
B3882 $15.00 $8.00 $12.00 $15.00
B3883 $15.00 $5.00 $10.00 $10.00
B3884 $15.00 $10.00 $15.00 $15.00
B3885 $15.00 $10.00 $15.00 $15.00
B3886 $15.00 $10.00 $15.00 $15.00
B3887 $15.00 $10.00 $15.00 $15.00
B3888 $15.00 $10.00 $15.00 $15.00
B3889 $15.00 $5.00 $15.00 $15.00
B3890 $15.00 $5.00 $15.00 $15.00
B3891 $15.00 $5.00 $15.00 $15.00
B3892 $15.00 $5.00 $10.00 $10.00
B3893 $15.00 $4.00 $15.00 $20.00
B3894 $15.00 $10.00 $15.00 $15.00
B3895 $15.00 $5.00 $15.00 $15.00
B3896 $15.00 $5.00 $15.00 $15.00
B3897 $15.00 $10.00 $15.00 $15.00
B3898 $15.00 $5.00 $15.00 $15.00
B3899 NADA NADA NADA NADA
B3900 NADA NADA NADA NADA
B3901 $15.00 $8.00 $12.00 $15.00
B3902 $15.00 $10.00 $15.00 $15.00
B3903 $15.00 $10.00 $15.00 $15.00
B3904 $15.00 $10.00 $15.00 $15.00
B3905 $15.00 $10.00 $15.00 $15.00
B3906 $15.00 $5.00 $15.00 $15.00
B3907 $15.00 $10.00 $15.00 $15.00
B3908 $15.00 $5.00 $15.00 $15.00
B3909 $15.00 $8.00 $12.00 $15.00
B3910 $15.00 $5.00 $15.00 $15.00
B3911 $15.00 $5.00 $15.00 $15.00
B3912 $15.00 $5.00 $10.00 $10.00
B3913 $15.00 $5.00 $10.00 $10.00
B3914 $15.00 $5.00 $15.00 $15.00
B3915 $15.00 $10.00 $15.00 $15.00
B3916 $15.00 $10.00 $15.00 $15.00
B3917 NADA NADA NADA NADA
B3918 $15.00 $5.00 $10.00 $10.00
B3919 $15.00 $10.00 $15.00 $15.00
B3920 $15.00 $10.00 $15.00 $15.00
B3921 $15.00 $5.00 $10.00 $10.00
B3922 $15.00 $10.00 $15.00 $15.00
B3923 $15.00 $10.00 $15.00 $15.00
B3924 $15.00 $5.00 $15.00 $15.00
B3925 $15.00 $5.00 $15.00 $15.00
B3926 $15.00 $8.00 $12.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3927 $15.00 $5.00 $15.00 $15.00
B3928 $15.00 $5.00 $15.00 $15.00
B3929 $15.00 $10.00 $12.00 $15.00
B3930 $15.00 $5.00 $12.00 $18.00
B3931 $15.00 $8.00 $12.00 $15.00
B3932 $15.00 $10.00 $15.00 $15.00
B3933 $15.00 $5.00 $10.00 $10.00
B3934 $15.00 $8.00 $12.00 $15.00
B3935 $15.00 $5.00 $10.00 $10.00
B3936 $15.00 $5.00 $10.00 $10.00
B3937 $15.00 $5.00 $10.00 $10.00
B3938 $15.00 $5.00 $10.00 $10.00
B3939 $15.00 $5.00 $10.00 $10.00
B3940 $15.00 $10.00 $15.00 $15.00
B3941 $15.00 $5.00 $10.00 $10.00
B3942 $15.00 $5.00 $10.00 $10.00
B3943 $15.00 $10.00 $15.00 $15.00
B3944 $15.00 $10.00 $15.00 $15.00
B3945 $15.00 $10.00 $15.00 $15.00
B3946 $15.00 $10.00 $15.00 $15.00
B3947 $15.00 $4.00 $15.00 $20.00
B3948 $15.00 $5.00 $10.00 $10.00
B3949 $15.00 $5.00 $10.00 $10.00
B3950 $15.00 $10.00 $15.00 $15.00
B3951 $15.00 $10.00 $15.00 $15.00
B3952 $15.00 $5.00 $15.00 $15.00
B3953 $15.00 $10.00 $15.00 $15.00
B3954 $15.00 $5.00 $15.00 $15.00
B3955 $15.00 $4.00 $15.00 $20.00
B3956 $15.00 $10.00 $15.00 $15.00
B3957 $15.00 $8.00 $12.00 $15.00
B3958 $15.00 $10.00 $15.00 $15.00
B3959 $15.00 $10.00 $15.00 $15.00
B3960 $15.00 $10.00 $15.00 $15.00
B3961 $15.00 $10.00 $15.00 $15.00
B3962 $15.00 $5.00 $15.00 $15.00
B3963 $15.00 $10.00 $15.00 $15.00
B3964 $15.00 $4.00 $15.00 $20.00
B3965 $15.00 $5.00 $15.00 $15.00
B3966 $15.00 $10.00 $15.00 $15.00
B3967 $15.00 $10.00 $10.00 $20.00
B3968 $15.00 $10.00 $15.00 $15.00
B3969 $15.00 $10.00 $15.00 $15.00
B3970 $15.00 $10.00 $15.00 $15.00
B3971 $15.00 $10.00 $15.00 $15.00
B3972 $15.00 $10.00 $15.00 $15.00
B3973 $15.00 $5.00 $15.00 $15.00
B3974 $15.00 $5.00 $15.00 $15.00
B3975 $15.00 $10.00 $15.00 $15.00
B3976 $15.00 $10.00 $15.00 $15.00
B3977 $15.00 $10.00 $15.00 $15.00
B3978 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B3979 $15.00 $10.00 $15.00 $15.00
B3980 $15.00 $10.00 $15.00 $15.00
B3981 $15.00 $10.00 $15.00 $15.00
B3982 $15.00 $10.00 $15.00 $15.00
B3983 $15.00 $10.00 $15.00 $15.00
B3984 $15.00 $10.00 $15.00 $15.00
B3985 $15.00 $10.00 $15.00 $15.00
B3986 $15.00 $5.00 $10.00 $10.00
B3987 $15.00 $5.00 $10.00 $10.00
B3988 $15.00 $5.00 $10.00 $10.00
B3989 $15.00 $10.00 $15.00 $15.00
B3990 $15.00 $10.00 $15.00 $15.00
B3991 $15.00 $5.00 $10.00 $10.00
B3992 $15.00 $8.00 $12.00 $15.00
B3993 $15.00 $10.00 $15.00 $15.00
B3994 $15.00 $12.00 $15.00 $18.00
B3995 $15.00 $5.00 $15.00 $15.00
B3996 $15.00 $8.00 $12.00 $15.00
B3997 $15.00 $5.00 $15.00 $15.00
B3998 $15.00 $10.00 $15.00 $15.00
B3999 $15.00 $5.00 $10.00 $10.00
B4000 $15.00 $10.00 $15.00 $15.00
B4001 $15.00 $8.00 $12.00 $15.00
B4002 $15.00 $10.00 $18.00 $20.00
B4003 $15.00 $8.00 $12.00 $15.00
B4004 $15.00 $10.00 $15.00 $15.00
B4005 $15.00 $8.00 $12.00 $15.00
B4006 $15.00 $10.00 $15.00 $15.00
B4007 $15.00 $5.00 $15.00 $15.00
B4008 $15.00 $5.00 $15.00 $15.00
B4009 $15.00 $5.00 $10.00 $10.00
B4010 $15.00 $8.00 $12.00 $15.00
B4011 $15.00 $5.00 $15.00 $15.00
B4012 $15.00 $5.00 $10.00 $10.00
B4013 $15.00 $8.00 $12.00 $15.00
B4014 NADA $5.00 $10.00 $15.00
B4015 $15.00 $10.00 $18.00 $20.00
B4016 $15.00 $5.00 $10.00 $10.00
B4017 $15.00 $5.00 $15.00 $15.00
B4018 $15.00 $5.00 $15.00 $15.00
B4019 $15.00 $5.00 $15.00 $15.00
B4020 $15.00 $5.00 $15.00 $15.00
B4021 NADA $3.00 $3.00 $3.00
B4022 NADA $3.00 $7.00 $10.00
B4023 NADA $3.00 $7.00 $10.00
B4024 $15.00 $15.00 $18.00 $22.00
B4025 $15.00 $10.00 $15.00 $18.00
B4026 $15.00 $15.00 $15.00 $20.00
B4027 $15.00 $8.00 $12.00 $15.00
B4028 $15.00 $5.00 $15.00 $15.00
B4029 $15.00 $10.00 $15.00 $15.00
B4030 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4031 $15.00 $10.00 $15.00 $18.00
B4032 $15.00 $10.00 $15.00 $15.00
B4033 $15.00 $10.00 $15.00 $15.00
B4034 $15.00 $5.00 $10.00 $10.00
B4035 $15.00 $5.00 $15.00 $15.00
B4036 $15.00 $10.00 $15.00 $15.00
B4037 $15.00 $10.00 $15.00 $15.00
B4038 $15.00 $5.00 $10.00 $10.00
B4039 $15.00 $5.00 $15.00 $15.00
B4040 $15.00 $10.00 $15.00 $18.00
B4041 $15.00 $5.00 $15.00 $18.00
B4042 $15.00 $10.00 $15.00 $15.00
B4043 $15.00 $10.00 $10.00 $10.00
B4044 $15.00 $12.00 $12.00 $12.00
B4045 $15.00 $12.00 $12.00 $12.00
B4046 $15.00 $4.00 $7.00 $10.00
B4047 $10.00 $10.00 $12.00 $15.00
B4048 $12.00 $15.00 $20.00 $20.00
B4049 $15.00 $3.00 $5.00 $7.00
B4050 $15.00 $5.00 $10.00 $10.00
B4051 $15.00 $10.00 $15.00 $15.00
B4052 $15.00 $10.00 $15.00 $18.00
B4053 $15.00 $5.00 $15.00 $15.00
B4054 $15.00 $4.00 $15.00 $20.00
B4055 $15.00 $8.00 $12.00 $15.00
B4056 $15.00 $5.00 $15.00 $15.00
B4057 $15.00 $10.00 $15.00 $15.00
B4058 $15.00 $10.00 $15.00 $15.00
B4059 $15.00 $10.00 $15.00 $15.00
B4060 $15.00 $10.00 $15.00 $15.00
B4061 $15.00 $5.00 $10.00 $10.00
B4062 $15.00 $10.00 $15.00 $15.00
B4063 $15.00 $10.00 $15.00 $15.00
B4064 $15.00 $10.00 $15.00 $15.00
B4065 $15.00 $10.00 $15.00 $15.00
B4066 $15.00 $8.00 $15.00 $15.00
B4067 $15.00 $5.00 $15.00 $15.00
B4068 $15.00 $5.00 $10.00 $10.00
B4069 $15.00 $10.00 $15.00 $15.00
B4070 $15.00 $10.00 $15.00 $15.00
B4071 $15.00 $10.00 $15.00 $15.00
B4072 $15.00 $5.00 $15.00 $15.00
B4073 $15.00 $10.00 $15.00 $15.00
B4074 $15.00 $10.00 $15.00 $15.00
B4075 $15.00 $5.00 $10.00 $10.00
B4076 $15.00 $10.00 $15.00 $15.00
B4077 $15.00 $10.00 $15.00 $15.00
B4078 $15.00 $10.00 $15.00 $15.00
B4079 $15.00 $10.00 $15.00 $15.00
B4080 $15.00 $5.00 $15.00 $15.00
B4081 $15.00 $10.00 $15.00 $15.00
B4082 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4083 $15.00 $8.00 $12.00 $15.00
B4084 $15.00 $10.00 $15.00 $15.00
B4085 $15.00 $10.00 $15.00 $15.00
B4086 $15.00 $10.00 $15.00 $15.00
B4087 $15.00 $5.00 $10.00 $10.00
B4088 $15.00 $5.00 $10.00 $10.00
B4089 $15.00 $10.00 $15.00 $15.00
B4090 $15.00 $5.00 $15.00 $15.00
B4091 $15.00 $10.00 $15.00 $18.00
B4092 $15.00 $10.00 $15.00 $18.00
B4093 $15.00 $5.00 $15.00 $18.00
B4094 $15.00 $10.00 $15.00 $18.00
B4095 $15.00 $10.00 $15.00 $18.00
B4096 $15.00 $5.00 $15.00 $15.00
B4097 $15.00 $8.00 $12.00 $15.00
B4098 $15.00 $10.00 $15.00 $15.00
B4099 $15.00 $10.00 $15.00 $15.00
B4100 $15.00 $8.00 $15.00 $15.00
B4101 $15.00 $5.00 $12.00 $15.00
B4102 $15.00 $5.00 $15.00 $15.00
B4103 $15.00 $10.00 $15.00 $15.00
B4104 $15.00 $10.00 $12.00 $15.00
B4105 $15.00 $4.00 $15.00 $20.00
B4106 $15.00 $5.00 $15.00 $15.00
B4107 $15.00 $8.00 $15.00 $15.00
B4108 $15.00 $10.00 $15.00 $15.00
B4109 $15.00 $10.00 $15.00 $15.00
B4110 $15.00 $10.00 $15.00 $18.00
B4111 $15.00 $10.00 $15.00 $15.00
B4112 $15.00 $5.00 $15.00 $15.00
B4113 $15.00 $5.00 $10.00 $10.00
B4114 $15.00 $10.00 $15.00 $15.00
B4115 $15.00 $10.00 $15.00 $15.00
B4116 $15.00 $10.00 $15.00 $15.00
B4117 $15.00 $5.00 $15.00 $15.00
B4118 $15.00 $10.00 $15.00 $15.00
B4119 $15.00 $10.00 $10.00 $10.00
B4120 $15.00 $5.00 $15.00 $15.00
B4121 $15.00 $8.00 $12.00 $15.00
B4122 $15.00 $10.00 $15.00 $15.00
B4123 $15.00 $10.00 $15.00 $15.00
B4124 $15.00 $10.00 $15.00 $15.00
B4125 $15.00 $8.00 $12.00 $15.00
B4126 $15.00 $10.00 $15.00 $15.00
B4127 $15.00 $10.00 $10.00 $10.00
B4128 $15.00 $10.00 $15.00 $15.00
B4129 $15.00 $10.00 $10.00 $10.00
B4130 $15.00 $10.00 $15.00 $15.00
B4131 $15.00 $8.00 $12.00 $15.00
B4132 $15.00 $10.00 $15.00 $15.00
B4133 $15.00 $8.00 $12.00 $15.00
B4134 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4135 $15.00 $5.00 $15.00 $15.00
B4136 $15.00 $5.00 $10.00 $10.00
B4137 $15.00 $10.00 $15.00 $15.00
B4138 $15.00 $5.00 $15.00 $15.00
B4139 $15.00 $10.00 $15.00 $15.00
B4140 $15.00 $5.00 $10.00 $10.00
B4141 $15.00 $4.00 $15.00 $20.00
B4142 $15.00 $5.00 $15.00 $15.00
B4143 $15.00 $5.00 $15.00 $15.00
B4144 $15.00 $5.00 $10.00 $10.00
B4145 $15.00 $8.00 $12.00 $15.00
B4146 $15.00 $10.00 $15.00 $15.00
B4147 $15.00 $10.00 $15.00 $15.00
B4148 $15.00 $4.00 $15.00 $20.00
B4149 $15.00 $5.00 $15.00 $15.00
B4150 NADA $7.00 $15.00 $15.00
B4151 NADA $7.00 $15.00 $15.00
B4152 NADA $7.00 $15.00 $15.00
B4153 $15.00 $10.00 $15.00 $15.00
B4154 $15.00 $5.00 $15.00 $15.00
B4155 $15.00 $10.00 $15.00 $15.00
B4156 $15.00 $10.00 $15.00 $15.00
B4157 $15.00 $5.00 $10.00 $10.00
B4158 $15.00 $4.00 $15.00 $20.00
B4159 $15.00 $5.00 $10.00 $10.00
B4160 $15.00 $10.00 $15.00 $15.00
B4161 $15.00 $5.00 $10.00 $10.00
B4162 $15.00 $4.00 $15.00 $20.00
B4163 $15.00 $12.00 $18.00 $22.00
B4164 $15.00 $5.00 $15.00 $15.00
B4165 $15.00 $5.00 $10.00 $10.00
B4166 $15.00 $15.00 $15.00 $15.00
B4167 $15.00 $5.00 $15.00 $15.00
B4168 $15.00 $5.00 $10.00 $10.00
B4169 $15.00 $5.00 $18.00 $18.00
B4170 $15.00 $5.00 $15.00 $15.00
B4171 $15.00 $5.00 $15.00 $15.00
B4172 $15.00 $10.00 $15.00 $15.00
B4173 $15.00 $10.00 $15.00 $15.00
B4174 $15.00 $12.00 $15.00 $18.00
B4175 $15.00 $10.00 $15.00 $15.00
B4176 $15.00 $10.00 $15.00 $15.00
B4177 $15.00 $4.00 $15.00 $20.00
B4178 $15.00 $5.00 $15.00 $15.00
B4179 $15.00 $5.00 $15.00 $15.00
B4180 $15.00 $5.00 $10.00 $10.00
B4181 $15.00 $3.00 $10.00 $12.00
B4182 $15.00 $8.00 $12.00 $15.00
B4183 $15.00 $10.00 $10.00 $10.00
B4184 $15.00 $10.00 $15.00 $15.00
B4185 $15.00 $8.00 $15.00 $18.00
B4186 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4187 $15.00 $5.00 $15.00 $15.00
B4188 $15.00 $8.00 $15.00 $20.00
B4189 $15.00 $10.00 $15.00 $15.00
B4190 NADA $5.00 $15.00 $20.00
B4191 $15.00 $5.00 $10.00 $10.00
B4192 NADA $5.00 $15.00 $20.00
B4193 $15.00 $5.00 $10.00 $15.00
B4194 $15.00 $8.00 $10.00 $12.00
B4195 $15.00 $10.00 $15.00 $15.00
B4196 $15.00 $10.00 $15.00 $15.00
B4197 $15.00 $10.00 $12.00 $15.00
B4198 $15.00 $8.00 $12.00 $15.00
B4199 NADA $5.00 $15.00 $20.00
B4200 $15.00 $8.00 $12.00 $15.00
B4201 $15.00 $10.00 $12.00 $15.00
B4202 $15.00 $5.00 $10.00 $10.00
B4203 $15.00 $10.00 $15.00 $15.00
B4204 $15.00 $10.00 $20.00 $20.00
B4205 $15.00 $8.00 $12.00 $15.00
B4206 $15.00 $5.00 $10.00 $10.00
B4207 $15.00 $5.00 $15.00 $15.00
B4208 $15.00 $10.00 $15.00 $15.00
B4209 $15.00 $10.00 $15.00 $15.00
B4210 $15.00 $10.00 $12.00 $15.00
B4211 NADA NADA NADA NADA
B4212 $15.00 $10.00 $15.00 $15.00
B4213 $15.00 $8.00 $12.00 $15.00
B4214 $15.00 $10.00 $15.00 $15.00
B4215 $15.00 $10.00 $15.00 $15.00
B4216 $15.00 $10.00 $15.00 $15.00
B4217 $15.00 $5.00 $15.00 $15.00
B4218 $15.00 $8.00 $12.00 $15.00
B4219 $15.00 $10.00 $15.00 $18.00
B4220 $15.00 $10.00 $15.00 $18.00
B4221 $15.00 $10.00 $15.00 $15.00
B4222 $15.00 $10.00 $15.00 $15.00
B4223 $15.00 $10.00 $15.00 $18.00
B4224 $15.00 $10.00 $15.00 $15.00
B4225 $15.00 $10.00 $15.00 $15.00
B4226 $15.00 $10.00 $15.00 $15.00
B4227 $15.00 $15.00 $20.00 $20.00
B4228 $15.00 $15.00 $20.00 $20.00
B4229 $15.00 $5.00 $15.00 $15.00
B4230 NADA $10.00 $15.00 $15.00
B4231 $15.00 $10.00 $15.00 $20.00
B4232 $15.00 $8.00 $15.00 $20.00
B4233 $15.00 $5.00 $15.00 $15.00
B4234 $15.00 $10.00 $15.00 $15.00
B4235 $15.00 $10.00 $15.00 $15.00
B4236 $15.00 $5.00 $15.00 $15.00
B4237 $15.00 $5.00 $10.00 $10.00
B4238 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4239 $15.00 $8.00 $12.00 $15.00
B4240 $15.00 $5.00 $15.00 $15.00
B4241 $15.00 $5.00 $15.00 $15.00
B4242 $15.00 $8.00 $12.00 $15.00
B4243 $15.00 $5.00 $15.00 $15.00
B4244 $15.00 $10.00 $15.00 $15.00
B4245 $15.00 $10.00 $15.00 $15.00
B4246 $15.00 $5.00 $15.00 $15.00
B4247 $15.00 $10.00 $15.00 $15.00
B4248 $15.00 $8.00 $12.00 $15.00
B4249 $15.00 $5.00 $10.00 $10.00
B4250 $15.00 $5.00 $15.00 $15.00
B4251 $15.00 $5.00 $15.00 $15.00
B4252 $15.00 $12.00 $15.00 $18.00
B4253 $15.00 $5.00 $15.00 $15.00
B4254 $15.00 $10.00 $15.00 $15.00
B4255 $15.00 $10.00 $15.00 $15.00
B4256 $15.00 $10.00 $15.00 $15.00
B4257 $15.00 $10.00 $15.00 $15.00
B4258 $15.00 $8.00 $12.00 $15.00
B4259 $15.00 $10.00 $15.00 $15.00
B4260 $15.00 $5.00 $15.00 $15.00
B4261 $15.00 $10.00 $15.00 $15.00
B4262 $15.00 $10.00 $15.00 $15.00
B4263 $15.00 $5.00 $10.00 $10.00
B4264 $15.00 $10.00 $15.00 $15.00
B4265 $15.00 $8.00 $12.00 $15.00
B4266 $15.00 $10.00 $15.00 $15.00
B4267 $15.00 $10.00 $15.00 $18.00
B4268 $15.00 $5.00 $15.00 $15.00
B4269 $15.00 $10.00 $15.00 $15.00
B4270 $15.00 $10.00 $15.00 $15.00
B4271 $15.00 $8.00 $12.00 $15.00
B4272 $15.00 $10.00 $15.00 $15.00
B4273 $15.00 $10.00 $15.00 $15.00
B4274 $15.00 $5.00 $10.00 $10.00
B4275 $15.00 $5.00 $15.00 $15.00
B4276 $15.00 $5.00 $15.00 $15.00
B4277 $15.00 $10.00 $15.00 $15.00
B4278 $15.00 $5.00 $15.00 $15.00
B4279 $15.00 $5.00 $15.00 $15.00
B4280 $15.00 $5.00 $15.00 $15.00
B4281 $15.00 $5.00 $10.00 $10.00
B4282 $15.00 $10.00 $15.00 $15.00
B4283 $15.00 $5.00 $15.00 $15.00
B4284 $15.00 $5.00 $10.00 $10.00
B4285 $15.00 $5.00 $15.00 $15.00
B4286 $15.00 $8.00 $12.00 $15.00
B4287 $15.00 $5.00 $15.00 $15.00
B4288 $15.00 $10.00 $15.00 $15.00
B4289 $15.00 $5.00 $10.00 $15.00
B4290 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
118
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4291 $15.00 $10.00 $15.00 $15.00
B4292 $15.00 $10.00 $15.00 $15.00
B4293 $15.00 $5.00 $15.00 $15.00
B4294 $15.00 $10.00 $15.00 $15.00
B4295 $15.00 $5.00 $10.00 $10.00
B4296 $15.00 $10.00 $15.00 $15.00
B4297 $15.00 $5.00 $15.00 $15.00
B4298 $15.00 $10.00 $18.00 $20.00
B4299 $15.00 $5.00 $15.00 $15.00
B4300 $15.00 $8.00 $12.00 $15.00
B4301 $15.00 $5.00 $10.00 $10.00
B4302 $15.00 $5.00 $10.00 $10.00
B4303 $15.00 $5.00 $15.00 $15.00
B4304 $15.00 $10.00 $15.00 $15.00
B4305 $15.00 $10.00 $15.00 $15.00
B4306 $15.00 $12.00 $15.00 $18.00
B4307 $15.00 $12.00 $15.00 $18.00
B4308 $15.00 $12.00 $15.00 $18.00
B4309 $15.00 $10.00 $15.00 $15.00
B4310 $15.00 $5.00 $10.00 $10.00
B4311 $15.00 $8.00 $12.00 $15.00
B4312 $15.00 $4.00 $15.00 $20.00
B4313 $15.00 $5.00 $15.00 $15.00
B4314 $15.00 $5.00 $10.00 $10.00
B4315 $15.00 $5.00 $15.00 $15.00
B4316 $15.00 $12.00 $15.00 $18.00
B4317 $15.00 $10.00 $15.00 $15.00
B4318 $15.00 $10.00 $15.00 $15.00
B4319 $15.00 $5.00 $15.00 $15.00
B4320 $15.00 $10.00 $15.00 $15.00
B4321 NADA $5.00 $15.00 $20.00
B4322 $15.00 $12.00 $18.00 $18.00
B4323 $15.00 $10.00 $12.00 $15.00
B4324 $15.00 $5.00 $15.00 $15.00
B4325 $15.00 $4.00 $15.00 $20.00
B4326 $15.00 $10.00 $15.00 $15.00
B4327 $15.00 $10.00 $15.00 $15.00
B4328 $15.00 $5.00 $15.00 $15.00
B4329 $15.00 $10.00 $15.00 $18.00
B4330 $15.00 $8.00 $12.00 $15.00
B4331 $15.00 $5.00 $10.00 $10.00
B4332 $15.00 $5.00 $20.00 $20.00
B4333 $15.00 $10.00 $15.00 $15.00
B4334 $15.00 $10.00 $15.00 $15.00
B4335 $15.00 $5.00 $15.00 $15.00
B4336 $15.00 $10.00 $15.00 $15.00
B4337 $15.00 $5.00 $10.00 $10.00
B4338 $15.00 $8.00 $12.00 $15.00
B4339 $15.00 $5.00 $15.00 $15.00
B4340 $15.00 $10.00 $15.00 $15.00
B4341 $15.00 $10.00 $15.00 $15.00
B4342 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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119
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4343 $15.00 $10.00 $15.00 $15.00
B4344 $15.00 $5.00 $15.00 $15.00
B4345 $15.00 $8.00 $12.00 $15.00
B4346 $15.00 $10.00 $15.00 $15.00
B4347 $15.00 $8.00 $10.00 $12.00
B4348 $15.00 $10.00 $15.00 $15.00
B4349 $15.00 $10.00 $15.00 $15.00
B4350 $15.00 $5.00 $10.00 $10.00
B4351 $15.00 $10.00 $15.00 $15.00
B4352 $15.00 $8.00 $12.00 $15.00
B4353 $15.00 $10.00 $10.00 $15.00
B4354 $15.00 $10.00 $10.00 $15.00
B4355 $15.00 $10.00 $10.00 $15.00
B4356 $15.00 $10.00 $10.00 $15.00
B4357 $15.00 $10.00 $10.00 $15.00
B4358 $15.00 $5.00 $15.00 $15.00
B4359 $15.00 $10.00 $15.00 $15.00
B4360 $15.00 $10.00 $15.00 $15.00
B4361 $15.00 $10.00 $15.00 $15.00
B4362 $15.00 $5.00 $15.00 $15.00
B4363 $15.00 $10.00 $15.00 $15.00
B4364 NADA $5.00 $10.00 $10.00
B4365 $15.00 $5.00 $10.00 $10.00
B4366 $15.00 $8.00 $12.00 $15.00
B4367 $15.00 $5.00 $12.00 $12.00
B4368 $15.00 $10.00 $18.00 $20.00
B4369 $15.00 $10.00 $18.00 $20.00
B4370 $15.00 $5.00 $12.00 $12.00
B4371 $15.00 $5.00 $10.00 $10.00
B4372 $15.00 $5.00 $15.00 $15.00
B4373 $15.00 $5.00 $15.00 $15.00
B4374 $15.00 $10.00 $10.00 $10.00
B4375 $15.00 $10.00 $10.00 $10.00
B4376 $15.00 $5.00 $10.00 $12.00
B4377 $15.00 $5.00 $5.00 $5.00
B4378 $15.00 $5.00 $5.00 $5.00
B4379 $15.00 $5.00 $5.00 $5.00
B4380 NADA $5.00 $10.00 $12.00
B4381 NADA $5.00 $10.00 $12.00
B4382 $15.00 $8.00 $12.00 $15.00
B4383 NADA $5.00 $10.00 $12.00
B4384 $15.00 $10.00 $10.00 $10.00
B4385 $15.00 $10.00 $10.00 $10.00
B4386 NADA $5.00 $10.00 $12.00
B4387 $15.00 $8.00 $15.00 $15.00
B4388 $15.00 $8.00 $15.00 $15.00
B4389 $15.00 $8.00 $15.00 $15.00
B4390 $15.00 $8.00 $15.00 $15.00
B4391 $15.00 $10.00 $15.00 $15.00
B4392 $15.00 $10.00 $15.00 $15.00
B4393 $15.00 $10.00 $15.00 $15.00
B4394 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
120
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4395 $15.00 $10.00 $15.00 $15.00
B4396 $15.00 $5.00 $15.00 $15.00
B4397 $15.00 $10.00 $15.00 $15.00
B4398 $15.00 $8.00 $15.00 $20.00
B4399 $15.00 $5.00 $10.00 $10.00
B4400 $15.00 $10.00 $10.00 $10.00
B4401 $15.00 $5.00 $10.00 $10.00
B4402 $15.00 $5.00 $10.00 $10.00
B4403 $15.00 $8.00 $12.00 $15.00
B4404 $15.00 $5.00 $10.00 $10.00
B4405 $15.00 $8.00 $12.00 $15.00
B4406 $15.00 $10.00 $15.00 $15.00
B4407 $15.00 $10.00 $15.00 $15.00
B4408 $15.00 $10.00 $15.00 $15.00
B4409 $15.00 $5.00 $15.00 $15.00
B4410 $15.00 $5.00 $15.00 $15.00
B4411 $15.00 $10.00 $15.00 $15.00
B4412 NADA $5.00 $15.00 $20.00
B4413 $15.00 $5.00 $15.00 $15.00
B4414 $15.00 $5.00 $15.00 $15.00
B4415 $15.00 $10.00 $15.00 $15.00
B4416 $15.00 $10.00 $15.00 $15.00
B4417 $15.00 $10.00 $15.00 $15.00
B4418 $15.00 $10.00 $15.00 $15.00
B4419 $15.00 $5.00 $15.00 $15.00
B4420 $15.00 $5.00 $15.00 $15.00
B4421 $15.00 $5.00 $15.00 $15.00
B4422 $15.00 $10.00 $15.00 $15.00
B4423 $15.00 $8.00 $12.00 $15.00
B4424 $15.00 $3.00 $10.00 $12.00
B4425 $15.00 $3.00 $10.00 $12.00
B4426 NADA $8.00 $15.00 $15.00
B4427 NADA $8.00 $10.00 $15.00
B4428 NADA $8.00 $15.00 $15.00
B4429 NADA $10.00 $15.00 $15.00
B4430 NADA $10.00 $15.00 $15.00
B4431 $15.00 $8.00 $10.00 $15.00
B4432 $15.00 $8.00 $10.00 $15.00
B4433 $15.00 $8.00 $10.00 $15.00
B4434 $15.00 NADA $10.00 $15.00
B4435 NADA $8.00 $15.00 $15.00
B4436 $15.00 NADA $18.00 $20.00
B4437 NADA $3.00 $7.00 $10.00
B4438 $15.00 $10.00 $15.00 $15.00
B4439 $15.00 NADA $18.00 $20.00
B4440 NADA $8.00 $10.00 $12.00
B4441 NADA $10.00 $18.00 $18.00
B4442 NADA $8.00 $15.00 $15.00
B4443 NADA $10.00 $18.00 $18.00
B4444 NADA $8.00 $10.00 $12.00
B4445 NADA $8.00 $15.00 $15.00
B4446 NADA $10.00 $18.00 $18.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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121
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4447 $10.00 $8.00 $10.00 $15.00
B4448 NADA $10.00 $15.00 $15.00
B4449 NADA $10.00 $15.00 $15.00
B4450 NADA NADA $10.00 $15.00
B4451 NADA $10.00 $18.00 $18.00
B4452 NADA $8.00 $15.00 $15.00
B4453 NADA $8.00 $10.00 $12.00
B4454 $15.00 $8.00 $12.00 $15.00
B4455 NADA $10.00 $17.00 $18.00
B4456 NADA $10.00 $18.00 $20.00
B4457 $15.00 $8.00 $12.00 $15.00
B4458 $15.00 $8.00 $10.00 $15.00
B4459 $15.00 $10.00 $15.00 $15.00
B4460 $15.00 $5.00 $15.00 $15.00
B4461 $15.00 $5.00 $15.00 $15.00
B4462 $15.00 $10.00 $15.00 $15.00
B4463 $15.00 $10.00 $15.00 $15.00
B4464 $15.00 $10.00 $15.00 $15.00
B4465 $15.00 $5.00 $10.00 $10.00
B4466 $15.00 $5.00 $10.00 $10.00
B4467 $15.00 $5.00 $15.00 $15.00
B4468 $15.00 $10.00 $15.00 $15.00
B4469 $15.00 $5.00 $15.00 $15.00
B4470 $15.00 $10.00 $20.00 $20.00
B4471 $15.00 $5.00 $15.00 $15.00
B4472 $15.00 $8.00 $12.00 $15.00
B4473 $15.00 $5.00 $15.00 $15.00
B4474 $15.00 $10.00 $15.00 $15.00
B4475 $15.00 $5.00 $15.00 $15.00
B4476 $15.00 $8.00 $10.00 $10.00
B4477 $15.00 $5.00 $15.00 $15.00
B4478 $15.00 $10.00 $15.00 $15.00
B4479 $15.00 $10.00 $15.00 $15.00
B4480 $15.00 $8.00 $12.00 $15.00
B4481 $15.00 $10.00 $15.00 $15.00
B4482 $15.00 $10.00 $15.00 $15.00
B4483 $15.00 $10.00 $15.00 $15.00
B4484 $15.00 $10.00 $15.00 $15.00
B4485 $15.00 $15.00 $18.00 $20.00
B4486 $15.00 $15.00 $18.00 $20.00
B4487 $15.00 $5.00 $15.00 $15.00
B4488 $15.00 $10.00 $15.00 $15.00
B4489 $15.00 $5.00 $15.00 $15.00
B4490 $15.00 $8.00 $12.00 $15.00
B4491 $15.00 $5.00 $10.00 $10.00
B4492 $15.00 $10.00 $15.00 $15.00
B4493 $15.00 $10.00 $15.00 $15.00
B4494 $15.00 $10.00 $15.00 $15.00
B4495 $15.00 $10.00 $15.00 $15.00
B4496 $15.00 $5.00 $15.00 $15.00
B4497 $15.00 $5.00 $15.00 $15.00
B4498 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
122
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4499 $15.00 $8.00 $12.00 $15.00
B4500 $15.00 $12.00 $15.00 $18.00
B4501 $15.00 $18.00 $18.00 $22.00
B4502 $15.00 $8.00 $12.00 $15.00
B4503 $15.00 $10.00 $15.00 $15.00
B4504 NADA $8.00 $12.00 $15.00
B4505 $15.00 $12.00 $16.00 $16.00
B4506 $15.00 $10.00 $15.00 $15.00
B4507 $15.00 $8.00 $10.00 $12.00
B4508 $15.00 $7.00 $15.00 $18.00
B4509 $15.00 $5.00 $15.00 $15.00
B4510 $15.00 $5.00 $10.00 $10.00
B4511 $15.00 $10.00 $10.00 $15.00
B4512 $15.00 $5.00 $10.00 $10.00
B4513 $15.00 $10.00 $15.00 $15.00
B4514 $15.00 $8.00 $12.00 $15.00
B4515 $15.00 $8.00 $12.00 $15.00
B4516 $15.00 $10.00 $15.00 $15.00
B4517 $15.00 $5.00 $10.00 $10.00
B4518 $15.00 $5.00 $10.00 $10.00
B4519 $15.00 $5.00 $10.00 $10.00
B4520 $15.00 $5.00 $10.00 $10.00
B4521 $15.00 $8.00 $12.00 $15.00
B4522 $15.00 $10.00 $15.00 $15.00
B4523 $15.00 $5.00 $15.00 $15.00
B4524 $15.00 $8.00 $12.00 $15.00
B4525 $15.00 $5.00 $10.00 $10.00
B4526 $15.00 $5.00 $10.00 $10.00
B4527 $15.00 $5.00 $15.00 $15.00
B4528 $15.00 $5.00 $15.00 $15.00
B4529 $15.00 $5.00 $10.00 $10.00
B4530 $15.00 $5.00 $15.00 $15.00
B4531 $15.00 $5.00 $15.00 $15.00
B4532 $15.00 $10.00 $15.00 $15.00
B4533 $15.00 $10.00 $15.00 $15.00
B4534 $15.00 $5.00 $10.00 $12.00
B4535 $15.00 $8.00 $10.00 $12.00
B4536 $15.00 $5.00 $15.00 $15.00
B4537 $15.00 $10.00 $15.00 $15.00
B4538 $15.00 $10.00 $15.00 $15.00
B4539 $15.00 $10.00 $15.00 $15.00
B4540 $15.00 $5.00 $15.00 $15.00
B4541 $15.00 $10.00 $12.00 $15.00
B4542 $15.00 $5.00 $12.00 $20.00
B4543 $15.00 $5.00 $10.00 $10.00
B4544 $15.00 $8.00 $12.00 $15.00
B4545 $15.00 $12.00 $15.00 $18.00
B4546 $15.00 $12.00 $15.00 $18.00
B4547 $15.00 $8.00 $10.00 $15.00
B4548 $15.00 $5.00 $15.00 $15.00
B4549 $15.00 $10.00 $15.00 $15.00
B4550 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
123
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4551 $15.00 $5.00 $15.00 $15.00
B4552 $15.00 $10.00 $15.00 $15.00
B4553 $15.00 $10.00 $12.00 $15.00
B4554 $15.00 $10.00 $15.00 $15.00
B4555 $15.00 $8.00 $12.00 $15.00
B4556 $15.00 $5.00 $15.00 $15.00
B4557 $15.00 $3.00 $10.00 $12.00
B4558 $15.00 $10.00 $12.00 $15.00
B4559 $15.00 $8.00 $12.00 $15.00
B4560 $15.00 $10.00 $15.00 $15.00
B4561 $15.00 $10.00 $15.00 $15.00
B4562 $15.00 $5.00 $15.00 $15.00
B4563 $15.00 $8.00 $12.00 $15.00
B4564 $15.00 $10.00 $12.00 $15.00
B4565 $15.00 $10.00 $15.00 $15.00
B4566 $15.00 $8.00 $12.00 $15.00
B4567 $15.00 $8.00 $12.00 $15.00
B4568 $15.00 $8.00 $12.00 $15.00
B4569 $15.00 $10.00 $12.00 $15.00
B4570 $15.00 $10.00 $12.00 $15.00
B4571 $15.00 $8.00 $12.00 $15.00
B4572 $15.00 $10.00 $15.00 $15.00
B4573 $15.00 $10.00 $20.00 $20.00
B4574 $15.00 $10.00 $20.00 $20.00
B4575 $15.00 $10.00 $12.00 $15.00
B4576 $15.00 $10.00 $12.00 $15.00
B4577 $15.00 $8.00 $12.00 $15.00
B4578 $15.00 $10.00 $12.00 $15.00
B4579 $15.00 $8.00 $12.00 $15.00
B4580 $15.00 $12.00 $15.00 $18.00
B4581 $15.00 $10.00 $12.00 $15.00
B4582 $15.00 $5.00 $10.00 $10.00
B4583 $15.00 $10.00 $12.00 $15.00
B4584 $15.00 $10.00 $15.00 $15.00
B4585 $15.00 $8.00 $15.00 $18.00
B4586 $15.00 $5.00 $15.00 $15.00
B4587 $15.00 $8.00 $12.00 $15.00
B4588 $15.00 $8.00 $12.00 $15.00
B4589 $15.00 $10.00 $12.00 $15.00
B4590 $15.00 $10.00 $12.00 $15.00
B4591 $15.00 $10.00 $12.00 $15.00
B4592 $15.00 $12.00 $15.00 $18.00
B4593 $15.00 $10.00 $15.00 $15.00
B4594 $15.00 $5.00 $15.00 $15.00
B4595 $15.00 $12.00 $15.00 $18.00
B4596 $15.00 $5.00 $15.00 $15.00
B4597 $15.00 $10.00 $15.00 $15.00
B4598 $15.00 $8.00 $12.00 $15.00
B4599 $15.00 $10.00 $12.00 $15.00
B4600 $15.00 $8.00 $12.00 $15.00
B4601 $15.00 $10.00 $12.00 $15.00
B4602 NADA $10.00 $17.00 $18.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
124
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4603 $15.00 $10.00 $15.00 $15.00
B4604 $15.00 $8.00 $12.00 $15.00
B4605 $15.00 $10.00 $15.00 $15.00
B4606 $15.00 $10.00 $15.00 $15.00
B4607 $15.00 $12.00 $15.00 $18.00
B4608 $15.00 $8.00 $12.00 $15.00
B4609 $15.00 $5.00 $15.00 $15.00
B4610 $15.00 $12.00 $15.00 $18.00
B4611 $15.00 $10.00 $15.00 $15.00
B4612 $15.00 $8.00 $12.00 $15.00
B4613 $15.00 $8.00 $12.00 $15.00
B4614 $15.00 $8.00 $15.00 $18.00
B4615 $15.00 $12.00 $15.00 $18.00
B4616 $15.00 $10.00 $15.00 $15.00
B4617 $15.00 $10.00 $15.00 $15.00
B4618 $15.00 $10.00 $15.00 $15.00
B4619 $15.00 $5.00 $15.00 $15.00
B4620 $15.00 $5.00 $10.00 $10.00
B4621 $15.00 $10.00 $15.00 $15.00
B4622 $15.00 $10.00 $15.00 $15.00
B4623 $15.00 $10.00 $15.00 $15.00
B4624 $15.00 $10.00 $15.00 $15.00
B4625 $15.00 $10.00 $15.00 $15.00
B4626 $15.00 $5.00 $10.00 $10.00
B4627 $15.00 $5.00 $15.00 $15.00
B4628 $15.00 $12.00 $15.00 $18.00
B4629 $15.00 $5.00 $15.00 $15.00
B4630 $15.00 $5.00 $15.00 $15.00
B4631 $15.00 $10.00 $15.00 $15.00
B4632 $15.00 $10.00 $15.00 $15.00
B4633 $15.00 $12.00 $15.00 $18.00
B4634 $15.00 $10.00 $15.00 $15.00
B4635 $15.00 $5.00 $10.00 $10.00
B4636 $15.00 $8.00 $12.00 $15.00
B4637 $15.00 $10.00 $15.00 $15.00
B4638 $15.00 $10.00 $15.00 $15.00
B4639 $15.00 $10.00 $15.00 $15.00
B4640 $15.00 $10.00 $15.00 $15.00
B4641 $15.00 $10.00 $12.00 $15.00
B4642 $15.00 $12.00 $15.00 $18.00
B4643 $15.00 $4.00 $15.00 $20.00
B4644 $15.00 $10.00 $15.00 $15.00
B4645 $15.00 $8.00 $12.00 $15.00
B4646 $15.00 $10.00 $20.00 $20.00
B4647 $15.00 $5.00 $10.00 $10.00
B4648 $15.00 $10.00 $15.00 $15.00
B4649 $15.00 $8.00 $12.00 $15.00
B4650 $15.00 $5.00 $10.00 $10.00
B4651 $15.00 $5.00 $10.00 $10.00
B4652 $15.00 $10.00 $15.00 $18.00
B4653 $15.00 $10.00 $15.00 $15.00
B4654 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
125
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4655 $15.00 $10.00 $15.00 $15.00
B4656 $15.00 $5.00 $15.00 $15.00
B4657 $15.00 $5.00 $15.00 $15.00
B4658 $15.00 $5.00 $15.00 $15.00
B4659 $15.00 $5.00 $10.00 $10.00
B4660 $15.00 $5.00 $15.00 $15.00
B4661 $15.00 $5.00 $10.00 $10.00
B4662 $15.00 $10.00 $20.00 $20.00
B4663 $15.00 $8.00 $12.00 $15.00
B4664 $15.00 $10.00 $15.00 $15.00
B4665 $15.00 $8.00 $12.00 $15.00
B4666 $15.00 $10.00 $15.00 $15.00
B4667 $15.00 $5.00 $15.00 $15.00
B4668 $15.00 $5.00 $15.00 $15.00
B4669 $15.00 $10.00 $15.00 $15.00
B4670 $15.00 $5.00 $15.00 $15.00
B4671 $15.00 $5.00 $15.00 $15.00
B4672 $15.00 $5.00 $15.00 $15.00
B4673 $15.00 $5.00 $10.00 $10.00
B4674 $15.00 $8.00 $15.00 $15.00
B4675 $15.00 $5.00 $15.00 $15.00
B4676 $15.00 $5.00 $10.00 $10.00
B4677 Ninguno $10.00 $15.00 $15.00
B4678 $15.00 $10.00 $15.00 $15.00
B4679 $15.00 $5.00 $15.00 $15.00
B4680 $15.00 $5.00 $15.00 $15.00
B4681 $15.00 $5.00 $10.00 $10.00
B4682 $15.00 $5.00 $15.00 $15.00
B4683 $15.00 $5.00 $15.00 $15.00
B4684 $15.00 $10.00 $15.00 $15.00
B4685 $15.00 $10.00 $15.00 $15.00
B4686 $15.00 $10.00 $15.00 $15.00
B4687 $15.00 $10.00 $15.00 $20.00
B4688 $15.00 $5.00 $15.00 $15.00
B4689 $15.00 $10.00 $15.00 $15.00
B4690 $15.00 $10.00 $15.00 $15.00
B4691 $15.00 $3.00 $3.00 $3.00
B4692 $15.00 $10.00 $20.00 $20.00
B4693 $10.00 $5.00 $10.00 $15.00
B4694 $15.00 $10.00 $15.00 $20.00
B4695 $10.00 $5.00 $10.00 $15.00
B4696 $15.00 $8.00 $12.00 $15.00
B4697 $15.00 $10.00 $15.00 $20.00
B4698 $10.00 $5.00 $10.00 $15.00
B4699 $15.00 $10.00 $15.00 $20.00
B4700 $10.00 $5.00 $10.00 $15.00
B4701 $10.00 $5.00 $10.00 $15.00
B4702 $15.00 $5.00 $15.00 $18.00
B4703 $15.00 $5.00 $15.00 $18.00
B4704 $15.00 $7.00 $18.00 $18.00
B4705 $15.00 $10.00 $15.00 $20.00
B4706 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4707 $15.00 $10.00 $15.00 $20.00
B4708 $15.00 $10.00 $15.00 $15.00
B4709 $15.00 $10.00 $15.00 $15.00
B4710 $15.00 $5.00 $15.00 $15.00
B4711 $10.00 $10.00 $15.00 $20.00
B4712 $15.00 $8.00 $12.00 $15.00
B4713 $15.00 $8.00 $12.00 $15.00
B4714 $15.00 $12.00 $15.00 $18.00
B4715 $15.00 $10.00 $15.00 $15.00
B4716 $15.00 $10.00 $15.00 $15.00
B4717 $15.00 $5.00 $15.00 $15.00
B4718 $15.00 $10.00 $15.00 $15.00
B4719 $15.00 $5.00 $10.00 $10.00
B4720 $15.00 $10.00 $15.00 $20.00
B4721 $15.00 $5.00 $15.00 $15.00
B4722 $15.00 $5.00 $10.00 $10.00
B4723 $15.00 $8.00 $12.00 $15.00
B4724 $15.00 $3.00 $7.00 $11.00
B4725 $15.00 $7.00 $12.00 $15.00
B4726 $15.00 $7.00 $12.00 $15.00
B4727 $15.00 $5.00 $10.00 $10.00
B4728 $15.00 $10.00 $10.00 $10.00
B4729 $15.00 $10.00 $15.00 $15.00
B4730 $15.00 $10.00 $15.00 $15.00
B4731 $15.00 $8.00 $12.00 $15.00
B4732 $15.00 $10.00 $15.00 $15.00
B4733 $15.00 $10.00 $20.00 $20.00
B4734 $15.00 $10.00 $15.00 $15.00
B4735 $15.00 $8.00 $12.00 $15.00
B4736 $15.00 $10.00 $15.00 $15.00
B4737 $15.00 $8.00 $12.00 $15.00
B4738 $15.00 $4.00 $15.00 $20.00
B4739 $15.00 $5.00 $15.00 $15.00
B4740 $15.00 $5.00 $10.00 $10.00
B4741 $15.00 $8.00 $12.00 $15.00
B4742 $15.00 $10.00 $15.00 $15.00
B4743 $15.00 $8.00 $12.00 $15.00
B4744 $15.00 $5.00 $10.00 $10.00
B4745 $15.00 $10.00 $15.00 $15.00
B4746 $15.00 $10.00 $15.00 $15.00
B4747 $15.00 $10.00 $15.00 $15.00
B4748 $15.00 $10.00 $15.00 $15.00
B4749 $15.00 $5.00 $10.00 $10.00
B4750 $12.00 $10.00 $12.00 $15.00
B4751 $15.00 $10.00 $15.00 $20.00
B4752 $15.00 $10.00 $15.00 $20.00
B4753 $15.00 $5.00 $10.00 $10.00
B4754 $15.00 $10.00 $15.00 $15.00
B4755 $15.00 $10.00 $15.00 $15.00
B4756 $15.00 $10.00 $15.00 $15.00
B4757 $15.00 $10.00 $15.00 $15.00
B4758 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4759 $15.00 $10.00 $15.00 $15.00
B4760 $15.00 $8.00 $15.00 $15.00
B4761 $15.00 $8.00 $15.00 $15.00
B4762 $15.00 $5.00 $10.00 $10.00
B4763 $15.00 $8.00 $15.00 $15.00
B4764 $15.00 $5.00 $10.00 $10.00
B4765 $15.00 $8.00 $15.00 $15.00
B4766 $15.00 $10.00 $15.00 $15.00
B4767 $15.00 $10.00 $15.00 $15.00
B4768 $15.00 $10.00 $15.00 $15.00
B4769 $15.00 $5.00 $10.00 $10.00
B4770 $15.00 $5.00 $15.00 $15.00
B4771 $15.00 $8.00 $12.00 $15.00
B4772 $15.00 $10.00 $15.00 $15.00
B4773 $15.00 $5.00 $15.00 $15.00
B4774 $15.00 $5.00 $15.00 $15.00
B4775 $15.00 $10.00 $15.00 $15.00
B4776 $15.00 $8.00 $12.00 $15.00
B4777 $15.00 $10.00 $15.00 $20.00
B4778 $15.00 $10.00 $15.00 $20.00
B4779 $15.00 $5.00 $10.00 $10.00
B4780 $15.00 $10.00 $15.00 $15.00
B4781 $15.00 $5.00 $15.00 $15.00
B4782 $15.00 $10.00 $15.00 $15.00
B4783 $15.00 $5.00 $15.00 $15.00
B4784 $15.00 $8.00 $12.00 $15.00
B4785 $15.00 $5.00 $10.00 $10.00
B4786 $15.00 $10.00 $15.00 $15.00
B4787 $15.00 $8.00 $10.00 $12.00
B4788 $15.00 $5.00 $15.00 $15.00
B4789 $15.00 $5.00 $15.00 $15.00
B4790 $15.00 $10.00 $15.00 $15.00
B4791 $15.00 $5.00 $10.00 $10.00
B4792 $15.00 $5.00 $15.00 $15.00
B4793 $15.00 $5.00 $10.00 $10.00
B4794 $15.00 $10.00 $15.00 $15.00
B4795 $15.00 $5.00 $10.00 $10.00
B4796 $15.00 $5.00 $10.00 $10.00
B4797 $15.00 $5.00 $15.00 $15.00
B4798 $15.00 $4.00 $15.00 $20.00
B4799 $15.00 $5.00 $15.00 $15.00
B4800 $15.00 $10.00 $15.00 $20.00
B4801 $15.00 $5.00 $15.00 $15.00
B4802 $15.00 $10.00 $15.00 $15.00
B4803 $15.00 $10.00 $18.00 $20.00
B4804 $10.00 $5.00 $10.00 $15.00
B4805 $15.00 $10.00 $15.00 $15.00
B4806 $15.00 $10.00 $15.00 $15.00
B4807 $15.00 $5.00 $10.00 $10.00
B4808 $15.00 $10.00 $15.00 $18.00
B4809 $15.00 $6.00 $8.00 $8.00
B4810 $12.00 $10.00 $12.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4811 $15.00 $10.00 $15.00 $20.00
B4812 $15.00 $5.00 $15.00 $15.00
B4813 $15.00 $10.00 $15.00 $15.00
B4814 $15.00 $10.00 $15.00 $15.00
B4815 $15.00 $5.00 $15.00 $15.00
B4816 $15.00 $10.00 $15.00 $15.00
B4817 $15.00 $8.00 $12.00 $15.00
B4818 $15.00 $10.00 $20.00 $20.00
B4819 $15.00 $10.00 $20.00 $20.00
B4820 $15.00 $10.00 $20.00 $20.00
B4821 $15.00 $10.00 $20.00 $20.00
B4822 $15.00 $10.00 $15.00 $15.00
B4823 $15.00 $8.00 $12.00 $15.00
B4824 $15.00 $5.00 $10.00 $10.00
B4825 $15.00 $10.00 $15.00 $15.00
B4826 $15.00 $10.00 $15.00 $15.00
B4827 $15.00 $8.00 $12.00 $15.00
B4828 NADA $10.00 $15.00 $20.00
B4829 $15.00 $5.00 $15.00 $15.00
B4830 $15.00 $5.00 $15.00 $15.00
B4831 $15.00 $8.00 $12.00 $15.00
B4832 $15.00 $5.00 $15.00 $15.00
B4833 $15.00 $5.00 $10.00 $10.00
B4834 $15.00 $10.00 $15.00 $15.00
B4835 $15.00 $5.00 $10.00 $10.00
B4836 $15.00 $10.00 $15.00 $15.00
B4837 NADA $3.00 $7.00 $10.00
B4838 NADA $3.00 $7.00 $10.00
B4839 $15.00 $10.00 $15.00 $20.00
B4840 $15.00 $8.00 $12.00 $15.00
B4841 $15.00 $5.00 $15.00 $15.00
B4842 $15.00 $8.00 $12.00 $15.00
B4843 $15.00 $8.00 $12.00 $15.00
B4844 $15.00 $10.00 $15.00 $15.00
B4845 $15.00 $15.00 $20.00 $20.00
B4846 $15.00 $10.00 $15.00 $15.00
B4847 $15.00 $10.00 $15.00 $20.00
B4848 $12.00 $10.00 $12.00 $15.00
B4849 $12.00 $10.00 $12.00 $15.00
B4850 $15.00 $10.00 $15.00 $20.00
B4851 $15.00 $10.00 $15.00 $15.00
B4852 $15.00 $5.00 $15.00 $15.00
B4853 $15.00 $10.00 $15.00 $15.00
B4854 $15.00 $8.00 $12.00 $15.00
B4855 $15.00 $5.00 $15.00 $15.00
B4856 $15.00 $10.00 $15.00 $15.00
B4857 $15.00 $7.00 $18.00 $20.00
B4858 $15.00 $7.00 $18.00 $20.00
B4859 $15.00 $5.00 $15.00 $15.00
B4860 $15.00 $8.00 $10.00 $12.00
B4861 $15.00 $5.00 $15.00 $15.00
B4862 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4863 $15.00 $8.00 $12.00 $15.00
B4864 $12.00 $10.00 $12.00 $15.00
B4865 $15.00 $5.00 $10.00 $15.00
B4866 $15.00 $5.00 $10.00 $15.00
B4867 $15.00 $5.00 $10.00 $15.00
B4868 $15.00 $10.00 $15.00 $20.00
B4869 $15.00 $8.00 $12.00 $15.00
B4870 $15.00 $12.00 $15.00 $18.00
B4871 $15.00 $10.00 $15.00 $15.00
B4872 $15.00 $10.00 $20.00 $20.00
B4873 $15.00 $10.00 $20.00 $20.00
B4874 $15.00 $7.00 $12.00 $15.00
B4875 $15.00 $10.00 $20.00 $20.00
B4876 $15.00 $10.00 $20.00 $20.00
B4877 $12.00 $10.00 $12.00 $15.00
B4878 $15.00 $5.00 $10.00 $10.00
B4879 $15.00 $5.00 $10.00 $10.00
B4880 $15.00 $8.00 $12.00 $15.00
B4881 $15.00 $5.00 $10.00 $10.00
B4882 $15.00 $10.00 $15.00 $15.00
B4883 $15.00 $5.00 $15.00 $15.00
B4884 $15.00 $5.00 $15.00 $15.00
B4885 $15.00 $10.00 $15.00 $15.00
B4886 NADA $10.00 $15.00 $20.00
B4887 $15.00 $5.00 $15.00 $15.00
B4888 $15.00 $10.00 $15.00 $15.00
B4889 $15.00 $5.00 $15.00 $15.00
B4890 $15.00 $10.00 $15.00 $15.00
B4891 $15.00 $10.00 $15.00 $15.00
B4892 $15.00 $8.00 $12.00 $15.00
B4893 $15.00 $10.00 $15.00 $15.00
B4894 $15.00 $5.00 $10.00 $10.00
B4895 $15.00 $10.00 $15.00 $15.00
B4896 $15.00 $10.00 $15.00 $15.00
B4897 $15.00 $10.00 $15.00 $15.00
B4898 $10.00 $10.00 $15.00 $20.00
B4899 $12.00 $10.00 $12.00 $15.00
B4900 $15.00 $15.00 $20.00 $25.00
B4901 $15.00 $10.00 $15.00 $15.00
B4902 $15.00 $5.00 $10.00 $10.00
B4903 $15.00 $10.00 $15.00 $15.00
B4904 NADA $10.00 $18.00 $20.00
B4905 $15.00 $5.00 $15.00 $15.00
B4906 $15.00 $5.00 $15.00 $15.00
B4907 $15.00 $5.00 $15.00 $15.00
B4908 $15.00 $5.00 $15.00 $15.00
B4909 $15.00 $10.00 $15.00 $15.00
B4910 $15.00 $10.00 $15.00 $15.00
B4911 $12.00 $10.00 $12.00 $15.00
B4912 $15.00 $5.00 $10.00 $10.00
B4913 $15.00 $5.00 $15.00 $15.00
B4914 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4915 $15.00 $10.00 $15.00 $15.00
B4916 $15.00 $5.00 $15.00 $15.00
B4917 $15.00 $10.00 $15.00 $15.00
B4918 $15.00 $10.00 $15.00 $20.00
B4919 $15.00 $10.00 $15.00 $20.00
B4920 $15.00 $12.00 $18.00 $22.00
B4921 $15.00 $10.00 $15.00 $18.00
B4922 $15.00 $5.00 $15.00 $15.00
B4923 $15.00 $10.00 $15.00 $15.00
B4924 $15.00 $10.00 $15.00 $15.00
B4925 $15.00 $10.00 $15.00 $18.00
B4926 $15.00 $10.00 $15.00 $18.00
B4927 $15.00 $10.00 $15.00 $15.00
B4928 $15.00 $10.00 $15.00 $15.00
B4929 $15.00 $8.00 $12.00 $15.00
B4930 $15.00 $5.00 $10.00 $10.00
B4931 $15.00 $10.00 $15.00 $15.00
B4932 $15.00 $5.00 $15.00 $15.00
B4933 $15.00 $5.00 $10.00 $10.00
B4934 $10.00 $5.00 $10.00 $15.00
B4935 $15.00 $10.00 $15.00 $15.00
B4936 $15.00 $10.00 $15.00 $15.00
B4937 $15.00 $15.00 $20.00 $20.00
B4938 $15.00 $5.00 $15.00 $15.00
B4939 $15.00 $10.00 $15.00 $18.00
B4940 $12.00 $10.00 $12.00 $15.00
B4941 $15.00 $10.00 $15.00 $18.00
B4942 $12.00 $10.00 $12.00 $15.00
B4943 $15.00 $10.00 $15.00 $15.00
B4944 $15.00 $10.00 $15.00 $15.00
B4945 $15.00 $10.00 $15.00 $15.00
B4946 $15.00 $5.00 $15.00 $15.00
B4947 $15.00 $10.00 $15.00 $15.00
B4948 $15.00 $12.00 $15.00 $18.00
B4949 $15.00 $10.00 $15.00 $15.00
B4950 $15.00 $8.00 $12.00 $15.00
B4951 $15.00 $5.00 $10.00 $10.00
B4952 $15.00 $5.00 $15.00 $15.00
B4953 $15.00 $8.00 $12.00 $15.00
B4954 $15.00 $5.00 $15.00 $15.00
B4955 $15.00 $5.00 $15.00 $15.00
B4956 $15.00 $5.00 $15.00 $15.00
B4957 $15.00 $10.00 $15.00 $15.00
B4958 $15.00 $10.00 $15.00 $15.00
B4959 $15.00 $10.00 $15.00 $15.00
B4960 $15.00 $10.00 $15.00 $15.00
B4961 $15.00 $5.00 $15.00 $15.00
B4962 $15.00 $10.00 $15.00 $15.00
B4963 $15.00 $10.00 $15.00 $15.00
B4964 $15.00 $10.00 $15.00 $20.00
B4965 $15.00 $10.00 $15.00 $15.00
B4966 $15.00 $15.00 $20.00 $20.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B4967 $15.00 $5.00 $15.00 $15.00
B4968 $15.00 $12.00 $18.00 $20.00
B4969 $15.00 $10.00 $15.00 $18.00
B4970 $15.00 $10.00 $15.00 $20.00
B4971 $15.00 $12.00 $18.00 $20.00
B4972 $15.00 $12.00 $18.00 $20.00
B4973 $15.00 $5.00 $10.00 $10.00
B4974 $15.00 $8.00 $12.00 $15.00
B4975 $15.00 $5.00 $15.00 $15.00
B4976 $15.00 $8.00 $12.00 $15.00
B4977 $15.00 $5.00 $15.00 $15.00
B4978 $15.00 $5.00 $15.00 $15.00
B4979 $15.00 $8.00 $12.00 $15.00
B4980 $15.00 $5.00 $15.00 $15.00
B4981 $15.00 $8.00 $15.00 $18.00
B4982 $15.00 $5.00 $10.00 $10.00
B4983 $15.00 $5.00 $15.00 $15.00
B4984 $15.00 $10.00 $15.00 $15.00
B4985 $15.00 $10.00 $15.00 $15.00
B4986 $15.00 $7.00 $7.00 $7.00
B4987 $15.00 $10.00 $15.00 $15.00
B4988 $15.00 $5.00 $15.00 $15.00
B4989 $15.00 $5.00 $15.00 $15.00
B4990 $15.00 $5.00 $10.00 $10.00
B4991 NADA $5.00 $15.00 $15.00
B4992 $15.00 $12.00 $18.00 $20.00
B4993 $15.00 $5.00 $15.00 $15.00
B4994 $15.00 $10.00 $15.00 $15.00
B4995 $15.00 $10.00 $15.00 $15.00
B4996 $15.00 $5.00 $7.00 $10.00
B4997 NADA $5.00 $10.00 $12.00
B4998 NADA $5.00 $10.00 $12.00
B4999 $15.00 $8.00 $12.00 $15.00
B5000 $15.00 $8.00 $12.00 $15.00
B5001 $15.00 $7.00 $18.00 $18.00
B5002 $15.00 $5.00 $12.00 $15.00
B5003 $15.00 $5.00 $10.00 $10.00
B5004 $15.00 $5.00 $15.00 $15.00
B5005 $15.00 $5.00 $15.00 $15.00
B5006 $15.00 $10.00 $15.00 $20.00
B5007 $12.00 $10.00 $12.00 $15.00
B5008 $15.00 $10.00 $15.00 $15.00
B5009 $15.00 $5.00 $15.00 $18.00
B5010 $15.00 $5.00 $15.00 $15.00
B5011 $15.00 $10.00 $15.00 $15.00
B5012 $15.00 $10.00 $15.00 $20.00
B5013 $15.00 $5.00 $15.00 $15.00
B5014 $15.00 $8.00 $12.00 $15.00
B5015 $15.00 $5.00 $7.00 $10.00
B5016 $15.00 $10.00 $15.00 $20.00
B5017 $15.00 $10.00 $15.00 $15.00
B5018 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5019 $15.00 $4.00 $15.00 $20.00
B5020 $15.00 $5.00 $15.00 $15.00
B5021 $15.00 $10.00 $15.00 $15.00
B5022 $15.00 $10.00 $12.00 $18.00
B5023 $15.00 $10.00 $15.00 $15.00
B5024 $15.00 $10.00 $12.00 $15.00
B5025 $15.00 $5.00 $12.00 $15.00
B5026 $15.00 $10.00 $15.00 $15.00
B5027 $15.00 $15.00 $18.00 $20.00
B5028 $15.00 $12.00 $15.00 $18.00
B5029 $15.00 $12.00 $15.00 $18.00
B5030 $15.00 $10.00 $15.00 $15.00
B5031 $10.00 $5.00 $10.00 $15.00
B5032 $15.00 $10.00 $15.00 $15.00
B5033 $15.00 $5.00 $10.00 $10.00
B5034 $15.00 $15.00 $18.00 $20.00
B5035 $15.00 $5.00 $15.00 $15.00
B5036 $15.00 $5.00 $10.00 $10.00
B5037 $15.00 $5.00 $10.00 $10.00
B5038 $10.00 $12.00 $15.00 $20.00
B5039 $15.00 $5.00 $15.00 $15.00
B5040 $15.00 $10.00 $15.00 $15.00
B5041 $15.00 $10.00 $15.00 $15.00
B5042 $15.00 $5.00 $15.00 $15.00
B5043 $15.00 $10.00 $15.00 $15.00
B5044 $15.00 $10.00 $15.00 $15.00
B5045 $15.00 $5.00 $10.00 $10.00
B5046 $15.00 $10.00 $15.00 $15.00
B5047 $15.00 $12.00 $15.00 $18.00
B5048 $15.00 $10.00 $12.00 $15.00
B5049 $15.00 $12.00 $15.00 $18.00
B5050 $15.00 $8.00 $12.00 $15.00
B5051 $15.00 $10.00 $15.00 $15.00
B5052 $15.00 $10.00 $15.00 $15.00
B5053 $15.00 $10.00 $15.00 $15.00
B5054 $15.00 $8.00 $12.00 $15.00
B5055 $15.00 $8.00 $12.00 $15.00
B5056 $15.00 $5.00 $15.00 $15.00
B5057 $15.00 $5.00 $18.00 $18.00
B5058 $12.00 $10.00 $12.00 $15.00
B5059 $15.00 $10.00 $15.00 $15.00
B5060 $15.00 $10.00 $12.00 $15.00
B5061 $15.00 $10.00 $15.00 $18.00
B5062 $15.00 $5.00 $10.00 $10.00
B5063 $15.00 $10.00 $20.00 $20.00
B5064 $15.00 $10.00 $15.00 $18.00
B5065 $15.00 $10.00 $15.00 $18.00
B5066 $15.00 $10.00 $15.00 $18.00
B5067 $15.00 $10.00 $15.00 $18.00
B5068 $15.00 $5.00 $15.00 $15.00
B5069 $15.00 $10.00 $20.00 $20.00
B5070 $15.00 $8.00 $15.00 $18.00
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5071 $15.00 $8.00 $15.00 $18.00
B5072 $15.00 $10.00 $15.00 $15.00
B5073 $15.00 $10.00 $15.00 $15.00
B5074 $15.00 $10.00 $15.00 $20.00
B5075 NADA $10.00 $15.00 $20.00
B5076 $15.00 $7.00 $15.00 $15.00
B5077 $15.00 $8.00 $10.00 $12.00
B5078 $15.00 $10.00 $15.00 $18.00
B5079 $15.00 $8.00 $15.00 $15.00
B5080 $15.00 $5.00 $10.00 $10.00
B5081 $15.00 $10.00 $15.00 $15.00
B5082 $15.00 $8.00 $12.00 $15.00
B5083 $15.00 $5.00 $15.00 $15.00
B5084 $15.00 $5.00 $10.00 $10.00
B5085 $15.00 $10.00 $15.00 $15.00
B5086 $15.00 $10.00 $15.00 $15.00
B5087 $15.00 $10.00 $10.00 $10.00
B5088 $15.00 $10.00 $10.00 $10.00
B5089 $15.00 $10.00 $10.00 $10.00
B5090 $15.00 $5.00 $10.00 $10.00
B5091 $15.00 $5.00 $15.00 $15.00
B5092 $15.00 $10.00 $15.00 $15.00
B5093 $15.00 $10.00 $15.00 $15.00
B5094 $15.00 $10.00 $10.00 $10.00
B5095 $15.00 $10.00 $15.00 $15.00
B5096 $15.00 $5.00 $15.00 $15.00
B5097 $15.00 $10.00 $15.00 $20.00
B5098 $15.00 $5.00 $10.00 $10.00
B5099 $15.00 $8.00 $12.00 $15.00
B5100 $15.00 $10.00 $15.00 $15.00
B5101 $15.00 $8.00 $12.00 $15.00
B5102 $15.00 $10.00 $18.00 $20.00
B5103 $15.00 $5.00 $15.00 $15.00
B5104 NADA $5.00 $10.00 $10.00
B5105 $15.00 $8.00 $12.00 $15.00
B5106 $15.00 $5.00 $15.00 $15.00
B5107 $10.00 $5.00 $10.00 $15.00
B5108 $15.00 $10.00 $15.00 $15.00
B5109 $15.00 $5.00 $15.00 $15.00
B5110 $15.00 $5.00 $15.00 $15.00
B5111 $15.00 $10.00 $20.00 $20.00
B5112 $15.00 $5.00 $15.00 $15.00
B5113 $15.00 $10.00 $15.00 $15.00
B5114 $15.00 $10.00 $15.00 $15.00
B5115 $15.00 $5.00 $15.00 $15.00
B5116 $15.00 $10.00 $15.00 $15.00
B5117 $15.00 $8.00 $12.00 $15.00
B5118 $15.00 $10.00 $15.00 $15.00
B5119 $15.00 $5.00 $10.00 $10.00
B5120 $15.00 $10.00 $15.00 $15.00
B5121 $15.00 $5.00 $15.00 $15.00
B5122 $15.00 $8.00 $12.00 $15.00
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5123 $15.00 $10.00 $15.00 $15.00
B5124 $15.00 $5.00 $10.00 $15.00
B5125 $15.00 $10.00 $15.00 $15.00
B5125 $15.00 $10.00 $15.00 $15.00
B5126 $15.00 $5.00 $10.00 $10.00
B5127 $15.00 $5.00 $15.00 $15.00
B5128 $15.00 $5.00 $10.00 $10.00
B5129 $15.00 $5.00 $15.00 $15.00
B5130 $15.00 $5.00 $10.00 $10.00
B5131 $15.00 $5.00 $10.00 $10.00
B5132 $15.00 $15.00 $15.00 $20.00
B5133 $15.00 $8.00 $15.00 $18.00
B5134 $15.00 $8.00 $15.00 $18.00
B5135 $15.00 $5.00 $10.00 $10.00
B5136 $15.00 $10.00 $15.00 $15.00
B5137 $15.00 $5.00 $15.00 $15.00
B5138 $15.00 $5.00 $10.00 $10.00
B5139 $15.00 $5.00 $10.00 $10.00
B5140 $12.00 $10.00 $12.00 $15.00
B5141 $15.00 $10.00 $15.00 $15.00
B5142 $15.00 $10.00 $15.00 $15.00
B5143 $15.00 $10.00 $15.00 $15.00
B5144 $15.00 $10.00 $18.00 $20.00
B5145 $15.00 $10.00 $15.00 $15.00
B5146 $15.00 $5.00 $15.00 $15.00
B5147 $15.00 $10.00 $18.00 $20.00
B5148 $15.00 $8.00 $12.00 $15.00
B5149 $15.00 $5.00 $15.00 $15.00
B5150 $15.00 $10.00 $12.00 $15.00
B5151 $15.00 $10.00 $15.00 $15.00
B5152 $15.00 $5.00 $10.00 $10.00
B5153 $15.00 $8.00 $12.00 $15.00
B5154 $15.00 $10.00 $12.00 $15.00
B5155 $15.00 $8.00 $10.00 $12.00
B5156 $15.00 $5.00 $10.00 $10.00
B5157 $15.00 $5.00 $10.00 $10.00
B5158 $15.00 $5.00 $15.00 $15.00
B5159 $15.00 $10.00 $15.00 $15.00
B5160 $15.00 $10.00 $15.00 $15.00
B5161 $15.00 $10.00 $15.00 $15.00
B5162 $15.00 $5.00 $15.00 $15.00
B5163 NADA $10.00 $15.00 $18.00
B5164 NADA $10.00 $15.00 $18.00
B5165 NADA $8.00 $10.00 $15.00
B5166 $15.00 $10.00 $15.00 $15.00
B5167 NADA $8.00 $12.00 $15.00
B5168 $15.00 $10.00 $15.00 $15.00
B5169 $15.00 $10.00 $15.00 $15.00
B5170 $15.00 $8.00 $12.00 $15.00
B5171 NADA $8.00 $15.00 $15.00
B5172 $15.00 $8.00 $12.00 $15.00
B5173 $15.00 $8.00 $12.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5174 $15.00 $10.00 $15.00 $15.00
B5175 $15.00 $10.00 $15.00 $15.00
B5176 $15.00 $5.00 $10.00 $10.00
B5177 $15.00 $5.00 $15.00 $15.00
B5178 $15.00 $4.00 $15.00 $18.00
B5179 $15.00 $7.00 $18.00 $20.00
B5180 $15.00 $7.00 $15.00 $18.00
B5181 $15.00 $5.00 $10.00 $10.00
B5182 $15.00 $18.00 $22.00 $25.00
B5183 $15.00 $7.00 $18.00 $20.00
B5184 $15.00 $10.00 $15.00 $15.00
B5185 $15.00 $10.00 $15.00 $15.00
B5186 $15.00 $5.00 $15.00 $15.00
B5187 $15.00 $5.00 $10.00 $10.00
B5188 $15.00 $10.00 $15.00 $20.00
B5189 $15.00 $5.00 $10.00 $10.00
B5190 $15.00 $10.00 $15.00 $15.00
B5191 $15.00 $5.00 $15.00 $15.00
B5192 $15.00 $10.00 $15.00 $20.00
B5193 $15.00 $5.00 $10.00 $10.00
B5194 $15.00 $10.00 $15.00 $20.00
B5195 $15.00 $5.00 $18.00 $18.00
B5196 $15.00 $10.00 $15.00 $15.00
B5197 $15.00 $10.00 $15.00 $15.00
B5198 $15.00 $10.00 $15.00 $20.00
B5199 $15.00 $5.00 $15.00 $15.00
B5200 $15.00 $10.00 $15.00 $15.00
B5201 $15.00 $5.00 $10.00 $15.00
B5202 $15.00 $5.00 $10.00 $15.00
B5203 NADA $6.00 $10.00 $12.00
B5204 $15.00 $10.00 $15.00 $20.00
B5205 $15.00 $15.00 $20.00 $20.00
B5206 NADA $3.00 $7.00 $10.00
B5207 NADA $6.00 $10.00 $12.00
B5208 $15.00 $10.00 $15.00 $15.00
B5209 $15.00 $10.00 $15.00 $18.00
B5210 $15.00 $10.00 $15.00 $18.00
B5211 $10.00 $10.00 $12.00 $15.00
B5212 NADA $10.00 $15.00 $18.00
B5213 $15.00 $5.00 $15.00 $15.00
B5214 NADA $10.00 $12.00 $15.00
B5215 NADA $12.00 $18.00 $18.00
B5216 $15.00 $10.00 $15.00 $18.00
B5217 $15.00 $10.00 $15.00 $18.00
B5218 $10.00 $10.00 $12.00 $15.00
B5219 $15.00 $3.00 $5.00 $7.00
B5220 $15.00 $15.00 $20.00 $20.00
B5221 $15.00 $8.00 $12.00 $15.00
B5222 $15.00 $10.00 $15.00 $15.00
B5223 $15.00 $10.00 $15.00 $20.00
B5224 $15.00 $10.00 $15.00 $15.00
B5225 $15.00 $10.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5226 $12.00 $10.00 $12.00 $15.00
B5227 $15.00 $8.00 $12.00 $15.00
B5228 $15.00 $12.00 $15.00 $18.00
B5229 $15.00 $8.00 $15.00 $15.00
B5230 $15.00 $5.00 $12.00 $15.00
B5231 $15.00 $10.00 $15.00 $18.00
B5232 $15.00 $10.00 $15.00 $18.00
B5233 $15.00 $10.00 $18.00 $20.00
B5234 $15.00 $10.00 $15.00 $15.00
B5235 $15.00 $10.00 $15.00 $15.00
B5236 $12.00 $10.00 $12.00 $15.00
B5237 $15.00 $15.00 $18.00 $22.00
B5238 $15.00 $15.00 $15.00 $20.00
B5239 $15.00 $8.00 $12.00 $15.00
B5240 $15.00 $8.00 $10.00 $12.00
B5241 $15.00 $10.00 $12.00 $15.00
B5242 $15.00 $10.00 $15.00 $15.00
B5243 $15.00 $5.00 $15.00 $15.00
B5244 $15.00 $4.00 $15.00 $20.00
B5245 $15.00 $5.00 $10.00 $10.00
B5246 $15.00 $5.00 $10.00 $10.00
B5247 $15.00 $5.00 $10.00 $10.00
B5248 $15.00 $5.00 $10.00 $10.00
B5249 $15.00 $5.00 $15.00 $15.00
B5250 $15.00 $10.00 $15.00 $15.00
B5251 $15.00 $5.00 $10.00 $10.00
B5252 $15.00 $10.00 $18.00 $18.00
B5253 $15.00 $10.00 $15.00 $15.00
B5254 $15.00 $8.00 $12.00 $15.00
B5255 $15.00 $10.00 $15.00 $20.00
B5256 $15.00 $5.00 $15.00 $15.00
B5257 $15.00 $8.00 $12.00 $12.00
B5258 $15.00 $10.00 $15.00 $15.00
B5259 $15.00 $10.00 $15.00 $15.00
B5260 $15.00 $15.00 $15.00 $20.00
B5261 $15.00 $5.00 $18.00 $20.00
B5262 $15.00 $8.00 $12.00 $15.00
B5263 $15.00 $10.00 $15.00 $15.00
B5264 $15.00 $10.00 $15.00 $20.00
B5265 $15.00 $5.00 $15.00 $18.00
B5266 $15.00 $5.00 $15.00 $18.00
B5267 $15.00 $5.00 $15.00 $18.00
B5268 $15.00 $5.00 $15.00 $18.00
B5269 $15.00 $5.00 $15.00 $18.00
B5270 $15.00 $5.00 $15.00 $18.00
B5271 $15.00 $10.00 $12.00 $15.00
B5272 $15.00 $10.00 $12.00 $15.00
B5273 $15.00 $10.00 $12.00 $15.00
B5274 $15.00 $12.00 $15.00 $15.00
B5275 $15.00 $5.00 $15.00 $15.00
B5276 $15.00 $5.00 $10.00 $10.00
B5277 $15.00 $8.00 $15.00 $18.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5278 $15.00 $10.00 $15.00 $20.00
B5279 $15.00 $10.00 $15.00 $20.00
B5280 $15.00 $8.00 $12.00 $15.00
B5281 $15.00 $15.00 $15.00 $20.00
B5282 $15.00 $12.00 $15.00 $18.00
B5283 $15.00 $10.00 $12.00 $15.00
B5284 $15.00 $12.00 $15.00 $18.00
B5286 $15.00 $5.00 $15.00 $15.00
B5287 $15.00 $5.00 $15.00 $15.00
B5288 $15.00 $5.00 $15.00 $15.00
B5289 $15.00 $4.00 $15.00 $20.00
B5290 $15.00 $6.00 $8.00 $8.00
B5291 $15.00 $5.00 $10.00 $15.00
B5292 $12.00 $10.00 $12.00 $15.00
B5293 $12.00 $10.00 $12.00 $15.00
B5294 $15.00 $5.00 $10.00 $10.00
B5295 $15.00 $5.00 $15.00 $15.00
B5296 $12.00 $10.00 $12.00 $15.00
B5297 $15.00 $10.00 $15.00 $20.00
B5298 $12.00 $10.00 $12.00 $15.00
B5299 $15.00 $8.00 $15.00 $18.00
B5300 $10.00 $5.00 $10.00 $15.00
B5301 $10.00 $5.00 $10.00 $15.00
B5302 $15.00 $10.00 $15.00 $18.00
B5303 $15.00 $10.00 $20.00 $20.00
B5304 $15.00 $10.00 $20.00 $20.00
B5305 $15.00 $10.00 $15.00 $18.00
B5306 $15.00 $10.00 $20.00 $20.00
B5307 $15.00 $10.00 $20.00 $20.00
B5308 $12.00 $10.00 $12.00 $15.00
B5309 $15.00 $5.00 $15.00 $15.00
B5310 $15.00 $8.00 $12.00 $15.00
B5311 $15.00 $10.00 $15.00 $15.00
B5312 $15.00 $5.00 $15.00 $15.00
B5313 NADA NADA NADA NADA
B5314 NADA $10.00 $15.00 $15.00
B5315 $15.00 $8.00 $15.00 $18.00
B5316 $15.00 $5.00 $10.00 $15.00
B5317 $15.00 $10.00 $15.00 $15.00
B5318 $15.00 $5.00 $10.00 $15.00
B5319 $15.00 $8.00 $12.00 $15.00
B5320 $15.00 $8.00 $12.00 $15.00
B5321 $12.00 $10.00 $12.00 $15.00
B5322 $15.00 $10.00 $15.00 $20.00
B5323 $15.00 $10.00 $15.00 $15.00
B5324 $15.00 $10.00 $15.00 $18.00
B5325 $15.00 $6.00 $8.00 $8.00
B5326 $15.00 $5.00 $15.00 $15.00
B5327 NADA $2.00 $2.00 $2.00
B5328 $15.00 $10.00 $15.00 $15.00
B5329 $15.00 $8.00 $12.00 $15.00
B5330 $15.00 $10.00 $20.00 $20.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5331 $15.00 $5.00 $15.00 $15.00
B5332 $15.00 $10.00 $15.00 $15.00
B5333 $15.00 $5.00 $15.00 $15.00
B5334 $15.00 $10.00 $15.00 $15.00
B5335 $12.00 $10.00 $12.00 $15.00
B5336 $15.00 $10.00 $15.00 $15.00
B5337 $12.00 $10.00 $12.00 $15.00
B5338 $15.00 $5.00 $10.00 $10.00
B5339 $15.00 $12.00 $15.00 $18.00
B5340 $10.00 $5.00 $10.00 $15.00
B5341 $15.00 $10.00 $18.00 $18.00
B5342 NADA $10.00 $20.00 $20.00
B5343 NADA $10.00 $20.00 $20.00
B5344 $15.00 $5.00 $10.00 $10.00
B5345 NADA $5.00 $10.00 $15.00
B5346 NADA $10.00 $15.00 $15.00
B5347 NADA $10.00 $20.00 $20.00
B5348 NADA $10.00 $20.00 $20.00
B5349 NADA $5.00 $10.00 $10.00
B5350 NADA $5.00 $10.00 $15.00
B5351 NADA $10.00 $15.00 $15.00
B5352 NADA $10.00 $20.00 $20.00
B5353 NADA $10.00 $20.00 $20.00
B5354 NADA $5.00 $10.00 $10.00
B5355 NADA $5.00 $10.00 $15.00
B5356 NADA $10.00 $15.00 $15.00
B5357 NADA $10.00 $20.00 $20.00
B5358 NADA $10.00 $20.00 $20.00
B5359 NADA $5.00 $10.00 $10.00
B5360 $12.00 $10.00 $12.00 $15.00
B5361 $15.00 $5.00 $15.00 $15.00
B5362 $15.00 $5.00 $15.00 $15.00
B5363 $15.00 $5.00 $10.00 $15.00
B5364 $15.00 $5.00 $10.00 $15.00
B5365 $15.00 $5.00 $10.00 $15.00
B5366 $15.00 $5.00 $20.00 $20.00
B5367 $15.00 $5.00 $20.00 $20.00
B5368 $15.00 $5.00 $10.00 $10.00
B5369 $15.00 $10.00 $15.00 $18.00
B5370 $15.00 $15.00 $15.00 $18.00
B5371 $15.00 $15.00 $15.00 $18.00
B5372 $15.00 $8.00 $15.00 $15.00
B5373 $15.00 $5.00 $15.00 $15.00
B5374 $15.00 $10.00 $20.00 $20.00
B5375 $15.00 $10.00 $20.00 $20.00
B5376 $15.00 $10.00 $20.00 $20.00
B5377 $15.00 $5.00 $15.00 $15.00
B5378 $15.00 $10.00 $15.00 $20.00
B5379 $15.00 $10.00 $15.00 $20.00
B5380 $15.00 $5.00 $10.00 $15.00
B5381 $15.00 $12.00 $15.00 $18.00
B5382 $15.00 $10.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5383 $15.00 $5.00 $10.00 $15.00
B5384 $15.00 $5.00 $10.00 $15.00
B5385 $15.00 $12.00 $15.00 $20.00
B5386 $15.00 $5.00 $15.00 $15.00
B5387 $15.00 $5.00 $15.00 $15.00
B5388 $15.00 $12.00 $15.00 $18.00
B5389 $15.00 $10.00 $15.00 $15.00
B5390 $15.00 $15.00 $20.00 $25.00
B5391 $15.00 $8.00 $10.00 $12.00
B5392 $15.00 $4.00 $15.00 $20.00
B5393 $12.00 $10.00 $12.00 $15.00
B5394 $15.00 $8.00 $12.00 $15.00
B5395 $15.00 $5.00 $10.00 $10.00
B5396 $15.00 $10.00 $15.00 $15.00
B5397 $15.00 $5.00 $15.00 $15.00
B5398 $15.00 $8.00 $10.00 $12.00
B5399 $15.00 $8.00 $10.00 $12.00
B5400 NADA $10.00 $15.00 $15.00
B5401 $15.00 $8.00 $12.00 $15.00
B5402 $15.00 $5.00 $15.00 $15.00
B5403 $15.00 $7.00 $15.00 $15.00
B5404 $15.00 $7.00 $15.00 $15.00
B5405 $15.00 $10.00 $15.00 $15.00
B5406 $15.00 $10.00 $15.00 $15.00
B5407 $15.00 $7.00 $15.00 $15.00
B5408 $15.00 $7.00 $15.00 $15.00
B5409 $15.00 $10.00 $15.00 $15.00
B5410 $15.00 $10.00 $15.00 $15.00
B5411 $15.00 $10.00 $15.00 $15.00
B5412 $15.00 $10.00 $15.00 $15.00
B5413 $15.00 $10.00 $15.00 $15.00
B5414 $15.00 $10.00 $15.00 $15.00
B5415 $15.00 $5.00 $15.00 $15.00
B5416 NADA $10.00 $17.00 $18.00
B5417 NADA $10.00 $15.00 $15.00
B5418 $15.00 $10.00 $15.00 $15.00
B5419 $15.00 $10.00 $15.00 $15.00
B5420 NADA $5.00 $10.00 $15.00
B5421 NADA $10.00 $15.00 $15.00
B5422 NADA $10.00 $20.00 $20.00
B5423 NADA $10.00 $20.00 $20.00
B5424 NADA $5.00 $10.00 $10.00
B5425 $15.00 $5.00 $10.00 $10.00
B5426 $15.00 $10.00 $15.00 $20.00
B5427 $15.00 $8.00 $10.00 $12.00
B5428 $12.00 $10.00 $12.00 $15.00
B5429 $15.00 $5.00 $10.00 $10.00
B5430 $15.00 $10.00 $15.00 $20.00
B5431 $15.00 $8.00 $12.00 $15.00
B5431 $15.00 $8.00 $12.00 $15.00
B5432 NADA $3.00 $7.00 $10.00
B5433 $15.00 $8.00 $12.00 $15.00
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5434 $15.00 $8.00 $12.00 $15.00
B5436 $15.00 $10.00 $15.00 $15.00
B5437 $15.00 $12.00 $15.00 $20.00
B5438 $15.00 $10.00 $15.00 $20.00
B5439 $15.00 $8.00 $12.00 $15.00
B5440 $15.00 $10.00 $15.00 $15.00
B5441 $15.00 $10.00 $20.00 $20.00
B5442 NADA $10.00 $15.00 $15.00
B5443 $15.00 $4.00 $15.00 $20.00
B5444 $15.00 $8.00 $12.00 $15.00
B5445 NADA NADA $10.00 $15.00
B5446 NADA NADA $10.00 $15.00
B5447 NADA $10.00 $15.00 $15.00
B5448 $15.00 $12.00 $15.00 $20.00
B5449 $15.00 $5.00 $15.00 $20.00
B5450 $15.00 $5.00 $15.00 $20.00
B5451 $15.00 $10.00 $15.00 $15.00
B5452 $15.00 $10.00 $15.00 $15.00
B5453 $15.00 $4.00 $15.00 $20.00
B5454 $15.00 $4.00 $15.00 $20.00
B5455 $15.00 $10.00 $15.00 $15.00
B5456 $15.00 $10.00 $15.00 $20.00
B5457 $15.00 $10.00 $15.00 $20.00
B5458 $15.00 $10.00 $15.00 $15.00
B5459 $15.00 $5.00 $15.00 $15.00
B5460 $15.00 $8.00 $12.00 $15.00
B5461 $15.00 $10.00 $12.00 $18.00
B5462 $15.00 $12.00 $15.00 $20.00
B5463 $15.00 $10.00 $12.00 $18.00
B5464 $15.00 $12.00 $15.00 $20.00
B5465 $15.00 $12.00 $15.00 $18.00
B5466 $15.00 $12.00 $15.00 $18.00
B5467 $15.00 $8.00 $12.00 $15.00
B5468 $15.00 $12.00 $15.00 $20.00
B5469 $15.00 $8.00 $12.00 $15.00
B5470 $15.00 $8.00 $12.00 $15.00
B5471 $15.00 $10.00 $12.00 $18.00
B5472 $15.00 $10.00 $15.00 $20.00
B5473 $15.00 $8.00 $12.00 $15.00
B5474 $15.00 $10.00 $12.00 $18.00
B5475 $15.00 $8.00 $12.00 $15.00
B5476 NADA $2.00 $2.00 $2.00
B5477 $15.00 $10.00 $15.00 $20.00
B5478 $15.00 $10.00 $15.00 $15.00
B5479 $15.00 $12.00 $15.00 $18.00
B5480 $15.00 $8.00 $12.00 $15.00
B5481 $15.00 $10.00 $15.00 $20.00
B5482 $15.00 $10.00 $15.00 $15.00
B5483 $15.00 $12.00 $15.00 $18.00
B5484 $15.00 $10.00 $15.00 $20.00
B5485 $15.00 $5.00 $15.00 $15.00
B5486 $15.00 $5.00 $18.00 $18.00
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5487 $15.00 $12.00 $15.00 $20.00
B5488 $15.00 $10.00 $12.00 $18.00
B5489 $15.00 $12.00 $15.00 $20.00
B5490 $15.00 $5.00 $15.00 $15.00
B5491 $15.00 $12.00 $15.00 $18.00
B5492 $15.00 $12.00 $15.00 $18.00
B5493 $15.00 $12.00 $15.00 $18.00
B5494 $15.00 $5.00 $15.00 $15.00
B5495 $15.00 $5.00 $15.00 $15.00
B5496 $15.00 $10.00 $12.00 $18.00
B5497 $15.00 $8.00 $12.00 $15.00
B5498 $15.00 $10.00 $12.00 $18.00
B5499 $15.00 $8.00 $12.00 $15.00
B5500 $15.00 $12.00 $15.00 $20.00
B5501 $15.00 $5.00 $10.00 $10.00
B5502 $15.00 $10.00 $18.00 $20.00
B5503 $15.00 $5.00 $15.00 $15.00
B5504 NADA $10.00 $15.00 $20.00
B5505 NADA $10.00 $15.00 $20.00
B5506 $15.00 $10.00 $15.00 $20.00
B5507 NADA $5.00 $10.00 $15.00
B5508 NADA $10.00 $12.00 $15.00
B5509 $15.00 $5.00 $15.00 $15.00
B5510 NADA $10.00 $12.00 $15.00
B5511 NADA $10.00 $12.00 $15.00
B5512 $15.00 $10.00 $12.00 $18.00
B5513 $15.00 $8.00 $12.00 $15.00
B5514 NADA $10.00 $12.00 $15.00
B5515 NADA $10.00 $15.00 $20.00
B5516 NADA $10.00 $12.00 $15.00
B5517 $15.00 $10.00 $15.00 $15.00
B5518 $15.00 $10.00 $15.00 $15.00
B5519 NADA $10.00 $15.00 $20.00
B5520 $12.00 $10.00 $12.00 $15.00
B5521 NADA $10.00 $15.00 $20.00
B5522 NADA $5.00 $10.00 $15.00
B5523 NADA $10.00 $15.00 $20.00
B5524 NADA $10.00 $15.00 $20.00
B5525 $15.00 $8.00 $12.00 $15.00
B5526 $15.00 $10.00 $15.00 $20.00
B5527 $15.00 $5.00 $15.00 $15.00
B5528 $15.00 $10.00 $15.00 $15.00
B5529 $10.00 $5.00 $10.00 $15.00
B5530 $10.00 $5.00 $10.00 $15.00
B5531 NADA $10.00 $15.00 $20.00
B5532 NADA $5.00 $10.00 $15.00
B5533 NADA $10.00 $15.00 $20.00
B5534 $15.00 $12.00 $15.00 $18.00
B5535 $15.00 $8.00 $12.00 $15.00
B5536 NADA $10.00 $15.00 $20.00
B5537 $15.00 $8.00 $12.00 $15.00
B5538 NADA $10.00 $15.00 $20.00
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5539 $15.00 $10.00 $15.00 $20.00
B5540 $15.00 $10.00 $15.00 $20.00
B5541 $15.00 $10.00 $15.00 $15.00
B5542 $15.00 $10.00 $15.00 $15.00
B5543 $15.00 $8.00 $12.00 $15.00
B5544 $15.00 $5.00 $10.00 $10.00
B5545 $12.00 $10.00 $12.00 $15.00
B5546 $15.00 $8.00 $13.00 $15.00
B5547 $15.00 $8.00 $13.00 $15.00
B5548 $15.00 $10.00 $15.00 $15.00
B5549 $15.00 $10.00 $15.00 $20.00
B5550 $15.00 $10.00 $15.00 $20.00
B5551 $15.00 $10.00 $15.00 $20.00
B5552 $12.00 $10.00 $12.00 $15.00
B5553 $12.00 $10.00 $12.00 $15.00
B5554 $15.00 $10.00 $15.00 $20.00
B5555 NADA $5.00 $15.00 $20.00
B5556 $15.00 $5.00 $15.00 $15.00
B5557 $15.00 $10.00 $15.00 $15.00
B5558 $15.00 $5.00 $15.00 $15.00
B5559 $12.00 $10.00 $12.00 $15.00
B5560 $15.00 $10.00 $15.00 $20.00
B5561 $15.00 $5.00 $15.00 $15.00
B5562 $15.00 $5.00 $10.00 $10.00
B5563 $15.00 $10.00 $18.00 $20.00
B5564 $15.00 $10.00 $15.00 $20.00
B5565 $15.00 $10.00 $15.00 $20.00
B5566 $15.00 $10.00 $18.00 $20.00
B5567 $15.00 $5.00 $15.00 $15.00
B5568 $15.00 $10.00 $15.00 $20.00
B5569 $15.00 $10.00 $18.00 $18.00
B5570 $15.00 $10.00 $18.00 $20.00
B5571 $15.00 $10.00 $18.00 $20.00
B5572 $15.00 $5.00 $15.00 $15.00
B5573 $10.00 $10.00 $15.00 $20.00
B5574 $12.00 $10.00 $12.00 $15.00
B5575 $15.00 $8.00 $12.00 $15.00
B5576 $15.00 $10.00 $15.00 $20.00
B5577 $12.00 $10.00 $12.00 $15.00
B5578 $15.00 $10.00 $15.00 $20.00
B5579 $15.00 $10.00 $18.00 $20.00
B5580 $15.00 $10.00 $15.00 $20.00
B5581 $15.00 $10.00 $18.00 $20.00
B5582 $15.00 $10.00 $12.00 $15.00
B5583 $15.00 $10.00 $12.00 $15.00
B5584 $15.00 $12.00 $15.00 $20.00
B5585 $15.00 $5.00 $15.00 $15.00
B5586 $15.00 $10.00 $18.00 $20.00
B5587 $12.00 $10.00 $12.00 $15.00
B5588 $15.00 $5.00 $15.00 $15.00
B5589 $15.00 $7.00 $15.00 $15.00
B5590 $15.00 $7.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5591 $15.00 $7.00 $15.00 $15.00
B5592 $15.00 $10.00 $15.00 $15.00
B5593 NADA $10.00 $15.00 $15.00
B5594 NADA $10.00 $15.00 $15.00
B5595 $15.00 $10.00 $15.00 $15.00
B5596 $15.00 $12.00 $12.00 $12.00
B5597 $15.00 $5.00 $10.00 $15.00
B5598 $15.00 $5.00 $10.00 $12.00
B5599 $15.00 $5.00 $10.00 $12.00
B5600 $15.00 $5.00 $10.00 $12.00
B5601 $15.00 $8.00 $12.00 $15.00
B5602 $15.00 $10.00 $20.00 $20.00
B5603 $15.00 $10.00 $20.00 $20.00
B5604 $15.00 $5.00 $10.00 $15.00
B5605 $15.00 $8.00 $12.00 $15.00
B5606 $12.00 $10.00 $12.00 $15.00
B5607 $15.00 $8.00 $12.00 $15.00
B5608 $15.00 $5.00 $10.00 $15.00
B5609 $15.00 $10.00 $15.00 $20.00
B5610 $15.00 $12.00 $18.00 $22.00
B5611 $15.00 $10.00 $15.00 $20.00
B5612 $15.00 $10.00 $15.00 $20.00
B5613 $15.00 $12.00 $18.00 $22.00
B5614 $15.00 $12.00 $18.00 $22.00
B5615 $15.00 $10.00 $15.00 $20.00
B5616 $15.00 $10.00 $15.00 $20.00
B5617 $15.00 $12.00 $18.00 $22.00
B5618 $15.00 $10.00 $15.00 $20.00
B5619 $15.00 $10.00 $15.00 $20.00
B5620 $15.00 $10.00 $15.00 $20.00
B5621 $15.00 $10.00 $15.00 $20.00
B5622 $15.00 $10.00 $15.00 $20.00
B5623 $15.00 $10.00 $15.00 $15.00
B5624 $15.00 $10.00 $15.00 $20.00
B5625 $12.00 $10.00 $12.00 $15.00
B5626 $15.00 $10.00 $15.00 $20.00
B5627 $15.00 $10.00 $15.00 $15.00
B5628 NADA $5.00 $15.00 $20.00
B5629 $15.00 $5.00 $15.00 $15.00
B5630 $15.00 $10.00 $15.00 $20.00
B5631 $15.00 $10.00 $18.00 $20.00
B5632 $15.00 $10.00 $18.00 $20.00
B5633 $15.00 $10.00 $20.00 $20.00
B5634 $15.00 $4.00 $15.00 $20.00
B5635 $15.00 $10.00 $12.00 $15.00
B5636 $15.00 $5.00 $15.00 $15.00
B5637 $15.00 $10.00 $15.00 $15.00
B5638 $10.00 $5.00 $10.00 $15.00
B5639 $15.00 $8.00 $12.00 $15.00
B5640 $15.00 $5.00 $15.00 $15.00
B5641 $15.00 $8.00 $12.00 $15.00
B5642 $15.00 $10.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5643 $15.00 $8.00 $12.00 $15.00
B5644 $15.00 $10.00 $15.00 $15.00
B5645 $15.00 $10.00 $15.00 $15.00
B5646 $15.00 $7.00 $15.00 $15.00
B5647 $15.00 $10.00 $15.00 $15.00
B5648 $15.00 $10.00 $15.00 $15.00
B5649 $15.00 $10.00 $12.00 $15.00
B5650 $15.00 $10.00 $15.00 $15.00
B5651 $15.00 $12.00 $15.00 $18.00
B5652 $15.00 $10.00 $15.00 $15.00
B5653 $15.00 $10.00 $15.00 $20.00
B5654 $15.00 $8.00 $12.00 $15.00
B5655 $15.00 $10.00 $15.00 $20.00
B5656 $15.00 $10.00 $15.00 $20.00
B5657 $15.00 $5.00 $8.00 $10.00
B5658 $15.00 $5.00 $15.00 $15.00
B5659 $15.00 $5.00 $15.00 $15.00
B5660 $15.00 $5.00 $15.00 $15.00
B5661 $15.00 $5.00 $15.00 $15.00
B5662 $15.00 $5.00 $15.00 $15.00
B5663 $15.00 $10.00 $15.00 $15.00
B5664 $15.00 $10.00 $15.00 $15.00
B5665 $12.00 $10.00 $12.00 $15.00
B5666 $15.00 $8.00 $12.00 $15.00
B5667 $15.00 $5.00 $10.00 $10.00
B5668 $15.00 $12.00 $12.00 $12.00
B5669 $15.00 $12.00 $15.00 $15.00
B5670 $15.00 $5.00 $15.00 $15.00
B5671 $15.00 $10.00 $15.00 $15.00
B5672 $15.00 $8.00 $15.00 $15.00
B5673 $15.00 $10.00 $10.00 $15.00
B5674 $15.00 $10.00 $15.00 $15.00
B5675 $15.00 $8.00 $12.00 $15.00
B5676 $15.00 $4.00 $15.00 $20.00
B5677 $15.00 $10.00 $15.00 $18.00
B5678 $10.00 $5.00 $10.00 $15.00
B5679 $15.00 $4.00 $15.00 $20.00
B5680 $15.00 $4.00 $15.00 $20.00
B5681 $15.00 $10.00 $15.00 $20.00
B5682 $15.00 $10.00 $15.00 $15.00
B5683 $15.00 $8.00 $12.00 $15.00
B5684 $15.00 $5.00 $10.00 $10.00
B5685 $15.00 $5.00 $10.00 $12.00
B5686 $15.00 $10.00 $15.00 $15.00
B5687 $15.00 $6.00 $8.00 $8.00
B5688 $15.00 $12.00 $18.00 $20.00
B5689 $15.00 $10.00 $12.00 $15.00
B5690 $15.00 $4.00 $15.00 $20.00
B5691 $15.00 $10.00 $10.00 $10.00
B5692 $15.00 $10.00 $15.00 $20.00
B5693 $15.00 $10.00 $15.00 $20.00
B5694 $15.00 $3.00 $10.00 $15.00
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5695 $15.00 $10.00 $15.00 $15.00
B5696 $15.00 $15.00 $20.00 $20.00
B5697 $15.00 $5.00 $15.00 $15.00
B5698 $15.00 $8.00 $20.00 $22.00
B5699 $15.00 $10.00 $15.00 $15.00
B5700 $12.00 $8.00 $12.00 $12.00
B5701 $15.00 $5.00 $10.00 $10.00
B5702 $20.00 $10.00 $15.00 $15.00
B5703 $15.00 $10.00 $15.00 $15.00
B5704 $15.00 $10.00 $15.00 $15.00
B5705 $15.00 $12.00 $15.00 $20.00
B5706 $12.00 $10.00 $12.00 $15.00
B5707 $15.00 $10.00 $15.00 $15.00
B5708 $15.00 $12.00 $18.00 $18.00
B5709 $15.00 $12.00 $18.00 $18.00
B5710 $15.00 $7.00 $18.00 $18.00
B5711 $15.00 $10.00 $20.00 $20.00
B5712 $15.00 $10.00 $20.00 $20.00
B5713 $15.00 $5.00 $12.00 $15.00
B5714 $15.00 $7.00 $15.00 $18.00
B5715 $15.00 $7.00 $15.00 $18.00
B5716 $12.00 $10.00 $12.00 $15.00
B5717 $15.00 $8.00 $12.00 $15.00
B5718 $10.00 $10.00 $10.00 $10.00
B5719 NADA $10.00 $15.00 $15.00
B5720 $15.00 $8.00 $10.00 $15.00
B5721 NADA $5.00 $15.00 $20.00
B5722 NADA $5.00 $15.00 $20.00
B5725 $15.00 $10.00 $15.00 $20.00
B5726 $15.00 $5.00 $15.00 $15.00
B5729 $15.00 $10.00 $15.00 $15.00
B5730 $15.00 $10.00 $15.00 $20.00
B5731 $15.00 $5.00 $15.00 $15.00
B5732 $15.00 $10.00 $12.00 $15.00
B5733 $15.00 $10.00 $12.00 $15.00
B5734 $15.00 $12.00 $20.00 $20.00
B5735 $15.00 $12.00 $20.00 $20.00
B5736 $15.00 $8.00 $15.00 $15.00
B5737 $15.00 $8.00 $15.00 $15.00
B5738 $15.00 NADA $10.00 $15.00
B5740 $10.00 $12.00 $15.00 $15.00
B5741 $10.00 $12.00 $15.00 $15.00
B5742 $15.00 $8.00 $12.00 $15.00
B5745 NADA $5.00 $10.00 $15.00
B5746 $15.00 $10.00 $15.00 $20.00
B5749 $15.00 $5.00 $15.00 $15.00
B5754 $15.00 $5.00 $15.00 $15.00
B5755 $15.00 $8.00 $10.00 $12.00
B5757 $15.00 $5.00 $15.00 $15.00
B5760 $15.00 $10.00 $12.00 $15.00
B5761 $15.00 $7.00 $12.00 $12.00
B5762 $15.00 $7.00 $12.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5764 $15.00 $10.00 $15.00 $15.00
B5765 NADA NADA NADA NADA
B5766 $15.00 $3.00 $7.00 $9.00
B5769 NADA $8.00 $12.00 $15.00
B5770 $15.00 $10.00 $10.00 $15.00
B5771 $15.00 $10.00 $10.00 $10.00
B5772 $15.00 $10.00 $10.00 $10.00
B5773 $15.00 $10.00 $15.00 $15.00
B5774 $15.00 $10.00 $15.00 $15.00
B5777 $15.00 $10.00 $15.00 $20.00
B5778 $15.00 $8.00 $12.00 $15.00
B5781 $15.00 $15.00 $18.00 $20.00
B5782 $15.00 $15.00 $18.00 $20.00
B5783 $15.00 $12.00 $15.00 $18.00
B5784 $15.00 $12.00 $15.00 $18.00
B5785 $15.00 $10.00 $10.00 $10.00
B5786 $15.00 $10.00 $10.00 $10.00
B5787 $15.00 $8.00 $12.00 $15.00
B5788 $15.00 $10.00 $10.00 $10.00
B5789 $15.00 $10.00 $12.00 $15.00
B5790 $15.00 $10.00 $10.00 $10.00
B5797 $15.00 $15.00 $15.00 $15.00
B5798 $15.00 $15.00 $15.00 $15.00
B5799 NADA $15.00 $20.00 $25.00
B5800 NADA $10.00 $15.00 $20.00
B5801 NADA $5.00 $10.00 $15.00
B5803 $15.00 $10.00 $12.00 $15.00
B5807 $15.00 $10.00 $15.00 $15.00
B5808 $15.00 $8.00 $10.00 $12.00
B5810 $15.00 $8.00 $12.00 $12.00
B5811 NADA $5.00 $10.00 $12.00
B5812 NADA $5.00 $10.00 $12.00
B5813 $15.00 $10.00 $15.00 $20.00
B5814 $15.00 $8.00 $12.00 $15.00
B5815 $15.00 $12.00 $15.00 $18.00
B5817 $15.00 $10.00 $15.00 $15.00
B5818 $15.00 $5.00 $12.00 $15.00
B5819 $15.00 $10.00 $10.00 $10.00
B5820 $15.00 $5.00 $10.00 $10.00
B5821 $15.00 $15.00 $20.00 $20.00
B5822 $12.00 $10.00 $12.00 $15.00
B5823 $15.00 $5.00 $10.00 $10.00
B5824 $15.00 $10.00 $10.00 $15.00
B5825 $15.00 $10.00 $10.00 $15.00
B5826 $15.00 $10.00 $10.00 $15.00
B5827 NADA $5.00 $15.00 $20.00
B5828 NADA $5.00 $15.00 $20.00
B5829 NADA $5.00 $20.00 $20.00
B5830 NADA $10.00 $15.00 $20.00
B5831 NADA $15.00 $20.00 $20.00
B5832 NADA $8.00 $12.00 $15.00
B5833 $15.00 NADA $15.00 $20.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5834 NADA $5.00 $10.00 $15.00
B5835 $15.00 $7.00 $7.00 $7.00
B5836 $15.00 $5.00 $5.00 $5.00
B5837 $15.00 $8.00 $12.00 $12.00
B5838 $15.00 $8.00 $12.00 $12.00
B5839 $15.00 $15.00 $20.00 $20.00
B5840 $15.00 $15.00 $20.00 $20.00
B5841 $15.00 $10.00 $18.00 $20.00
B5842 $15.00 $10.00 $15.00 $18.00
B5843 $15.00 $15.00 $18.00 $20.00
B5844 $15.00 $10.00 $15.00 $15.00
B5845 $15.00 $10.00 $10.00 $10.00
B5846 $15.00 $12.00 $15.00 $18.00
B5847 $15.00 $5.00 $15.00 $15.00
B5848 $15.00 $10.00 $18.00 $20.00
B5849 NADA $5.00 $10.00 $12.00
B5850 $15.00 $5.00 $5.00 $5.00
B5851 NADA NADA $10.00 $15.00
B5852 $15.00 $7.00 $15.00 $18.00
B5853 NADA $8.00 $10.00 $15.00
B5854 $15.00 $4.00 $15.00 $18.00
B5855 $15.00 $7.00 $18.00 $20.00
B5856 $15.00 $12.00 $15.00 $18.00
B5857 $15.00 $8.00 $12.00 $18.00
B5858 $15.00 $10.00 $18.00 $20.00
B5859 $15.00 $8.00 $12.00 $15.00
B5860 NADA $5.00 $10.00 $12.00
B5861 $15.00 $5.00 $10.00 $12.00
B5862 $15.00 $5.00 $5.00 $5.00
B5863 $15.00 $8.00 $12.00 $15.00
B5864 $15.00 $8.00 $15.00 $15.00
B5865 $15.00 $7.00 $18.00 $20.00
B5866 $15.00 $15.00 $15.00 $18.00
B5867 $15.00 $10.00 $12.00 $15.00
B5868 $15.00 $10.00 $15.00 $18.00
B5869 $15.00 $12.00 $15.00 $18.00
B5870 $15.00 $8.00 $10.00 $12.00
B5871 $15.00 $10.00 $15.00 $15.00
B5872 $15.00 $5.00 $18.00 $18.00
B5873 $15.00 $10.00 $20.00 $20.00
B5874 $15.00 $10.00 $10.00 $10.00
B5875 $15.00 $10.00 $12.00 $15.00
B5876 $15.00 $10.00 $10.00 $10.00
B5877 $15.00 $10.00 $10.00 $10.00
B5878 $15.00 $10.00 $15.00 $15.00
B5879 $15.00 $10.00 $15.00 $15.00
B5880 $15.00 $10.00 $15.00 $15.00
B5881 $15.00 $10.00 $15.00 $15.00
B5883 $15.00 $10.00 $15.00 $18.00
B5884 $15.00 $10.00 $20.00 $20.00
B5885 $15.00 $10.00 $10.00 $10.00
B5886 $15.00 $12.00 $12.00 $12.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5887 $15.00 $10.00 $15.00 $18.00
B5888 $15.00 $12.00 $12.00 $12.00
B5889 $15.00 $5.00 $10.00 $12.00
B5890 $15.00 $5.00 $15.00 $15.00
B5891 $15.00 $8.00 $10.00 $15.00
B5892 $15.00 $10.00 $10.00 $10.00
B5893 $15.00 $5.00 $15.00 $15.00
B5894 $15.00 $2.00 $3.00 $5.00
B5895 $15.00 $10.00 $15.00 $15.00
B5896 $15.00 $10.00 $15.00 $15.00
B5897 $15.00 $15.00 $20.00 $20.00
B5898 $15.00 $15.00 $20.00 $20.00
B5899 $15.00 NADA $18.00 $20.00
B5900 $15.00 $10.00 $18.00 $18.00
B5901 $15.00 $8.00 $12.00 $15.00
B5902 $15.00 $10.00 $15.00 $18.00
B5903 $15.00 $10.00 $15.00 $20.00
B5904 $15.00 $5.00 $10.00 $10.00
B5905 $15.00 $10.00 $20.00 $20.00
B5906 $15.00 $5.00 $12.00 $12.00
B5907 $15.00 $5.00 $12.00 $12.00
B5908 $15.00 $10.00 $15.00 $15.00
B5909 $15.00 $10.00 $15.00 $15.00
B5910 $15.00 $10.00 $15.00 $15.00
B5911 $15.00 $10.00 $15.00 $15.00
B5912 $15.00 $10.00 $15.00 $15.00
B5913 $15.00 $5.00 $15.00 $15.00
B5914 $15.00 $8.00 $12.00 $15.00
B5915 $15.00 $10.00 $10.00 $10.00
B5916 $15.00 $10.00 $18.00 $20.00
B5917 $15.00 $18.00 $22.00 $25.00
B5918 $15.00 $10.00 $15.00 $18.00
B5919 $15.00 $10.00 $15.00 $18.00
B5920 $15.00 $10.00 $15.00 $18.00
B5921 NADA $10.00 $15.00 $20.00
B5923 NADA $5.00 $10.00 $12.00
B5924 $15.00 $8.00 $12.00 $15.00
B5925 $15.00 $3.00 $20.00 $20.00
B5926 $15.00 $5.00 $25.00 $25.00
B5927 NADA $8.00 $10.00 $15.00
B5928 $10.00 $5.00 $10.00 $10.00
B5931 NADA NADA $10.00 $15.00
B5932 $15.00 $10.00 $15.00 $15.00
B5933 $15.00 $5.00 $15.00 $15.00
B5934 $15.00 $8.00 $12.00 $15.00
B5935 $15.00 $15.00 $20.00 $20.00
B5936 $15.00 $5.00 $15.00 $15.00
B5937 $15.00 $10.00 $15.00 $15.00
B5938 $15.00 $15.00 $20.00 $20.00
B5939 NADA $10.00 $15.00 $15.00
B5940 $10.00 $5.00 $10.00 $10.00
B5941 $10.00 $5.00 $10.00 $10.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5942 NADA $10.00 $15.00 $15.00
B5943 $10.00 $5.00 $10.00 $10.00
B5944 $15.00 $10.00 $15.00 $15.00
B5945 $15.00 $8.00 $15.00 $15.00
B5946 $15.00 $10.00 $15.00 $18.00
B5947 NADA $10.00 $15.00 $15.00
B5948 $15.00 $8.00 $10.00 $15.00
B5949 $15.00 $8.00 $12.00 $15.00
B5950 $15.00 $10.00 $15.00 $15.00
B5951 $10.00 $5.00 $10.00 $10.00
B5952 NADA $10.00 $18.00 $18.00
B5953 NADA $8.00 $15.00 $15.00
B5954 NADA $8.00 $10.00 $12.00
B5955 $15.00 NADA $18.00 $20.00
B5956 NADA $10.00 $18.00 $18.00
B5957 NADA $8.00 $15.00 $15.00
B5958 NADA $8.00 $10.00 $12.00
B5959 $15.00 $10.00 $15.00 $20.00
B5961 NADA $10.00 $15.00 $15.00
B5962 $15.00 $10.00 $18.00 $18.00
B5963 $15.00 $10.00 $18.00 $20.00
B5964 $15.00 $5.00 $15.00 $15.00
B5965 NADA $10.00 $12.00 $15.00
B5966 NADA $10.00 $15.00 $18.00
B5967 NADA $12.00 $18.00 $18.00
B5968 $15.00 $10.00 $18.00 $18.00
B5969 $15.00 $5.00 $15.00 $15.00
B5970 $15.00 $10.00 $18.00 $20.00
B5971 $15.00 NADA $18.00 $20.00
B5972 $15.00 $15.00 $18.00 $22.00
B5973 $15.00 $15.00 $15.00 $20.00
B5974 $15.00 $10.00 $15.00 $18.00
B5975 $10.00 $5.00 $10.00 $10.00
B5976 $15.00 $10.00 $15.00 $20.00
B5977 $15.00 $10.00 $15.00 $20.00
B5978 $15.00 $10.00 $12.00 $15.00
B5979 $15.00 $10.00 $15.00 $20.00
B5980 $15.00 $8.00 $15.00 $15.00
B5981 NADA $10.00 $15.00 $15.00
B5982 $15.00 $15.00 $20.00 $22.00
B5983 $15.00 $10.00 $15.00 $18.00
B5984 $15.00 $10.00 $12.00 $15.00
B5985 $15.00 $15.00 $20.00 $20.00
B5986 $15.00 $15.00 $20.00 $20.00
B5987 $15.00 $10.00 $18.00 $20.00
B5988 NADA $5.00 $20.00 $20.00
B5989 $15.00 $5.00 $10.00 $10.00
B5990 $10.00 $5.00 $10.00 $10.00
B5991 $15.00 $5.00 $15.00 $15.00
B5992 $15.00 $5.00 $10.00 $15.00
B5993 $15.00 NADA $10.00 $15.00
B5994 NADA $10.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B5995 $15.00 $10.00 $15.00 $15.00
B5996 $15.00 $5.00 $10.00 $10.00
B5997 $10.00 $5.00 $10.00 $10.00
B5998 $15.00 $10.00 $18.00 $20.00
B5999 $15.00 $8.00 $12.00 $15.00
B6000 $15.00 $8.00 $12.00 $15.00
B6001 NADA $10.00 $15.00 $15.00
B6002 $15.00 $5.00 $15.00 $18.00
B6003 $15.00 $5.00 $5.00 $5.00
B6004 $15.00 $10.00 $15.00 $15.00
B6005 $15.00 $10.00 $15.00 $20.00
B6006 $15.00 $5.00 $15.00 $18.00
B6007 NADA $10.00 $15.00 $15.00
B6008 $15.00 $10.00 $15.00 $15.00
B6009 $15.00 $10.00 $18.00 $20.00
B6010 $15.00 $10.00 $15.00 $15.00
B6011 $15.00 $5.00 $10.00 $10.00
B6012 $15.00 $8.00 $12.00 $15.00
B6013 $15.00 $5.00 $15.00 $18.00
B6014 $15.00 $5.00 $7.00 $10.00
B6015 $15.00 $5.00 $15.00 $15.00
B6016 $15.00 $5.00 $18.00 $18.00
B6017 $15.00 $5.00 $5.00 $5.00
B6018 $15.00 $5.00 $15.00 $15.00
B6019 $10.00 $5.00 $10.00 $10.00
B6020 $15.00 $5.00 $18.00 $18.00
B6021 $15.00 $12.00 $15.00 $20.00
B6022 $15.00 $12.00 $15.00 $20.00
B6023 NADA $10.00 $15.00 $15.00
B6024 $15.00 $15.00 $20.00 $20.00
B6025 $15.00 $15.00 $20.00 $20.00
B6026 $15.00 $15.00 $20.00 $20.00
B6027 $15.00 $5.00 $10.00 $10.00
B6028 $15.00 $8.00 $15.00 $20.00
B6029 $15.00 $10.00 $15.00 $15.00
B6030 $15.00 $5.00 $5.00 $5.00
B6031 $15.00 $5.00 $15.00 $15.00
B6032 $15.00 $5.00 $10.00 $10.00
B6033 $10.00 $5.00 $10.00 $10.00
B6034 $15.00 $5.00 $7.00 $10.00
B6036 $15.00 $10.00 $18.00 $25.00
B6037 $15.00 $5.00 $5.00 $5.00
B6038 $15.00 $8.00 $10.00 $12.00
B6039 $15.00 $10.00 $12.00 $15.00
B6040 $15.00 $2.00 $20.00 $20.00
B6041 $15.00 $5.00 $15.00 $15.00
B6042 NADA $7.00 $15.00 $15.00
B6043 NADA $7.00 $15.00 $15.00
B6044 NADA $7.00 $15.00 $15.00
B6045 $15.00 $4.00 $15.00 $15.00
B6046 $15.00 $4.00 $15.00 $15.00
B6047 $15.00 $4.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6048 $15.00 $4.00 $15.00 $15.00
B6049 NADA $5.00 $15.00 $20.00
B6050 $15.00 $5.00 $15.00 $15.00
B6051 $15.00 $8.00 $15.00 $15.00
B6052 $15.00 $10.00 $15.00 $15.00
B6053 NADA NADA NADA NADA
B6054 $15.00 $10.00 $15.00 $15.00
B6055 $15.00 $10.00 $15.00 $15.00
B6056 $15.00 $10.00 $15.00 $15.00
B6057 $15.00 $5.00 $10.00 $10.00
B6058 $10.00 $5.00 $10.00 $10.00
B6059 $15.00 $10.00 $15.00 $15.00
B6060 $10.00 $5.00 $10.00 $10.00
B6061 $15.00 $5.00 $15.00 $15.00
B6062 $15.00 $10.00 $15.00 $15.00
B6063 $15.00 $12.00 $15.00 $18.00
B6064 $15.00 $10.00 $15.00 $20.00
B6065 $15.00 $5.00 $10.00 $10.00
B6066 $10.00 $5.00 $10.00 $10.00
B6067 NADA $10.00 $15.00 $15.00
B6068 $15.00 $5.00 $10.00 $15.00
B6069 $15.00 $5.00 $15.00 $15.00
B6070 $15.00 $5.00 $15.00 $15.00
B6071 $15.00 $10.00 $20.00 $20.00
B6072 $15.00 $10.00 $17.00 $20.00
B6073 $15.00 $8.00 $15.00 $18.00
B6074 $15.00 $15.00 $18.00 $20.00
B6075 $15.00 $10.00 $18.00 $18.00
B6076 $15.00 $10.00 $18.00 $18.00
B6077 $15.00 $5.00 $10.00 $12.00
B6078 $15.00 $5.00 $10.00 $12.00
B6079 $15.00 $8.00 $12.00 $15.00
B6080 $15.00 $7.00 $12.00 $15.00
B6081 $15.00 $15.00 $20.00 $20.00
B6082 $15.00 $10.00 $12.00 $15.00
B6083 $15.00 $4.00 $15.00 $20.00
B6084 $15.00 $10.00 $18.00 $20.00
B6085 $10.00 $5.00 $10.00 $10.00
B6086 $15.00 $10.00 $15.00 $15.00
B6087 $15.00 $15.00 $15.00 $20.00
B6088 $15.00 $10.00 $15.00 $20.00
B6089 $10.00 $8.00 $10.00 $15.00
B6090 $15.00 $10.00 $12.00 $15.00
B6091 $15.00 $10.00 $12.00 $15.00
B6092 $15.00 $10.00 $12.00 $15.00
B6093 NADA NADA NADA NADA
B6094 $15.00 $10.00 $15.00 $15.00
B6095 $15.00 $15.00 $20.00 $20.00
B6096 $15.00 $10.00 $15.00 $15.00
B6097 $15.00 $5.00 $15.00 $15.00
B6098 $15.00 $10.00 $15.00 $15.00
B6099 $15.00 $12.00 $15.00 $18.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6100 $15.00 $15.00 $20.00 $25.00
B6101 $15.00 $12.00 $15.00 $18.00
B6102 $15.00 $10.00 $15.00 $20.00
B6103 $15.00 $10.00 $15.00 $15.00
B6104 NADA $10.00 $15.00 $15.00
B6105 $15.00 $5.00 $10.00 $10.00
B6106 NADA $10.00 $15.00 $15.00
B6109 $15.00 $15.00 $20.00 $20.00
B6110 $15.00 $10.00 $15.00 $15.00
B6111 $10.00 $5.00 $10.00 $10.00
B6112 NADA $10.00 $15.00 $15.00
B6113 $10.00 $5.00 $10.00 $10.00
B6115 $15.00 $10.00 $15.00 $15.00
B6116 $15.00 $5.00 $10.00 $15.00
B6117 $15.00 $8.00 $15.00 $18.00
B6118 $10.00 $5.00 $10.00 $10.00
B6119 $10.00 $5.00 $10.00 $10.00
B6120 $15.00 $5.00 $15.00 $15.00
B6121 $15.00 $5.00 $15.00 $15.00
B6122 $15.00 $5.00 $10.00 $15.00
B6123 $15.00 $5.00 $10.00 $10.00
B6124 $15.00 $5.00 $10.00 $15.00
B6125 $10.00 $8.00 $10.00 $15.00
B6126 NADA $5.00 $10.00 $15.00
B6127 $10.00 $5.00 $10.00 $10.00
B6128 NADA $2.00 $5.00 $5.00
B6129 $15.00 $10.00 $15.00 $20.00
B6130 $15.00 $10.00 $15.00 $20.00
B6131 $15.00 $5.00 $15.00 $15.00
B6132 NADA $5.00 $20.00 $20.00
B6133 $15.00 $10.00 $15.00 $18.00
B6134 $15.00 NADA $10.00 $15.00
B6135 NADA $5.00 $20.00 $20.00
B6136 NADA $5.00 $20.00 $20.00
B6137 $15.00 $5.00 $15.00 $15.00
B6138 $15.00 $10.00 $12.00 $15.00
B6139 $15.00 $10.00 $15.00 $15.00
B6140 $10.00 $5.00 $10.00 $10.00
B6141 $15.00 $10.00 $12.00 $15.00
B6142 $10.00 $5.00 $10.00 $10.00
B6143 $15.00 $8.00 $12.00 $15.00
B6144 $15.00 $8.00 $12.00 $15.00
B6145 $10.00 $5.00 $10.00 $10.00
B6146 $15.00 $5.00 $15.00 $15.00
B6147 $10.00 $5.00 $10.00 $10.00
B6148 $15.00 $5.00 $15.00 $15.00
B6149 $15.00 NADA $15.00 $20.00
B6150 $15.00 $10.00 $20.00 $20.00
B6151 $15.00 $5.00 $15.00 $15.00
B6152 $15.00 $15.00 $20.00 $20.00
B6153 $15.00 $10.00 $20.00 $20.00
B6154 $15.00 $8.00 $12.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6156 $15.00 $10.00 $15.00 $15.00
B6159 $15.00 $10.00 $15.00 $18.00
B6160 $15.00 $10.00 $15.00 $15.00
B6163 $15.00 $5.00 $10.00 $15.00
B6164 $15.00 $5.00 $15.00 $15.00
B6165 NADA $5.00 $12.00 $18.00
B6166 $15.00 $12.00 $18.00 $20.00
B6167 $15.00 $15.00 $18.00 $20.00
B6168 $15.00 $12.00 $18.00 $22.00
B6172 $15.00 $8.00 $15.00 $20.00
B6173 $15.00 $10.00 $12.00 $15.00
B6180 $10.00 $5.00 $10.00 $15.00
B6181 $15.00 $5.00 $15.00 $15.00
B6182 $15.00 $5.00 $10.00 $10.00
B6183 $15.00 $8.00 $15.00 $18.00
B6184 $10.00 $8.00 $18.00 $20.00
B6185 $10.00 $8.00 $18.00 $20.00
B6187 NADA $10.00 $20.00 $20.00
B6188 NADA $10.00 $20.00 $20.00
B6189 $15.00 $10.00 $15.00 $15.00
B6190 NADA $10.00 $20.00 $20.00
B6191 NADA $10.00 $20.00 $20.00
B6192 $15.00 $5.00 $7.00 $12.00
B6193 $15.00 $10.00 $15.00 $15.00
B6194 $15.00 $5.00 $10.00 $15.00
B6195 $15.00 $5.00 $20.00 $20.00
B6196 $15.00 $10.00 $18.00 $25.00
B6197 $15.00 $10.00 $15.00 $15.00
B6198 $15.00 $15.00 $20.00 $20.00
B6199 $15.00 $10.00 $15.00 $20.00
B6200 NADA NADA NADA NADA
B6201 $15.00 $10.00 $20.00 $20.00
B6202 $15.00 $10.00 $20.00 $20.00
B6203 NADA $10.00 $20.00 $20.00
B6204 $15.00 $10.00 $15.00 $15.00
B6205 $15.00 $8.00 $12.00 $15.00
B6206 $15.00 $10.00 $18.00 $20.00
B6207 $15.00 $12.00 $15.00 $18.00
B6208 $15.00 $10.00 $15.00 $18.00
B6209 $15.00 $10.00 $12.00 $18.00
B6210 $15.00 $10.00 $10.00 $10.00
B6211 $15.00 $10.00 $15.00 $15.00
B6212 $15.00 $8.00 $12.00 $15.00
B6213 $15.00 $8.00 $12.00 $15.00
B6214 $15.00 $8.00 $12.00 $15.00
B6215 $15.00 $12.00 $15.00 $18.00
B6216 $15.00 $12.00 $15.00 $18.00
B6217 $15.00 $10.00 $18.00 $25.00
B6218 $15.00 $8.00 $12.00 $15.00
B6219 $15.00 $10.00 $12.00 $18.00
B6220 $15.00 $8.00 $10.00 $12.00
B6221 $15.00 $10.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6222 $15.00 $10.00 $12.00 $18.00
B6223 $15.00 $3.00 $7.00 $11.00
B6224 $15.00 $3.00 $7.00 $11.00
B6225 $15.00 $10.00 $12.00 $18.00
B6226 $15.00 $15.00 $20.00 $25.00
B6227 $15.00 $12.00 $15.00 $18.00
B6228 $15.00 $5.00 $15.00 $15.00
B6229 $15.00 $15.00 $20.00 $25.00
B6230 $15.00 $5.00 $20.00 $20.00
B6231 $15.00 $8.00 $12.00 $15.00
B6232 $15.00 $8.00 $12.00 $15.00
B6233 $15.00 $12.00 $15.00 $20.00
B6234 $15.00 $10.00 $12.00 $18.00
B6235 NADA $3.00 $3.00 $3.00
B6236 $15.00 $5.00 $20.00 $20.00
B6237 $15.00 $8.00 $12.00 $15.00
B6238 $15.00 $5.00 $15.00 $15.00
B6239 $15.00 $10.00 $12.00 $18.00
B6240 $15.00 $12.00 $15.00 $20.00
B6241 $15.00 $12.00 $15.00 $18.00
B6242 $15.00 $10.00 $12.00 $18.00
B6243 $15.00 $8.00 $12.00 $15.00
B6244 $15.00 $10.00 $12.00 $15.00
B6245 $15.00 $12.00 $15.00 $18.00
B6246 NADA $10.00 $15.00 $15.00
B6248 $15.00 $5.00 $15.00 $15.00
B6249 $15.00 $5.00 $15.00 $15.00
B6250 $15.00 $15.00 $20.00 $20.00
B6251 $15.00 $5.00 $15.00 $15.00
B6252 $15.00 $8.00 $12.00 $20.00
B6253 $15.00 $12.00 $15.00 $20.00
B6254 $15.00 $10.00 $12.00 $18.00
B6255 $15.00 $10.00 $12.00 $18.00
B6256 $15.00 $12.00 $15.00 $18.00
B6257 $15.00 $8.00 $10.00 $12.00
B6258 $15.00 $12.00 $15.00 $18.00
B6259 $15.00 $4.00 $15.00 $20.00
B6260 $15.00 $10.00 $12.00 $18.00
B6261 $15.00 $8.00 $10.00 $12.00
B6262 $15.00 $10.00 $15.00 $18.00
B6263 $15.00 $10.00 $20.00 $20.00
B6264 $15.00 $12.00 $15.00 $20.00
B6265 NADA $10.00 $20.00 $20.00
B6266 $15.00 $5.00 $20.00 $20.00
B6267 $15.00 $10.00 $15.00 $15.00
B6268 $15.00 $4.00 $7.00 $10.00
B6269 $18.00 $12.00 $18.00 $20.00
B6270 $15.00 $5.00 $15.00 $20.00
B6271 $15.00 $12.00 $15.00 $20.00
B6273 $15.00 $12.00 $15.00 $18.00
B6274 NADA $8.00 $10.00 $12.00
B6275 $15.00 $12.00 $18.00 $18.00
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6277 $15.00 $12.00 $18.00 $18.00
B6278 $15.00 $10.00 $25.00 $25.00
B6279 $15.00 $7.00 $15.00 $15.00
B6280 $15.00 $7.00 $15.00 $15.00
B6281 $15.00 $10.00 $15.00 $15.00
B6282 $15.00 $5.00 $10.00 $12.00
B6283 $15.00 $10.00 $15.00 $15.00
B6284 $15.00 $5.00 $10.00 $12.00
B6285 $15.00 $10.00 $15.00 $15.00
B6286 NADA $3.00 $7.00 $10.00
B6287 $15.00 $10.00 $15.00 $15.00
B6288 $15.00 $4.00 $15.00 $20.00
B6289 $15.00 $10.00 $18.00 $20.00
B6290 $15.00 $10.00 $15.00 $15.00
B6291 $15.00 $10.00 $15.00 $15.00
B6292 $15.00 $4.00 $15.00 $20.00
B6293 NADA $10.00 $15.00 $15.00
B6295 $15.00 $10.00 $18.00 $20.00
B6296 $15.00 $5.00 $15.00 $15.00
B6297 $15.00 $8.00 $12.00 $15.00
B6299 $15.00 $15.00 $18.00 $20.00
B6300 $15.00 $5.00 $10.00 $12.00
B6301 $15.00 $10.00 $15.00 $15.00
B6302 $15.00 $10.00 $15.00 $15.00
B6303 $15.00 $10.00 $18.00 $25.00
B6304 $15.00 $10.00 $15.00 $15.00
B6305 NADA $5.00 $15.00 $20.00
B6307 $15.00 $5.00 $15.00 $15.00
B6308 $15.00 $5.00 $10.00 $12.00
B6309 $15.00 $15.00 $18.00 $20.00
B6312 $15.00 $15.00 $20.00 $25.00
B6313 NADA $10.00 $15.00 $15.00
B6314 $15.00 $5.00 $15.00 $15.00
B6315 $15.00 $10.00 $15.00 $15.00
B6316 $15.00 $5.00 $10.00 $10.00
B6317 $15.00 $5.00 $10.00 $10.00
B6319 $15.00 $10.00 $15.00 $15.00
B6321 $15.00 $5.00 $10.00 $10.00
B6322 $15.00 $8.00 $12.00 $15.00
B6323 $15.00 $5.00 $10.00 $10.00
B6324 $15.00 $8.00 $12.00 $15.00
B6325 $15.00 $10.00 $18.00 $20.00
B6326 NADA $10.00 $15.00 $15.00
B6327 $15.00 $10.00 $18.00 $18.00
B6328 $15.00 $10.00 $15.00 $20.00
B6329 $15.00 $10.00 $20.00 $20.00
B6330 $15.00 $8.00 $12.00 $15.00
B6331 $15.00 $8.00 $12.00 $15.00
B6332 $15.00 $10.00 $20.00 $20.00
B6333 $15.00 $10.00 $15.00 $20.00
B6334 $15.00 $10.00 $15.00 $20.00
B6335 $15.00 $10.00 $15.00 $20.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6336 $15.00 $8.00 $12.00 $15.00
B6337 $15.00 $10.00 $15.00 $20.00
B6338 $15.00 $5.00 $10.00 $10.00
B6339 $15.00 $5.00 $10.00 $15.00
B6340 $15.00 $8.00 $12.00 $15.00
B6341 $15.00 $5.00 $10.00 $10.00
B6342 $15.00 $10.00 $15.00 $15.00
B6343 $15.00 $10.00 $15.00 $15.00
B6344 $15.00 $5.00 $10.00 $10.00
B6345 $15.00 $10.00 $15.00 $15.00
B6346 $15.00 $10.00 $15.00 $15.00
B6347 $15.00 $5.00 $10.00 $10.00
B6348 $15.00 $5.00 $15.00 $15.00
B6349 $15.00 $15.00 $20.00 $20.00
B6350 $15.00 $10.00 $15.00 $15.00
B6351 $15.00 $5.00 $10.00 $10.00
B6352 $15.00 $8.00 $12.00 $15.00
B6353 $15.00 $5.00 $15.00 $15.00
B6354 $15.00 $15.00 $20.00 $20.00
B6355 $15.00 $10.00 $18.00 $20.00
B6356 $15.00 $15.00 $18.00 $18.00
B6357 $15.00 $10.00 $12.00 $15.00
B6358 $15.00 $6.00 $12.00 $15.00
B6359 $15.00 $10.00 $15.00 $15.00
B6360 $15.00 $10.00 $15.00 $18.00
B6361 $15.00 $10.00 $12.00 $15.00
B6362 $15.00 $4.00 $15.00 $20.00
B6363 $15.00 $4.00 $15.00 $18.00
B6364 $15.00 $10.00 $12.00 $15.00
B6365 $10.00 $10.00 $15.00 $20.00
B6366 $15.00 $10.00 $15.00 $20.00
B6367 $15.00 $5.00 $18.00 $18.00
B6368 $15.00 $10.00 $15.00 $15.00
B6369 $15.00 $5.00 $7.00 $10.00
B6370 $15.00 $5.00 $15.00 $15.00
B6371 $15.00 $5.00 $15.00 $15.00
B6372 $15.00 $5.00 $5.00 $5.00
B6373 $15.00 $10.00 $15.00 $20.00
B6374 $15.00 $12.00 $18.00 $20.00
B6375 $15.00 $10.00 $18.00 $20.00
B6376 $15.00 $10.00 $18.00 $20.00
B6377 $15.00 $10.00 $18.00 $20.00
B6378 $15.00 $8.00 $12.00 $15.00
B6379 $15.00 $5.00 $10.00 $10.00
B6380 $15.00 $10.00 $12.00 $15.00
B6381 $15.00 $10.00 $15.00 $15.00
B6382 $15.00 $8.00 $12.00 $15.00
B6383 $15.00 $5.00 $10.00 $10.00
B6384 $10.00 $5.00 $10.00 $10.00
B6385 $15.00 $10.00 $15.00 $20.00
B6386 $15.00 $10.00 $15.00 $20.00
B6387 $15.00 $10.00 $12.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6388 $15.00 $10.00 $12.00 $15.00
B6389 $15.00 $10.00 $15.00 $20.00
B6390 $15.00 $5.00 $10.00 $10.00
B6391 $15.00 $8.00 $12.00 $15.00
B6392 $15.00 $5.00 $10.00 $10.00
B6393 $15.00 $10.00 $15.00 $15.00
B6394 $15.00 $10.00 $15.00 $20.00
B6395 $15.00 $10.00 $15.00 $15.00
B6396 $15.00 $15.00 $20.00 $20.00
B6397 $15.00 $10.00 $15.00 $15.00
B6398 $15.00 $10.00 $15.00 $15.00
B6399 $15.00 $10.00 $20.00 $20.00
B6400 $15.00 $10.00 $20.00 $20.00
B6401 $15.00 $10.00 $20.00 $20.00
B6402 $15.00 $10.00 $20.00 $20.00
B6403 $15.00 $8.00 $12.00 $15.00
B6404 $15.00 $8.00 $12.00 $15.00
B6405 $15.00 $10.00 $20.00 $20.00
B6406 $15.00 $10.00 $15.00 $15.00
B6407 $15.00 $10.00 $15.00 $15.00
B6408 $10.00 $5.00 $10.00 $10.00
B6409 $15.00 $8.00 $10.00 $12.00
B6410 $15.00 $10.00 $15.00 $15.00
B6411 NADA $10.00 $15.00 $15.00
B6412 $15.00 $10.00 $15.00 $18.00
B6413 $15.00 $10.00 $18.00 $20.00
B6414 $15.00 $10.00 $18.00 $20.00
B6415 $15.00 $12.00 $18.00 $20.00
B6416 $15.00 $10.00 $15.00 $18.00
B6417 $15.00 $10.00 $18.00 $20.00
B6418 $15.00 $10.00 $18.00 $20.00
B6419 $15.00 $12.00 $18.00 $20.00
B6420 $15.00 $5.00 $20.00 $20.00
B6421 $15.00 $5.00 $15.00 $15.00
B6422 $15.00 $5.00 $15.00 $15.00
B6423 $15.00 $10.00 $12.00 $15.00
B6424 $15.00 $15.00 $20.00 $25.00
B6425 NADA $2.00 $5.00 $5.00
B6426 $15.00 $10.00 $15.00 $20.00
B6427 NADA $5.00 $15.00 $20.00
B6428 $15.00 $10.00 $18.00 $20.00
B6429 $15.00 $4.00 $7.00 $10.00
B6430 $15.00 $4.00 $7.00 $10.00
B6431 $15.00 $15.00 $20.00 $20.00
B6432 $15.00 $4.00 $15.00 $20.00
B6433 $15.00 $8.00 $15.00 $18.00
B6434 $15.00 $10.00 $18.00 $20.00
B6435 $15.00 $8.00 $15.00 $18.00
B6436 $15.00 $10.00 $15.00 $15.00
B6437 $15.00 $10.00 $15.00 $15.00
B6438 $15.00 $10.00 $15.00 $20.00
B6439 $15.00 $5.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6440 $15.00 $5.00 $10.00 $10.00
B6441 $15.00 $5.00 $10.00 $12.00
B6442 $15.00 $10.00 $15.00 $20.00
B6443 $15.00 $5.00 $15.00 $15.00
B6444 $15.00 $5.00 $15.00 $15.00
B6445 $15.00 $5.00 $15.00 $15.00
B6446 $15.00 $5.00 $10.00 $10.00
B6447 $15.00 $5.00 $10.00 $15.00
B6448 $15.00 $10.00 $20.00 $20.00
B6449 $15.00 $10.00 $20.00 $20.00
B6450 $15.00 $7.00 $15.00 $15.00
B6451 $15.00 $10.00 $15.00 $15.00
B6452 NADA $10.00 $15.00 $20.00
B6453 $15.00 $15.00 $20.00 $20.00
B6454 $15.00 $12.00 $12.00 $12.00
B6455 $15.00 $12.00 $15.00 $18.00
B6456 $15.00 $10.00 $12.00 $15.00
B6457 $15.00 $10.00 $15.00 $20.00
B6458 $15.00 $10.00 $15.00 $20.00
B6459 $15.00 $5.00 $10.00 $15.00
B6460 $15.00 $10.00 $20.00 $20.00
B6461 $15.00 $5.00 $15.00 $15.00
B6462 $15.00 $10.00 $15.00 $20.00
B6463 $15.00 $10.00 $20.00 $20.00
B6464 $15.00 $8.00 $12.00 $15.00
B6465 $15.00 $8.00 $12.00 $15.00
B6466 $15.00 $10.00 $15.00 $20.00
B6467 $15.00 $5.00 $10.00 $12.00
B6468 $15.00 $8.00 $12.00 $15.00
B6469 $15.00 $12.00 $15.00 $18.00
B6470 $15.00 $5.00 $10.00 $12.00
B6471 $15.00 $8.00 $12.00 $15.00
B6472 $15.00 $12.00 $15.00 $18.00
B6473 $15.00 $10.00 $12.00 $15.00
B6474 NADA $5.00 $20.00 $20.00
B6475 $15.00 $10.00 $15.00 $20.00
B6476 $15.00 $5.00 $10.00 $10.00
B6477 $15.00 $10.00 $15.00 $20.00
B6478 $15.00 $10.00 $15.00 $20.00
B6479 $15.00 $5.00 $15.00 $15.00
B6480 $15.00 $5.00 $15.00 $15.00
B6481 $15.00 $5.00 $15.00 $15.00
B6483 $15.00 $10.00 $15.00 $20.00
B6484 $15.00 $10.00 $15.00 $20.00
B6485 $15.00 $10.00 $15.00 $20.00
B6486 $10.00 $5.00 $10.00 $10.00
B6487 $15.00 $10.00 $15.00 $20.00
B6488 $15.00 $10.00 $15.00 $20.00
B6489 $15.00 $12.00 $18.00 $22.00
B6490 $10.00 $5.00 $10.00 $10.00
B6493 $15.00 $5.00 $10.00 $10.00
B6494 $15.00 $10.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6495 $15.00 $10.00 $15.00 $15.00
B6496 NADA $10.00 $15.00 $18.00
B6498 $15.00 $3.00 $7.00 $11.00
B6499 $15.00 $7.50 $10.00 $10.00
B6500 $15.00 $8.00 $12.00 $12.00
B6501 $15.00 $7.00 $10.00 $10.00
B6502 $15.00 $7.00 $10.00 $10.00
B6503 $15.00 $10.00 $10.00 $15.00
B6504 NADA $5.00 $10.00 $10.00
B6506 $15.00 $10.00 $20.00 $20.00
B6507 $15.00 $10.00 $15.00 $15.00
B6508 $15.00 $8.00 $12.00 $15.00
B6509 $15.00 $10.00 $12.00 $15.00
B6510 $15.00 $5.00 $10.00 $15.00
B6513 $15.00 $10.00 $12.00 $18.00
B6514 $15.00 $10.00 $15.00 $20.00
B6515 $15.00 $5.00 $10.00 $15.00
B6518 $15.00 $8.00 $15.00 $15.00
B6519 $15.00 $10.00 $15.00 $15.00
B6520 $15.00 $7.00 $12.00 $12.00
B6521 NADA NADA NADA NADA
B6522 $15.00 $3.00 $7.00 $9.00
B6523 $15.00 $10.00 $15.00 $15.00
B6524 $12.00 $8.00 $12.00 $12.00
B6525 $15.00 $5.00 $15.00 $15.00
B6526 $15.00 $10.00 $10.00 $15.00
B6527 $15.00 $10.00 $15.00 $15.00
B6528 $15.00 $10.00 $15.00 $20.00
B6529 $15.00 $10.00 $12.00 $15.00
B6530 NADA $10.00 $15.00 $15.00
B6531 NADA $10.00 $15.00 $15.00
B6532 $15.00 $5.00 $10.00 $12.00
B6533 NADA NADA NADA NADA
B6534 $15.00 $8.00 $12.00 $15.00
B6535 $15.00 $5.00 $10.00 $10.00
B6536 $15.00 $8.00 $12.00 $15.00
B6537 $15.00 $5.00 $8.00 $10.00
B6538 $15.00 $5.00 $15.00 $15.00
B6539 $15.00 $10.00 $20.00 $20.00
B6540 $15.00 $5.00 $15.00 $15.00
B6541 $15.00 $5.00 $15.00 $15.00
B6542 $15.00 $10.00 $15.00 $15.00
B6543 $15.00 $10.00 $10.00 $15.00
B6544 $15.00 $12.00 $15.00 $15.00
B6545 $15.00 $5.00 $15.00 $15.00
B6546 $15.00 $12.00 $12.00 $12.00
B6547 $15.00 $15.00 $20.00 $20.00
B6548 $15.00 $8.00 $12.00 $15.00
B6549 $15.00 $5.00 $10.00 $12.00
B6550 $15.00 $8.00 $10.00 $15.00
B6551 NADA $5.00 $15.00 $20.00
B6552 NADA $5.00 $15.00 $20.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6553 $15.00 $10.00 $12.00 $15.00
B6554 $15.00 $5.00 $15.00 $15.00
B6555 $15.00 $5.00 $15.00 $15.00
B6556 $15.00 $10.00 $10.00 $15.00
B6557 $15.00 $10.00 $10.00 $15.00
B6558 $15.00 $10.00 $20.00 $20.00
B6559 $15.00 $10.00 $10.00 $15.00
B6560 $15.00 $8.00 $12.00 $15.00
B6561 $15.00 $10.00 $15.00 $15.00
B6562 $15.00 $10.00 $15.00 $15.00
B6563 $15.00 $15.00 $18.00 $20.00
B6564 $15.00 $3.00 $7.00 $11.00
B6565 $15.00 $7.00 $12.00 $15.00
B6566 $15.00 $7.00 $12.00 $15.00
B6567 $15.00 $5.00 $15.00 $15.00
B6568 $15.00 $3.00 $7.00 $11.00
B6569 $15.00 $10.00 $15.00 $15.00
B6570 $15.00 $15.00 $20.00 $20.00
B6571 $15.00 $10.00 $15.00 $15.00
B6572 $15.00 $10.00 $10.00 $15.00
B6573 $15.00 $8.00 $20.00 $22.00
B6574 $20.00 $10.00 $15.00 $15.00
B6575 $15.00 $5.00 $10.00 $10.00
B6576 $15.00 $10.00 $12.00 $15.00
B6577 $15.00 $5.00 $10.00 $10.00
B6578 $15.00 $10.00 $15.00 $15.00
B6579 $15.00 $10.00 $15.00 $15.00
B6580 $15.00 $10.00 $12.00 $18.00
B6581 NADA $5.00 $10.00 $15.00
B6582 NADA $10.00 $15.00 $20.00
B6583 NADA $15.00 $20.00 $25.00
B6584 NADA $10.00 $15.00 $20.00
B6585 $15.00 $15.00 $20.00 $25.00
B6586 NADA $5.00 $10.00 $12.00
B6587 NADA $5.00 $10.00 $12.00
B6588 $15.00 $3.00 $10.00 $15.00
B6589 $15.00 $10.00 $15.00 $20.00
B6590 $15.00 $8.00 $12.00 $15.00
B6591 $15.00 $12.00 $15.00 $20.00
B6592 $15.00 $12.00 $15.00 $20.00
B6593 $15.00 $5.00 $15.00 $15.00
B6594 $15.00 $8.00 $12.00 $15.00
B6595 $15.00 $10.00 $15.00 $15.00
B6596 $15.00 $10.00 $15.00 $15.00
B6597 $15.00 $10.00 $10.00 $10.00
B6598 $15.00 $10.00 $20.00 $20.00
B6599 $15.00 $10.00 $15.00 $15.00
B6600 $15.00 $10.00 $15.00 $15.00
B6601 $15.00 $8.00 $15.00 $18.00
B6602 $15.00 $10.00 $15.00 $18.00
B6603 $15.00 $8.00 $15.00 $15.00
B6604 $15.00 $5.00 $10.00 $12.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6605 $15.00 $8.00 $12.00 $15.00
B6606 $15.00 $10.00 $15.00 $20.00
B6607 $15.00 $5.00 $15.00 $15.00
B6608 $15.00 $10.00 $15.00 $18.00
B6609 $15.00 $10.00 $15.00 $20.00
B6610 $15.00 $10.00 $20.00 $20.00
B6611 $15.00 $10.00 $20.00 $20.00
B6612 $15.00 $15.00 $18.00 $20.00
B6613 $15.00 $15.00 $18.00 $20.00
B6614 $15.00 $12.00 $15.00 $18.00
B6615 $15.00 $12.00 $15.00 $18.00
B6616 $15.00 $12.00 $15.00 $20.00
B6617 $15.00 $8.00 $15.00 $20.00
B6618 $15.00 $8.00 $15.00 $15.00
B6619 $15.00 $12.00 $15.00 $20.00
B6620 $15.00 $8.00 $12.00 $15.00
B6621 NADA $10.00 $15.00 $15.00
B6622 $15.00 $10.00 $15.00 $15.00
B6623 $15.00 $15.00 $20.00 $20.00
B6624 $15.00 $10.00 $15.00 $18.00
B6625 $10.00 $12.00 $15.00 $20.00
B6626 NADA $10.00 $15.00 $15.00
B6627 NADA NADA $10.00 $15.00
B6628 NADA $10.00 $18.00 $18.00
B6629 $15.00 $10.00 $12.00 $15.00
B6630 $15.00 $15.00 $15.00 $18.00
B6631 $15.00 $8.00 $12.00 $15.00
B6632 $15.00 $15.00 $20.00 $20.00
B6633 $15.00 $15.00 $20.00 $20.00
B6634 NADA $10.00 $15.00 $15.00
B6635 $15.00 $10.00 $15.00 $15.00
B6636 $15.00 $10.00 $15.00 $15.00
B6637 $15.00 $10.00 $10.00 $10.00
B6638 $15.00 $10.00 $10.00 $10.00
B6639 $15.00 $10.00 $10.00 $10.00
B6640 $15.00 $10.00 $15.00 $15.00
B6641 $15.00 $10.00 $15.00 $15.00
B6642 $15.00 $15.00 $20.00 $20.00
B6643 $15.00 $10.00 $15.00 $15.00
B6644 $15.00 $7.00 $10.00 $12.00
B6645 $15.00 $5.00 $15.00 $15.00
B6646 $15.00 $5.00 $12.00 $12.00
B6647 $15.00 $5.00 $10.00 $10.00
B6648 NADA $5.00 $10.00 $15.00
B6649 NADA $5.00 $10.00 $15.00
B6650 NADA $5.00 $10.00 $15.00
B6651 $15.00 $6.00 $8.00 $8.00
B6652 $15.00 $5.00 $10.00 $10.00
B6653 $15.00 $5.00 $15.00 $15.00
B6654 $15.00 $5.00 $15.00 $15.00
B6655 $15.00 $5.00 $10.00 $10.00
B6656 $15.00 $8.00 $12.00 $15.00
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6657 $15.00 $8.00 $12.00 $15.00
B6658 NADA $10.00 $15.00 $15.00
B6659 $15.00 $5.00 $10.00 $10.00
B6660 NADA $10.00 $15.00 $15.00
B6661 $15.00 $8.00 $12.00 $15.00
B6662 $15.00 $10.00 $15.00 $15.00
B6663 $15.00 $7.00 $12.00 $15.00
B6664 $15.00 $12.00 $15.00 $20.00
B6665 $15.00 $10.00 $12.00 $18.00
B6666 $15.00 $15.00 $20.00 $25.00
B6667 $15.00 $5.00 $15.00 $15.00
B6668 $15.00 $15.00 $20.00 $20.00
B6669 $15.00 $8.00 $12.00 $15.00
B6670 $15.00 $10.00 $12.00 $15.00
B6671 $15.00 $8.00 $10.00 $15.00
B6672 $15.00 $8.00 $10.00 $15.00
B6673 $15.00 $10.00 $15.00 $15.00
B6674 $10.00 $10.00 $10.00 $10.00
B6675 NADA $8.00 $15.00 $20.00
B6676 $15.00 $15.00 $20.00 $20.00
B6677 $15.00 $10.00 $15.00 $20.00
B6678 $15.00 $5.00 $5.00 $5.00
B6679 $15.00 $8.00 $10.00 $12.00
B6680 $15.00 $5.00 $15.00 $15.00
B6681 $15.00 $8.00 $12.00 $12.00
B6682 $15.00 $10.00 $15.00 $15.00
B6683 NADA $10.00 $15.00 $20.00
B6684 $15.00 $5.00 $15.00 $15.00
B6685 $15.00 $10.00 $15.00 $15.00
B6686 NADA $15.00 $20.00 $25.00
B6687 $15.00 $10.00 $15.00 $15.00
B6688 $15.00 $10.00 $15.00 $18.00
B6689 $15.00 $10.00 $15.00 $18.00
B6690 NADA $5.00 $15.00 $20.00
B6691 $15.00 $10.00 $15.00 $20.00
B6692 $15.00 $7.00 $12.00 $15.00
B6693 $15.00 $10.00 $15.00 $15.00
B6694 $15.00 $10.00 $15.00 $15.00
B6695 $15.00 $10.00 $15.00 $15.00
B6696 $15.00 $5.00 $15.00 $20.00
B6697 $15.00 $15.00 $20.00 $20.00
B6698 $15.00 $10.00 $12.00 $15.00
B6699 $15.00 $10.00 $15.00 $15.00
B6700 $15.00 $10.00 $15.00 $15.00
B6701 $15.00 $10.00 $15.00 $15.00
B6702 $15.00 $15.00 $15.00 $15.00
B6703 $15.00 $5.00 $18.00 $18.00
B6704 $15.00 $10.00 $12.00 $15.00
B6705 $15.00 $10.00 $15.00 $15.00
B6706 $15.00 $15.00 $15.00 $15.00
B6707 $15.00 $10.00 $12.00 $15.00
B6708 $15.00 $10.00 $15.00 $18.00
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6709 $15.00 $10.00 $15.00 $18.00
B6710 $15.00 $5.00 $15.00 $15.00
B6711 $15.00 NADA $10.00 $15.00
B6712 $10.00 $5.00 $10.00 $10.00
B6713 $15.00 $10.00 $15.00 $15.00
B6714 $15.00 $6.00 $10.00 $12.00
B6715 $15.00 $10.00 $15.00 $15.00
B6716 NADA $5.00 $10.00 $15.00
B6717 $15.00 $8.00 $12.00 $15.00
B6718 $15.00 $10.00 $12.00 $18.00
B6719 $15.00 $10.00 $15.00 $15.00
B6720 $15.00 $8.00 $10.00 $12.00
B6721 $15.00 $8.00 $12.00 $15.00
B6722 $15.00 $5.00 $10.00 $10.00
B6723 NADA $10.00 $15.00 $20.00
B6724 $15.00 $10.00 $20.00 $25.00
B6725 $15.00 $5.00 $10.00 $10.00
B6726 $15.00 $10.00 $12.00 $15.00
B6727 $15.00 $5.00 $15.00 $15.00
B6728 NADA NADA $12.00 $15.00
B6729 $15.00 NADA $12.00 $15.00
B6730 $15.00 $3.00 $7.00 $11.00
B6731 NADA $8.00 $12.00 $15.00
B6732 $15.00 NADA $12.00 $15.00
B6733 $10.00 $5.00 $10.00 $10.00
B6734 $10.00 $5.00 $10.00 $10.00
B6735 $15.00 $10.00 $12.00 $15.00
B6736 $15.00 $12.00 $15.00 $18.00
B6737 $15.00 $5.00 $15.00 $15.00
B6738 $15.00 $10.00 $15.00 $15.00
B6739 $15.00 $5.00 $15.00 $15.00
B6740 $15.00 $8.00 $12.00 $15.00
B6741 $15.00 $15.00 $20.00 $25.00
B6742 $15.00 $10.00 $20.00 $20.00
B6743 $15.00 $5.00 $12.00 $15.00
B6744 $15.00 $10.00 $15.00 $18.00
B6745 $15.00 $10.00 $15.00 $18.00
B6746 $15.00 $5.00 $15.00 $15.00
B6747 $15.00 $5.00 $15.00 $15.00
B6748 $20.00 $10.00 $20.00 $20.00
B6749 $15.00 $10.00 $15.00 $15.00
B6750 $15.00 $10.00 $15.00 $15.00
B6751 $15.00 $10.00 $15.00 $15.00
B6752 $15.00 $5.00 $12.00 $15.00
B6753 $15.00 $8.00 $12.00 $15.00
B6754 $15.00 $5.00 $15.00 $15.00
B6755 $15.00 $10.00 $10.00 $10.00
B6756 $15.00 $5.00 $15.00 $15.00
B6757 $15.00 $10.00 $15.00 $18.00
B6758 $15.00 $15.00 $20.00 $20.00
B6759 $15.00 $18.00 $22.00 $25.00
B6760 $15.00 $10.00 $15.00 $15.00
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CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6761 $15.00 $10.00 $15.00 $15.00
B6762 $15.00 $8.00 $15.00 $15.00
B6763 NADA $10.00 $15.00 $20.00
B6764 NADA $15.00 $20.00 $25.00
B6765 NADA $10.00 $15.00 $20.00
B6766 NADA $5.00 $10.00 $10.00
B6767 $15.00 $5.00 $10.00 $10.00
B6768 $15.00 $10.00 $15.00 $15.00
B6769 $15.00 $18.00 $21.00 $25.00
B6770 $15.00 $18.00 $21.00 $25.00
B6771 $15.00 $5.00 $10.00 $10.00
B6772 $15.00 $7.00 $18.00 $20.00
B6773 $15.00 $10.00 $15.00 $18.00
B6774 $15.00 $15.00 $18.00 $20.00
B6775 $15.00 NADA $10.00 $15.00
B6776 $15.00 $10.00 $15.00 $15.00
B6777 $15.00 $4.00 $15.00 $18.00
B6778 $15.00 $5.00 $15.00 $15.00
B6779 $15.00 $5.00 $18.00 $18.00
B6780 $15.00 $2.00 $3.00 $5.00
B6781 $15.00 $5.00 $18.00 $18.00
B6782 $15.00 $5.00 $18.00 $18.00
B6783 $15.00 $5.00 $15.00 $15.00
B6784 $15.00 $5.00 $10.00 $12.00
B6785 $15.00 $5.00 $15.00 $15.00
B6788 NADA $5.00 $10.00 $15.00
B6789 $15.00 $10.00 $15.00 $15.00
B6790 $15.00 $7.00 $18.00 $20.00
B6791 $15.00 $7.00 $15.00 $18.00
B6792 $15.00 $5.00 $15.00 $15.00
B6793 NADA $10.00 $15.00 $15.00
B6794 $15.00 $5.00 $15.00 $15.00
B6795 $15.00 $10.00 $15.00 $20.00
B6796 NADA $8.00 $10.00 $12.00
B6797 NADA $8.00 $15.00 $15.00
B6798 NADA $10.00 $18.00 $18.00
B6799 $15.00 NADA $18.00 $20.00
B6800 $15.00 $10.00 $15.00 $15.00
B6801 $15.00 $12.00 $15.00 $18.00
B6802 $15.00 $10.00 $12.00 $15.00
B6803 $15.00 $8.00 $10.00 $12.00
B6804 $15.00 $10.00 $15.00 $15.00
B6805 $15.00 $10.00 $15.00 $15.00
B6806 $15.00 $10.00 $15.00 $15.00
B6807 $15.00 $10.00 $15.00 $20.00
B6808 $10.00 $5.00 $10.00 $10.00
B6809 $15.00 $15.00 $15.00 $15.00
B6810 $15.00 $15.00 $15.00 $15.00
B6811 $15.00 $5.00 $10.00 $10.00
B6812 $15.00 $12.00 $15.00 $18.00
B6813 $15.00 $5.00 $15.00 $15.00
B6814 $15.00 $10.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6815 $15.00 $10.00 $15.00 $18.00
B6816 $15.00 $5.00 $10.00 $10.00
B6817 $15.00 $10.00 $20.00 $20.00
B6818 $15.00 $10.00 $20.00 $25.00
B6819 $15.00 $8.00 $12.00 $15.00
B6820 $15.00 $10.00 $15.00 $15.00
B6821 $15.00 $8.00 $12.00 $15.00
B6822 $15.00 $10.00 $15.00 $15.00
B6823 $15.00 $10.00 $15.00 $15.00
B6824 $15.00 $10.00 $15.00 $15.00
B6825 $15.00 $10.00 $15.00 $15.00
B6826 $15.00 $5.00 $15.00 $15.00
B6827 $15.00 $5.00 $15.00 $20.00
B6828 $15.00 $5.00 $12.00 $20.00
B6829 $15.00 $5.00 $10.00 $10.00
B6830 $15.00 $5.00 $10.00 $10.00
B6831 $15.00 $5.00 $12.00 $20.00
B6832 $15.00 $10.00 $15.00 $20.00
B6833 $10.00 $5.00 $10.00 $10.00
B6834 $10.00 $5.00 $10.00 $10.00
B6835 $15.00 $10.00 $10.00 $10.00
B6836 $15.00 $12.00 $15.00 $18.00
B6837 $15.00 $4.00 $15.00 $20.00
B6838 $15.00 $10.00 $15.00 $15.00
B6839 $15.00 $10.00 $18.00 $25.00
B6840 $15.00 $5.00 $12.00 $20.00
B6841 $15.00 $10.00 $15.00 $15.00
B6842 $15.00 $10.00 $15.00 $20.00
B6843 $15.00 $5.00 $15.00 $20.00
B6844 $15.00 $5.00 $12.00 $20.00
B6845 $15.00 $5.00 $15.00 $20.00
B6846 $15.00 $5.00 $12.00 $12.00
B6847 $15.00 $5.00 $12.00 $12.00
B6848 $15.00 $5.00 $15.00 $20.00
B6849 $15.00 $10.00 $15.00 $20.00
B6850 NADA $10.00 $15.00 $15.00
B6851 $15.00 $5.00 $10.00 $10.00
B6852 $10.00 $5.00 $10.00 $10.00
B6853 $10.00 $5.00 $10.00 $10.00
B6854 $15.00 $10.00 $15.00 $15.00
B6855 $15.00 $5.00 $10.00 $10.00
B6856 $15.00 $5.00 $15.00 $15.00
B6857 $15.00 $10.00 $18.00 $25.00
B6858 $15.00 $8.00 $12.00 $15.00
B6859 $15.00 $5.00 $10.00 $10.00
B6860 NADA $5.00 $15.00 $20.00
B6861 $15.00 $5.00 $12.00 $20.00
B6862 $15.00 $5.00 $10.00 $12.00
B6863 $15.00 $5.00 $10.00 $12.00
B6864 $15.00 $10.00 $15.00 $20.00
B6865 $15.00 $5.00 $15.00 $15.00
B6866 $15.00 $5.00 $10.00 $10.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6867 $15.00 $10.00 $15.00 $20.00
B6868 $15.00 $5.00 $15.00 $15.00
B6869 $15.00 $10.00 $15.00 $15.00
B6870 $15.00 $15.00 $20.00 $20.00
B6871 $15.00 $15.00 $15.00 $15.00
B6872 $15.00 $8.00 $10.00 $15.00
B6873 $15.00 $10.00 $12.00 $18.00
B6874 $15.00 $10.00 $20.00 $20.00
B6875 $15.00 $10.00 $18.00 $20.00
B6876 $15.00 $10.00 $15.00 $20.00
B6877 $15.00 $5.00 $10.00 $10.00
B6878 $15.00 $12.00 $15.00 $20.00
B6879 $10.00 $5.00 $10.00 $10.00
B6880 $15.00 $12.00 $15.00 $20.00
B6881 $15.00 $10.00 $15.00 $20.00
B6882 $15.00 $10.00 $15.00 $15.00
B6883 NADA $10.00 $15.00 $15.00
B6884 $15.00 $5.00 $12.00 $20.00
B6885 $15.00 $10.00 $15.00 $15.00
B6886 $15.00 $10.00 $20.00 $25.00
B6887 $15.00 $10.00 $15.00 $20.00
B6888 $15.00 $8.00 $12.00 $15.00
B6889 NADA $10.00 $15.00 $15.00
B6890 $10.00 $5.00 $10.00 $10.00
B6891 $15.00 $5.00 $10.00 $10.00
B6892 $15.00 $5.00 $15.00 $15.00
B6893 $15.00 $10.00 $15.00 $15.00
B6894 $15.00 $8.00 $12.00 $15.00
B6895 $15.00 $5.00 $10.00 $10.00
B6896 $15.00 $8.00 $10.00 $15.00
B6897 $15.00 $8.00 $12.00 $15.00
B6898 $15.00 $18.00 $22.00 $25.00
B6899 $15.00 $10.00 $15.00 $15.00
B6900 $15.00 $10.00 $15.00 $15.00
B6901 $15.00 $5.00 $15.00 $20.00
B6902 $10.00 $5.00 $10.00 $10.00
B6903 $15.00 $10.00 $15.00 $15.00
B6904 $15.00 $10.00 $15.00 $15.00
B6905 $15.00 $7.00 $12.00 $15.00
B6906 $15.00 $8.00 $15.00 $18.00
B6907 $15.00 $8.00 $12.00 $15.00
B6908 $10.00 $5.00 $10.00 $10.00
B6909 $15.00 $12.00 $15.00 $20.00
B6910 $15.00 $12.00 $15.00 $20.00
B6911 $15.00 $12.00 $15.00 $20.00
B6912 $15.00 $15.00 $20.00 $20.00
B6913 $15.00 $12.00 $15.00 $15.00
B6914 $15.00 $10.00 $12.00 $15.00
B6915 $15.00 $8.00 $18.00 $20.00
B6916 $15.00 $8.00 $18.00 $20.00
B6917 $15.00 $8.00 $18.00 $20.00
B6918 $15.00 $5.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6919 $15.00 $15.00 $20.00 $20.00
B6920 $15.00 $5.00 $15.00 $15.00
B6921 $15.00 $10.00 $15.00 $15.00
B6922 $10.00 $5.00 $10.00 $10.00
B6923 $10.00 $5.00 $10.00 $10.00
B6924 NADA $10.00 $15.00 $18.00
B6925 NADA $12.00 $18.00 $18.00
B6926 $15.00 $8.00 $18.00 $20.00
B6927 $15.00 $10.00 $15.00 $15.00
B6928 $15.00 NADA $18.00 $20.00
B6929 $15.00 $10.00 $15.00 $20.00
B6930 $15.00 $5.00 $10.00 $10.00
B6931 $15.00 $8.00 $12.00 $15.00
B6932 $15.00 $10.00 $15.00 $20.00
B6933 $15.00 $15.00 $15.00 $15.00
B6934 $10.00 $5.00 $10.00 $10.00
B6935 $15.00 $10.00 $15.00 $15.00
B6936 $15.00 $15.00 $20.00 $20.00
B6937 $15.00 $10.00 $15.00 $15.00
B6938 $15.00 $5.00 $10.00 $15.00
B6939 $15.00 $10.00 $15.00 $15.00
B6940 NADA $10.00 $15.00 $18.00
B6941 $15.00 $8.00 $12.00 $15.00
B6942 $15.00 $5.00 $10.00 $12.00
B6943 $15.00 $10.00 $15.00 $18.00
B6944 $15.00 $15.00 $20.00 $20.00
B6945 $15.00 $10.00 $15.00 $20.00
B6946 $15.00 $5.00 $15.00 $15.00
B6947 $15.00 $10.00 $15.00 $15.00
B6948 $15.00 $10.00 $15.00 $15.00
B6949 $15.00 $5.00 $10.00 $15.00
B6950 $15.00 $10.00 $15.00 $15.00
B6951 $15.00 $15.00 $18.00 $22.00
B6952 $15.00 $15.00 $15.00 $20.00
B6953 $15.00 $10.00 $15.00 $18.00
B6954 $15.00 $15.00 $20.00 $20.00
B6955 $15.00 $15.00 $20.00 $20.00
B6956 $15.00 $8.00 $12.00 $15.00
B6957 $15.00 $10.00 $15.00 $20.00
B6958 $15.00 $5.00 $15.00 $15.00
B6959 $15.00 $10.00 $18.00 $20.00
B6960 $15.00 $10.00 $15.00 $15.00
B6961 $15.00 $5.00 $15.00 $18.00
B6962 $15.00 $10.00 $15.00 $20.00
B6963 $15.00 $10.00 $12.00 $15.00
B6964 $15.00 $10.00 $15.00 $20.00
B6965 $15.00 $10.00 $15.00 $20.00
B6966 $15.00 $10.00 $12.00 $15.00
B6967 $10.00 $5.00 $10.00 $10.00
B6968 $15.00 $5.00 $10.00 $10.00
B6969 $15.00 $8.00 $10.00 $12.00
B6970 $15.00 $10.00 $12.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B6971 $15.00 $15.00 $20.00 $20.00
B6972 $15.00 $15.00 $20.00 $20.00
B6973 NADA NADA $7.00 $10.00
B6974 NADA NADA $7.00 $10.00
B6975 $15.00 $10.00 $18.00 $18.00
B6976 $15.00 $10.00 $18.00 $18.00
B6977 NADA $5.00 $10.00 $15.00
B6978 $15.00 $10.00 $15.00 $20.00
B6979 $15.00 $5.00 $15.00 $20.00
B6980 $15.00 $5.00 $15.00 $20.00
B6981 $10.00 $5.00 $10.00 $10.00
B6982 NADA $10.00 $15.00 $15.00
B6983 $15.00 $10.00 $15.00 $20.00
B6984 $15.00 $15.00 $20.00 $20.00
B6985 $10.00 $5.00 $10.00 $10.00
B6986 $15.00 $10.00 $15.00 $20.00
B6987 $15.00 $10.00 $15.00 $20.00
B6988 $15.00 $10.00 $18.00 $25.00
B6989 $15.00 NADA $12.00 $15.00
B6990 $15.00 $5.00 $15.00 $15.00
B6991 NADA $7.00 $15.00 $15.00
B6992 $15.00 NADA $10.00 $15.00
B6993 $15.00 $10.00 $15.00 $15.00
B6994 $15.00 $10.00 $15.00 $18.00
B6995 $15.00 $10.00 $15.00 $15.00
B6996 $15.00 $5.00 $10.00 $10.00
B6997 $15.00 $10.00 $15.00 $15.00
B6998 $15.00 $15.00 $20.00 $22.00
B6999 $15.00 $10.00 $12.00 $15.00
B7000 NADA NADA NADA NADA
B7001 $15.00 $10.00 $12.00 $15.00
B7002 $15.00 $10.00 $12.00 $15.00
B7003 $15.00 NADA $10.00 $15.00
B7004 $15.00 $10.00 $12.00 $15.00
B7005 $15.00 $10.00 $15.00 $20.00
B7006 $15.00 $8.00 $15.00 $15.00
B7007 NADA NADA NADA NADA
B7008 NADA $5.00 $15.00 $20.00
B7009 $15.00 $10.00 $15.00 $20.00
B7010 $15.00 $5.00 $18.00 $20.00
B7011 $15.00 $10.00 $15.00 $15.00
B7012 $15.00 $5.00 $10.00 $10.00
B7013 $15.00 NADA $12.00 $15.00
B7014 $15.00 $15.00 $15.00 $20.00
B7015 $15.00 $10.00 $15.00 $15.00
B7016 $15.00 $10.00 $12.00 $15.00
B7017 $15.00 $12.00 $15.00 $18.00
B7018 $10.00 $5.00 $10.00 $10.00
B7020 $15.00 $15.00 $18.00 $20.00
B7022 $15.00 $5.00 $15.00 $18.00
B7023 $15.00 $10.00 $15.00 $20.00
B7024 $10.00 $5.00 $10.00 $10.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B7025 $10.00 $5.00 $10.00 $10.00
B7026 $15.00 $6.00 $12.00 $15.00
B7027 $15.00 $10.00 $15.00 $20.00
B7028 $15.00 $5.00 $5.00 $5.00
B7029 $10.00 $5.00 $10.00 $10.00
B7030 $15.00 $15.00 $20.00 $20.00
B7031 $15.00 $10.00 $15.00 $15.00
B7032 $15.00 $10.00 $15.00 $20.00
B7033 $15.00 $10.00 $15.00 $15.00
B7034 NADA NADA NADA NADA
B7035 $15.00 $5.00 $10.00 $10.00
B7036 NADA NADA NADA NADA
B7037 $15.00 $5.00 $10.00 $15.00
B7038 $10.00 $5.00 $10.00 $10.00
B7039 $15.00 $5.00 $15.00 $18.00
B7040 $15.00 $10.00 $20.00 $20.00
B7041 $15.00 $10.00 $15.00 $15.00
B7042 $10.00 $5.00 $10.00 $10.00
B7043 $15.00 $10.00 $15.00 $15.00
B7044 $15.00 $10.00 $15.00 $15.00
B7045 $15.00 $5.00 $15.00 $15.00
B7046 $15.00 $5.00 $15.00 $15.00
B7047 $15.00 $10.00 $18.00 $20.00
B7048 $15.00 $12.00 $15.00 $18.00
B7049 $15.00 $12.00 $15.00 $18.00
B7050 $15.00 $5.00 $12.00 $20.00
B7051 $15.00 $10.00 $18.00 $20.00
B7052 $10.00 $5.00 $10.00 NADA
B7053 $15.00 $10.00 $15.00 $15.00
B7054 $15.00 NADA $20.00 $20.00
B7055 $15.00 $5.00 $7.00 $10.00
B7056 $15.00 $5.00 $10.00 $10.00
B7057 $15.00 $5.00 $15.00 $15.00
B7058 $15.00 $10.00 $15.00 $20.00
B7059 $15.00 NADA $12.00 $15.00
B7060 $15.00 $8.00 $15.00 $20.00
B7061 $15.00 $5.00 $7.00 $10.00
B7062 $15.00 $8.00 $15.00 $20.00
B7063 $15.00 $10.00 $18.00 $20.00
B7064 $15.00 $10.00 $15.00 $20.00
B7065 $15.00 $8.00 $10.00 $12.00
B7066 $10.00 $5.00 $10.00 $10.00
B7067 $10.00 $5.00 $10.00 $10.00
B7068 $15.00 $5.00 $15.00 $15.00
B7069 $15.00 $10.00 $15.00 $15.00
B7070 NADA $5.00 $20.00 $20.00
B7071 $15.00 $12.00 $15.00 $18.00
B7072 $15.00 $10.00 $15.00 $18.00
B7073 $15.00 $12.00 $18.00 $18.00
B7074 $15.00 $12.00 $18.00 $18.00
B7075 $30.00 $10.00 $24.00 $36.00
B7076 NADA $5.00 $20.00 $20.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B7077 $15.00 $5.00 $15.00 $15.00
B7079 $15.00 $10.00 $15.00 $20.00
B7080 $15.00 $10.00 $15.00 $15.00
B7081 $15.00 $10.00 $15.00 $20.00
B7082 $15.00 $8.00 $12.00 $20.00
B7083 $15.00 $10.00 $12.00 $15.00
B7084 $15.00 $10.00 $15.00 $20.00
B7085 $15.00 $5.00 $15.00 $15.00
B7086 $15.00 $8.00 $12.00 $15.00
B7087 $15.00 $10.00 $18.00 $25.00
B7088 $15.00 $10.00 $15.00 $20.00
B7089 $15.00 $10.00 $15.00 $20.00
B7090 $10.00 $8.00 $18.00 $20.00
B7091 $15.00 $8.00 $15.00 $18.00
B7092 $15.00 $5.00 $15.00 $15.00
B7093 $15.00 $5.00 $15.00 $15.00
B7094 $15.00 $10.00 $20.00 $20.00
B7095 $15.00 $15.00 $15.00 $20.00
B7096 $15.00 $10.00 $20.00 $20.00
B7097 NADA NADA NADA NADA
B7099 $15.00 $10.00 $20.00 $20.00
B7100 $15.00 $10.00 $20.00 $20.00
B7101 $15.00 $5.00 $10.00 $10.00
B7104 NADA $8.00 $15.00 $20.00
B7109 $10.00 $5.00 $10.00 $10.00
B7111 $15.00 $5.00 $12.00 $20.00
B7112 $15.00 $10.00 $15.00 $15.00
B7113 $15.00 $12.00 $18.00 $18.00
B7114 $15.00 $15.00 $20.00 $20.00
B7115 $15.00 $15.00 $18.00 $18.00
B7116 $15.00 $8.00 $12.00 $15.00
B7117 $15.00 $10.00 $15.00 $15.00
B7118 $15.00 $5.00 $10.00 $15.00
B7119 $15.00 $8.00 $12.00 $12.00
B7120 $15.00 $8.00 $12.00 $12.00
B7121 $15.00 $8.00 $12.00 $15.00
B7122 $15.00 $5.00 $10.00 $12.00
B7123 $15.00 $10.00 $15.00 $15.00
B7124 $15.00 $12.00 $15.00 $18.00
B7125 $15.00 $8.00 $12.00 $18.00
B7126 $15.00 $10.00 $12.00 $18.00
B7127 $15.00 $8.00 $10.00 $10.00
B7128 $15.00 $8.00 $12.00 $15.00
B7129 $15.00 $12.00 $15.00 $20.00
B7130 $15.00 $12.00 $15.00 $20.00
B7131 $15.00 $10.00 $20.00 $20.00
B7132 $10.00 $5.00 $10.00 $10.00
B7133 $15.00 $8.00 $12.00 $15.00
B7134 $15.00 $8.00 $12.00 $15.00
B7135 $15.00 $12.00 $15.00 $20.00
B7136 $15.00 $8.00 $15.00 $20.00
B7137 $15.00 $8.00 $15.00 $20.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B7138 $15.00 $8.00 $12.00 $15.00
B7139 $15.00 $10.00 $12.00 $18.00
B7140 $15.00 $12.00 $15.00 $18.00
B7141 $15.00 $8.00 $12.00 $15.00
B7142 $15.00 $12.00 $15.00 $18.00
B7143 $15.00 $10.00 $12.00 $18.00
B7144 $15.00 $12.00 $15.00 $20.00
B7145 $15.00 $12.00 $15.00 $20.00
B7146 $15.00 $12.00 $15.00 $18.00
B7147 $15.00 $5.00 $12.00 $15.00
B7148 $15.00 $10.00 $12.00 $18.00
B7149 $15.00 $12.00 $15.00 $20.00
B7150 $15.00 $12.00 $15.00 $20.00
B7151 $15.00 $10.00 $12.00 $18.00
B7152 $15.00 $12.00 $15.00 $18.00
B7153 $15.00 $12.00 $15.00 $20.00
B7154 $15.00 $12.00 $15.00 $20.00
B7155 $15.00 $8.00 $12.00 $15.00
B7156 $10.00 $5.00 $10.00 $10.00
B7157 $15.00 $8.00 $15.00 $15.00
B7158 $15.00 $12.00 $18.00 $22.00
B7159 $15.00 $15.00 $18.00 $20.00
B7160 $15.00 $12.00 $18.00 $20.00
B7161 $15.00 $10.00 $15.00 $15.00
B7162 NADA $10.00 $20.00 $20.00
B7163 $15.00 $12.00 $15.00 $20.00
B7164 $15.00 $8.00 $12.00 $15.00
B7165 $15.00 $8.00 $12.00 $15.00
B7166 $15.00 $12.00 $15.00 $20.00
B7167 $10.00 $5.00 $10.00 $10.00
B7168 $15.00 $10.00 $15.00 $15.00
B7169 NADA $10.00 $20.00 $20.00
B7170 NADA $10.00 $20.00 $20.00
B7171 $15.00 $5.00 $20.00 $20.00
B7172 $15.00 $8.00 $12.00 $15.00
B7173 $15.00 $12.00 $15.00 $20.00
B7174 $15.00 $8.00 $12.00 $15.00
B7175 $15.00 $10.00 $15.00 $20.00
B7176 $15.00 $10.00 $12.00 $18.00
B7177 $15.00 $10.00 $12.00 $18.00
B7178 $15.00 $12.00 $15.00 $20.00
B7179 $15.00 $10.00 $12.00 $18.00
B7180 $15.00 $8.00 $12.00 $15.00
B7181 $15.00 $12.00 $15.00 $20.00
B7182 $15.00 $8.00 $12.00 $15.00
B7183 $15.00 $5.00 $10.00 $10.00
B7184 $15.00 $5.00 $20.00 $20.00
B7185 $15.00 $5.00 $15.00 $15.00
B7186 $15.00 $10.00 $12.00 $18.00
B7187 $15.00 $10.00 $12.00 $18.00
B7188 $15.00 $12.00 $15.00 $18.00
B7189 $15.00 $10.00 $12.00 $18.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B7190 $15.00 $10.00 $12.00 $18.00
B7191 $15.00 $12.00 $15.00 $20.00
B7192 $15.00 $12.00 $15.00 $18.00
B7193 $15.00 $10.00 $12.00 $18.00
B7194 $15.00 $8.00 $12.00 $15.00
B7195 $15.00 $10.00 $15.00 $20.00
B7196 $15.00 $15.00 $15.00 $15.00
B7197 $10.00 $5.00 $10.00 $10.00
B7198 $15.00 $5.00 $15.00 $15.00
B7199 $15.00 $5.00 $12.00 $20.00
B7200 $15.00 $5.00 $12.00 $20.00
B7201 $15.00 $5.00 $10.00 $12.00
B7202 $15.00 $10.00 $15.00 $20.00
B7203 $15.00 $4.00 $7.00 $10.00
B7204 $15.00 $8.00 $10.00 $12.00
B7205 $15.00 $4.00 $15.00 $20.00
B7206 $15.00 $4.00 $15.00 $20.00
B7207 $15.00 $10.00 $18.00 $20.00
B7208 $15.00 $15.00 $18.00 $20.00
B7209 $15.00 $8.00 $12.00 $15.00
B7210 $15.00 $5.00 $10.00 $12.00
B7211 $15.00 $10.00 $15.00 $20.00
B7213 $15.00 $10.00 $18.00 $20.00
B7214 $15.00 NADA $15.00 $20.00
B7218 $15.00 $10.00 $15.00 $20.00
B7219 $15.00 $5.00 $10.00 $10.00
B7220 $15.00 $10.00 $15.00 $15.00
B7221 $15.00 $5.00 $10.00 $12.00
B7222 $15.00 $5.00 $10.00 $10.00
B7223 $15.00 $10.00 $15.00 $15.00
B7224 $15.00 $10.00 $15.00 $15.00
B7225 $15.00 $10.00 $20.00 $25.00
B7226 $15.00 $15.00 $20.00 $20.00
B7227 $15.00 $15.00 $18.00 $20.00
B7228 $15.00 $5.00 $15.00 $15.00
B7229 $15.00 $8.00 $12.00 $15.00
B7230 $15.00 $10.00 $10.00 $10.00
B7231 $15.00 $5.00 $15.00 $15.00
B7234 $15.00 $5.00 $10.00 $10.00
B7235 $15.00 $5.00 $15.00 $15.00
B7236 $15.00 $10.00 $15.00 $18.00
B7237 $18.00 $12.00 $18.00 $20.00
B7238 $15.00 $8.00 $12.00 $15.00
B7240 $15.00 $10.00 $15.00 $15.00
B7241 $15.00 $10.00 $15.00 $20.00
B7242 $15.00 $12.00 $15.00 $20.00
B7243 $15.00 $8.00 $10.00 $12.00
B7244 $15.00 $5.00 $15.00 $20.00
B7245 $15.00 $5.00 $15.00 $20.00
B7246 $15.00 $7.00 $15.00 $15.00
B7247 $15.00 $5.00 $10.00 $10.00
B7248 $15.00 $8.00 $12.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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173
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B7249 $15.00 $10.00 $15.00 $15.00
B7250 $15.00 $10.00 $15.00 $15.00
B7251 $15.00 $10.00 $12.00 $18.00
B7252 $15.00 $10.00 $12.00 $15.00
B7253 $15.00 $12.00 $15.00 $18.00
B7254 $15.00 $10.00 $15.00 $15.00
B7255 $15.00 $10.00 $15.00 $15.00
B7256 $15.00 $5.00 $10.00 $10.00
B7257 $15.00 $5.00 $15.00 $15.00
B7258 $15.00 $12.00 $15.00 $18.00
B7259 $15.00 $10.00 $15.00 $15.00
B7260 $15.00 $10.00 $20.00 $20.00
B7261 $15.00 $5.00 $12.00 $20.00
B7262 $15.00 $8.00 $12.00 $15.00
B7263 NADA $5.00 $15.00 $20.00
B7264 $15.00 $8.00 $10.00 $12.00
B7265 $15.00 $8.00 $10.00 $12.00
B7266 $15.00 $8.00 $10.00 $12.00
B7267 $15.00 $8.00 $10.00 $12.00
B7268 $15.00 $3.00 $7.00 $11.00
B7269 NADA $3.00 $3.00 $3.00
B7270 $15.00 $3.00 $7.00 $11.00
B7271 $15.00 $10.00 $15.00 $20.00
B7272 $15.00 $10.00 $15.00 $20.00
B7273 $15.00 $10.00 $15.00 $15.00
B7274 $15.00 $5.00 $10.00 $15.00
B7275 NADA $10.00 $15.00 $18.00
B7276 NADA $10.00 $18.00 $18.00
B7277 $10.00 $5.00 $10.00 $10.00
B7278 $15.00 $15.00 $20.00 $20.00
B7279 NADA $5.00 $15.00 $20.00
B7280 NADA $12.00 $18.00 $18.00
B7281 $15.00 $5.00 $15.00 $15.00
B7283 $15.00 $5.00 $15.00 $15.00
B7284 $15.00 $10.00 $15.00 $20.00
B7285 $15.00 $10.00 $18.00 $25.00
B7286 $15.00 $5.00 $10.00 $15.00
B7288 NADA $5.00 $15.00 $20.00
B7290 $15.00 $12.00 $15.00 $20.00
B7291 $15.00 $12.00 $15.00 $18.00
B7292 $15.00 $10.00 $10.00 $10.00
B7297 $15.00 NADA $15.00 $20.00
B7298 $15.00 $12.00 $15.00 $18.00
B7299 $15.00 $12.00 $15.00 $18.00
B7300 $15.00 $10.00 $18.00 $18.00
B7301 $15.00 $10.00 $15.00 $15.00
B7303 $15.00 $5.00 $15.00 $15.00
B7304 $10.00 $5.00 $10.00 $10.00
B7305 $15.00 $10.00 $15.00 $20.00
B7308 $15.00 NADA $15.00 $18.00
B7309 $18.00 $10.00 $18.00 $20.00
B7310 $18.00 $10.00 $18.00 $20.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
B7313 $15.00 $10.00 $15.00 $20.00
B7314 $15.00 $10.00 $15.00 $20.00
B7315 $15.00 $5.00 $15.00 $20.00
B7316 $15.00 $10.00 $20.00 $25.00
B7317 $10.00 $5.00 $10.00 $10.00
B7318 $15.00 $15.00 $20.00 $20.00
B7319 $15.00 $10.00 $18.00 $20.00
B7320 $15.00 $15.00 $18.00 $18.00
B7321 $15.00 $10.00 $15.00 $20.00
B7322 $15.00 $10.00 $18.00 $20.00
B7323 $15.00 $5.00 $15.00 $15.00
B7324 $15.00 $10.00 $15.00 $15.00
B7325 $15.00 $10.00 $18.00 $25.00
B7326 $10.00 $5.00 $10.00 $10.00
B7330 NADA $5.00 $10.00 $15.00
B7331 $15.00 $10.00 $15.00 $15.00
B7332 $15.00 $5.00 $12.00 $20.00
B7333 $18.00 $10.00 $18.00 $20.00
B7334 $18.00 $10.00 $18.00 $20.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
BA1 $15.00 $10.00 $15.00 $15.00
BA2 $15.00 $10.00 $15.00 $15.00
BA3 $15.00 $5.00 $15.00 $15.00
BA4 $15.00 $5.00 $15.00 $15.00
BA5 $15.00 $10.00 $15.00 $15.00
BA6 $15.00 $10.00 $15.00 $15.00
BA7 $15.00 $5.00 $15.00 $15.00
BA8 $15.00 $10.00 $15.00 $15.00
BA9 $15.00 $5.00 $15.00 $15.00
BA10 $15.00 $10.00 $15.00 $15.00
BA11 $15.00 $10.00 $15.00 $15.00
BA12 $15.00 $5.00 $10.00 $10.00
BA13 $15.00 $10.00 $15.00 $15.00
BA14 $15.00 $10.00 $15.00 $15.00
BA15 $15.00 $10.00 $15.00 $15.00
BA16 $15.00 $10.00 $15.00 $15.00
BA17 $15.00 $10.00 $15.00 $15.00
BA18 $15.00 $10.00 $15.00 $15.00
BA19 $15.00 $10.00 $15.00 $15.00
BA20 $15.00 $10.00 $15.00 $15.00
BA21 $15.00 $10.00 $15.00 $15.00
BA22 $15.00 $10.00 $15.00 $15.00
BA23 $15.00 $10.00 $15.00 $15.00
BA24 $15.00 $10.00 $15.00 $15.00
BA25 $15.00 $5.00 $15.00 $15.00
BA26 $15.00 $10.00 $15.00 $15.00
BA27 $15.00 $10.00 $15.00 $15.00
BA28 $15.00 $10.00 $15.00 $15.00
BA29 $15.00 $10.00 $15.00 $15.00
BA30 $15.00 $10.00 $15.00 $15.00
BA31 $15.00 $10.00 $15.00 $15.00
BA32 $15.00 $10.00 $15.00 $15.00
BA33 $15.00 $5.00 $15.00 $15.00
BA34 $15.00 $5.00 $15.00 $15.00
BA35 $15.00 $10.00 $15.00 $15.00
BA36 $15.00 $10.00 $15.00 $15.00
BA37 $15.00 $10.00 $15.00 $15.00
BA38 $15.00 $10.00 $15.00 $15.00
BA39 $15.00 $10.00 $15.00 $15.00
BA40 $15.00 $10.00 $15.00 $15.00
BA41 $15.00 $5.00 $15.00 $15.00
BA42 $15.00 $10.00 $15.00 $15.00
BA43 $15.00 $5.00 $15.00 $15.00
BA44 $15.00 $5.00 $15.00 $15.00
BA45 $15.00 $10.00 $15.00 $15.00
BA46 $15.00 $10.00 $15.00 $15.00
BA47 $15.00 $10.00 $15.00 $15.00
BA48 $15.00 $10.00 $15.00 $15.00
BA49 $15.00 $5.00 $15.00 $15.00
BA50 $15.00 $5.00 $15.00 $15.00
BA51 $15.00 $10.00 $15.00 $15.00
BA52 $15.00 $8.00 $12.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
BA53 $15.00 $10.00 $15.00 $15.00
BA54 $15.00 $5.00 $15.00 $15.00
BA55 $15.00 $10.00 $15.00 $15.00
BA56 $15.00 $10.00 $15.00 $15.00
BA57 $15.00 $5.00 $15.00 $15.00
BA58 $15.00 $5.00 $15.00 $15.00
BA59 $15.00 $10.00 $15.00 $15.00
BA60 $15.00 $10.00 $15.00 $15.00
BA61 $15.00 $5.00 $10.00 $10.00
BA62 $15.00 $5.00 $15.00 $15.00
BA63 $15.00 $10.00 $15.00 $15.00
BA64 $15.00 $5.00 $15.00 $15.00
BA65 $15.00 $10.00 $15.00 $15.00
BA66 $15.00 $8.00 $12.00 $15.00
BA67 $15.00 $10.00 $15.00 $15.00
BA68 $15.00 $5.00 $15.00 $15.00
BA69 $15.00 $10.00 $15.00 $15.00
BA70 $15.00 $10.00 $15.00 $15.00
BA71 $15.00 $8.00 $12.00 $15.00
BA72 $15.00 $5.00 $15.00 $15.00
BA73 $15.00 $10.00 $15.00 $15.00
BA74 $15.00 $5.00 $10.00 $10.00
BA75 $15.00 $5.00 $15.00 $15.00
BA76 $15.00 $10.00 $15.00 $15.00
BA77 $15.00 $5.00 $10.00 $10.00
BA78 $15.00 $8.00 $12.00 $15.00
BA79 $15.00 $5.00 $15.00 $15.00
BA80 $15.00 $10.00 $15.00 $15.00
BA81 $15.00 $10.00 $15.00 $15.00
BA82 $15.00 $8.00 $12.00 $15.00
BA83 $15.00 $5.00 $15.00 $15.00
BA84 $15.00 $10.00 $15.00 $15.00
BA85 $15.00 $5.00 $15.00 $15.00
BA86 $15.00 $10.00 $15.00 $15.00
BA87 $15.00 $5.00 $15.00 $15.00
BA88 $15.00 $5.00 $15.00 $15.00
BA89 $15.00 $10.00 $15.00 $15.00
BA90 $15.00 $5.00 $15.00 $15.00
BA91 $15.00 $10.00 $15.00 $15.00
BA92 $15.00 $8.00 $12.00 $15.00
BA93 $15.00 $5.00 $15.00 $15.00
BA94 $15.00 $10.00 $15.00 $15.00
BA95 $15.00 $5.00 $15.00 $15.00
BA96 $15.00 $10.00 $15.00 $15.00
BA97 $15.00 $10.00 $15.00 $15.00
BA98 $15.00 $5.00 $15.00 $15.00
BA99 $15.00 $10.00 $15.00 $15.00
BA100 $15.00 $5.00 $10.00 $10.00
BA101 $15.00 $5.00 $15.00 $15.00
BA102 $15.00 $10.00 $15.00 $15.00
BA103 $15.00 $10.00 $15.00 $15.00
BA104 $15.00 $10.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
BA105 $15.00 $5.00 $10.00 $10.00
BA106 $15.00 $10.00 $15.00 $15.00
BA107 $15.00 $5.00 $15.00 $15.00
BA108 $15.00 $10.00 $15.00 $15.00
BA109 $15.00 $8.00 $12.00 $15.00
BA110 $15.00 $5.00 $10.00 $10.00
BA111 $15.00 $5.00 $15.00 $15.00
BA112 $15.00 $10.00 $15.00 $15.00
BA113 $15.00 $10.00 $15.00 $15.00
BA114 $15.00 $8.00 $12.00 $15.00
BA115 $15.00 $5.00 $15.00 $15.00
BA116 $15.00 $5.00 $15.00 $15.00
BA117 $15.00 $10.00 $15.00 $15.00
BA118 $15.00 $8.00 $12.00 $15.00
BA119 $15.00 $8.00 $12.00 $15.00
BA120 $15.00 $5.00 $10.00 $10.00
BA121 $15.00 $5.00 $15.00 $15.00
BA122 $15.00 $10.00 $15.00 $15.00
BA123 $15.00 $5.00 $15.00 $15.00
BA124 $15.00 $8.00 $12.00 $15.00
BA125 $15.00 $10.00 $15.00 $15.00
BA126 $15.00 $5.00 $15.00 $15.00
BA127 $15.00 $10.00 $15.00 $15.00
BA128 $15.00 $5.00 $15.00 $15.00
BA129 $15.00 $10.00 $15.00 $15.00
BA130 $15.00 $10.00 $15.00 $15.00
BA131 $15.00 $10.00 $15.00 $15.00
BA132 $15.00 $5.00 $15.00 $15.00
BA133 $15.00 $10.00 $15.00 $15.00
BA134 $15.00 $10.00 $15.00 $15.00
BA135 $15.00 $10.00 $15.00 $15.00
BA136 $15.00 $5.00 $10.00 $10.00
BA137 $15.00 $5.00 $15.00 $15.00
BA138 $15.00 $10.00 $15.00 $15.00
BA139 $15.00 $10.00 $15.00 $15.00
BA140 $15.00 $10.00 $15.00 $15.00
BA141 $15.00 $5.00 $15.00 $15.00
BA142 $15.00 $10.00 $15.00 $15.00
BA143 $15.00 $10.00 $15.00 $15.00
BA144 $15.00 $5.00 $15.00 $15.00
BA145 $15.00 $10.00 $15.00 $15.00
BA146 $15.00 $10.00 $15.00 $15.00
BA147 $15.00 $5.00 $10.00 $10.00
BA148 $15.00 $8.00 $12.00 $15.00
BA149 $15.00 $10.00 $15.00 $15.00
BA150 $15.00 $6.00 $8.00 $8.00
BA151 $15.00 $10.00 $15.00 $15.00
BA152 $15.00 $5.00 $10.00 $10.00
BA153 $15.00 $5.00 $15.00 $15.00
BA154 $15.00 $10.00 $15.00 $15.00
BA155 $15.00 $5.00 $15.00 $15.00
BA156 $15.00 $10.00 $15.00 $15.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
BA157 $15.00 $10.00 $15.00 $15.00
BA158 $15.00 $10.00 $15.00 $15.00
BA159 $15.00 $6.00 $8.00 $8.00
BA160 $15.00 $5.00 $15.00 $15.00
BA161 $15.00 $10.00 $15.00 $15.00
BA162 $15.00 $5.00 $15.00 $15.00
BA163 $15.00 $10.00 $15.00 $15.00
BA164 $15.00 $10.00 $15.00 $15.00
BA165 $15.00 $10.00 $15.00 $15.00
BA166 $15.00 $10.00 $15.00 $15.00
BA167 $15.00 $10.00 $15.00 $15.00
BA168 $15.00 $10.00 $15.00 $15.00
BA169 $15.00 $5.00 $15.00 $15.00
BA170 $15.00 $10.00 $15.00 $15.00
BA171 $15.00 $6.00 $8.00 $8.00
BA172 $15.00 $10.00 $15.00 $15.00
BA173 $15.00 $5.00 $15.00 $15.00
BA174 $15.00 $10.00 $15.00 $15.00
BA175 $15.00 $5.00 $10.00 $10.00
BA176 $15.00 $5.00 $15.00 $15.00
BA177 $15.00 $10.00 $15.00 $15.00
BA178 $15.00 $10.00 $15.00 $15.00
BA179 $15.00 $5.00 $15.00 $15.00
BA180 $15.00 $10.00 $15.00 $15.00
BA181 $15.00 $5.00 $15.00 $15.00
BA182 $15.00 $5.00 $15.00 $15.00
BA183 $15.00 $10.00 $15.00 $15.00
BA184 $15.00 $10.00 $15.00 $15.00
BA185 $15.00 $5.00 $15.00 $15.00
BA186 $15.00 $10.00 $15.00 $15.00
BA187 $15.00 $10.00 $15.00 $15.00
BA188 $15.00 $10.00 $15.00 $15.00
BA189 $15.00 $10.00 $15.00 $15.00
BA190 $15.00 $10.00 $15.00 $15.00
BA191 $15.00 $10.00 $15.00 $15.00
BA192 $15.00 $5.00 $15.00 $15.00
BA193 $15.00 $5.00 $15.00 $15.00
BA194 $15.00 $10.00 $15.00 $15.00
BA195 $15.00 $10.00 $15.00 $15.00
BA196 $15.00 $10.00 $15.00 $15.00
BA197 $15.00 $10.00 $15.00 $15.00
BA198 $15.00 $10.00 $15.00 $15.00
BA199 $15.00 $10.00 $15.00 $15.00
BA200 $15.00 $10.00 $15.00 $15.00
BA201 $15.00 $10.00 $15.00 $15.00
BA202 $15.00 $10.00 $15.00 $15.00
BA203 $15.00 $10.00 $15.00 $15.00
BA204 $15.00 $5.00 $15.00 $15.00
BA205 $15.00 $10.00 $15.00 $15.00
BA206 $15.00 $10.00 $15.00 $15.00
BA207 $15.00 $5.00 $15.00 $15.00
BA208 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
BA209 $15.00 $10.00 $15.00 $15.00
BA210 $15.00 $10.00 $15.00 $15.00
BA211 $15.00 $10.00 $15.00 $15.00
BA212 $15.00 $10.00 $15.00 $15.00
BA213 $15.00 $10.00 $15.00 $15.00
BA214 $15.00 $5.00 $15.00 $15.00
BA215 $15.00 $10.00 $15.00 $15.00
BA216 $15.00 $10.00 $15.00 $15.00
BA217 $15.00 $10.00 $15.00 $15.00
BA218 $15.00 $10.00 $15.00 $15.00
BA219 $15.00 $10.00 $15.00 $15.00
BA220 $15.00 $4.00 $15.00 $20.00
BA221 N/C $10.00 $15.00 $15.00
BA222 $15.00 $4.00 $15.00 $20.00
BA223 $15.00 $10.00 $15.00 $15.00
BA224 $15.00 $8.00 $12.00 $15.00
BA225 $15.00 $5.00 $15.00 $15.00
BA226 $15.00 $5.00 $15.00 $15.00
BA227 $15.00 $10.00 $15.00 $15.00
BA228 $15.00 $10.00 $15.00 $15.00
BA229 $15.00 $10.00 $15.00 $15.00
BA230 $15.00 $10.00 $15.00 $15.00
BA231 $15.00 $6.00 $8.00 $8.00
BA232 $15.00 $5.00 $10.00 $10.00
BA233 $15.00 $5.00 $15.00 $15.00
BA234 $15.00 $5.00 $10.00 $10.00
BA235 $15.00 $5.00 $15.00 $15.00
BA236 $15.00 $10.00 $15.00 $15.00
BA237 $15.00 $5.00 $10.00 $10.00
BA238 $15.00 $10.00 $15.00 $15.00
BA239 $15.00 $10.00 $15.00 $15.00
BA240 $15.00 $8.00 $12.00 $15.00
BA241 $15.00 $5.00 $10.00 $10.00
BA242 $15.00 $5.00 $10.00 $10.00
BA243 $15.00 $8.00 $12.00 $15.00
BA244 $15.00 $5.00 $15.00 $15.00
BA245 $15.00 $10.00 $15.00 $15.00
BA246 $15.00 $10.00 $15.00 $15.00
BA247 $15.00 $5.00 $10.00 $10.00
BA248 $15.00 $10.00 $15.00 $15.00
BA249 $15.00 $5.00 $10.00 $10.00
BA250 $15.00 $5.00 $15.00 $15.00
BA251 $15.00 $5.00 $10.00 $10.00
BA252 $15.00 $5.00 $15.00 $15.00
BA253 $15.00 $5.00 $15.00 $15.00
BA254 $15.00 $10.00 $15.00 $15.00
BA255 $15.00 $10.00 $15.00 $15.00
BA256 $15.00 $5.00 $10.00 $10.00
BA257 $15.00 $5.00 $15.00 $15.00
BA258 $15.00 $10.00 $15.00 $15.00
BA259 $15.00 $5.00 $10.00 $10.00
BA260 $15.00 $5.00 $10.00 $10.00
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
BA261 $15.00 $8.00 $12.00 $15.00
BA262 $15.00 $5.00 $15.00 $15.00
BA263 $15.00 $6.00 $8.00 $8.00
BA264 $15.00 $6.00 $8.00 $8.00
BA265 $15.00 $8.00 $12.00 $15.00
BA266 $15.00 $5.00 $10.00 $10.00
BA267 $15.00 $5.00 $15.00 $15.00
BA268 $15.00 $5.00 $15.00 $15.00
BA269 $15.00 $10.00 $15.00 $15.00
BA270 $15.00 $10.00 $15.00 $15.00
BA271 $15.00 $5.00 $10.00 $10.00
BA272 $15.00 $5.00 $10.00 $10.00
BA273 $15.00 $10.00 $15.00 $15.00
BA274 $15.00 $5.00 $10.00 $10.00
BA275 $15.00 $5.00 $10.00 $10.00
BA276 $15.00 $5.00 $10.00 $10.00
BA277 $15.00 $5.00 $10.00 $10.00
BA278 $15.00 $5.00 $15.00 $15.00
BA279 $15.00 $5.00 $15.00 $15.00
BA280 $15.00 $10.00 $15.00 $15.00
BA281 $15.00 $5.00 $15.00 $15.00
BA282 $15.00 $5.00 $15.00 $15.00
BA283 $15.00 $10.00 $15.00 $15.00
BA284 $15.00 $5.00 $15.00 $15.00
BA285 $15.00 $8.00 $12.00 $15.00
BA286 $15.00 $5.00 $15.00 $15.00
BA287 $15.00 $10.00 $15.00 $15.00
BA288 $15.00 $5.00 $10.00 $10.00
BA289 $15.00 $10.00 $15.00 $15.00
BA290 $15.00 $8.00 $12.00 $15.00
BA291 $15.00 $10.00 $15.00 $15.00
BA292 $15.00 $8.00 $12.00 $15.00
BA293 $15.00 $10.00 $15.00 $15.00
BA294 $15.00 $5.00 $15.00 $15.00
BA295 $15.00 $10.00 $15.00 $15.00
BA296 $15.00 $10.00 $15.00 $15.00
BA297 $15.00 $5.00 $15.00 $15.00
BA298 $15.00 $10.00 $15.00 $15.00
BA299 $15.00 $5.00 $10.00 $10.00
BA300 $15.00 $8.00 $12.00 $15.00
BA301 $15.00 $10.00 $15.00 $15.00
BA302 $15.00 $10.00 $15.00 $15.00
BA303 $15.00 $5.00 $15.00 $15.00
BA304 $15.00 $5.00 $15.00 $15.00
BA305 $15.00 $5.00 $15.00 $15.00
BA306 $15.00 $8.00 $12.00 $15.00
BA307 $15.00 $5.00 $15.00 $15.00
BA308 $15.00 $10.00 $15.00 $15.00
BA309 $15.00 $6.00 $8.00 $8.00
BA310 $15.00 $5.00 $10.00 $10.00
BA311 $15.00 $10.00 $15.00 $15.00
BA312 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
BA313 $15.00 $5.00 $15.00 $15.00
BA314 $15.00 $8.00 $12.00 $15.00
BA315 $15.00 $10.00 $15.00 $15.00
BA316 $15.00 $5.00 $10.00 $10.00
BA317 $15.00 $6.00 $8.00 $8.00
BA318 $15.00 $5.00 $15.00 $15.00
BA319 $15.00 $5.00 $15.00 $15.00
BA320 $15.00 $5.00 $15.00 $15.00
BA321 $15.00 $10.00 $15.00 $15.00
BA322 $15.00 $5.00 $15.00 $15.00
BA323 $15.00 $5.00 $10.00 $10.00
BA324 $15.00 $10.00 $15.00 $15.00
BA325 $15.00 $5.00 $15.00 $15.00
BA326 $15.00 $5.00 $10.00 $10.00
BA327 $15.00 $8.00 $12.00 $15.00
BA328 $15.00 $5.00 $15.00 $15.00
BA329 $15.00 $10.00 $15.00 $15.00
BA330 $15.00 $10.00 $15.00 $15.00
BA331 $15.00 $10.00 $15.00 $15.00
BA332 $15.00 $10.00 $15.00 $15.00
BA333 $15.00 $8.00 $12.00 $15.00
BA334 $15.00 $5.00 $15.00 $15.00
BA335 $15.00 $5.00 $15.00 $15.00
BA336 $15.00 $10.00 $15.00 $15.00
BA337 $15.00 $5.00 $15.00 $15.00
BA338 $15.00 $8.00 $12.00 $15.00
BA339 $15.00 $5.00 $15.00 $15.00
BA340 $15.00 $10.00 $15.00 $15.00
BA341 $15.00 $5.00 $15.00 $15.00
BA342 $15.00 $5.00 $10.00 $10.00
BA343 $15.00 $5.00 $15.00 $15.00
BA344 $15.00 $5.00 $15.00 $15.00
BA345 $15.00 $10.00 $15.00 $15.00
BA346 $15.00 $10.00 $15.00 $15.00
BA347 $15.00 $10.00 $15.00 $15.00
BA348 $15.00 $10.00 $15.00 $15.00
BA349 $15.00 $10.00 $15.00 $15.00
BA350 $15.00 $5.00 $10.00 $10.00
BA351 $15.00 $10.00 $15.00 $15.00
BA352 $15.00 $8.00 $12.00 $15.00
BA353 $15.00 $5.00 $10.00 $10.00
BA354 $15.00 $8.00 $12.00 $15.00
BA355 $15.00 $5.00 $15.00 $15.00
BA356 $15.00 $10.00 $15.00 $15.00
BA357 $15.00 $10.00 $15.00 $15.00
BA358 $15.00 $10.00 $15.00 $15.00
BA359 $15.00 $10.00 $15.00 $15.00
BA360 $15.00 $10.00 $15.00 $15.00
BA361 $15.00 $10.00 $15.00 $15.00
BA362 $15.00 $10.00 $15.00 $15.00
BA363 $15.00 $10.00 $15.00 $15.00
BA364 $15.00 $5.00 $10.00 $10.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
BA365 $15.00 $10.00 $15.00 $15.00
BA366 $15.00 $5.00 $15.00 $15.00
BA367 $15.00 $5.00 $15.00 $15.00
BA368 $15.00 $10.00 $15.00 $15.00
BA369 $15.00 $10.00 $15.00 $15.00
BA370 $15.00 $5.00 $15.00 $15.00
BA371 $15.00 $5.00 $15.00 $15.00
BA372 $15.00 $10.00 $15.00 $15.00
BA373 $15.00 $5.00 $10.00 $10.00
BA374 $15.00 $5.00 $10.00 $10.00
BA375 $15.00 $5.00 $10.00 $10.00
BA376 $15.00 $5.00 $15.00 $15.00
BA377 $15.00 $5.00 $15.00 $15.00
BA378 $15.00 $5.00 $15.00 $15.00
BA379 $15.00 $10.00 $15.00 $15.00
BA380 $15.00 $5.00 $10.00 $10.00
BA382 $15.00 $8.00 $12.00 $15.00
BA383 $15.00 $5.00 $15.00 $15.00
BA384 $15.00 $10.00 $15.00 $15.00
BA385 $15.00 $10.00 $15.00 $15.00
BA386 $15.00 $10.00 $15.00 $15.00
BA387 $15.00 $5.00 $15.00 $15.00
BA388 $15.00 $8.00 $12.00 $15.00
BA389 $15.00 $10.00 $15.00 $15.00
BA390 $15.00 $10.00 $15.00 $15.00
BA391 $15.00 $10.00 $15.00 $15.00
BA392 $15.00 $5.00 $10.00 $10.00
BA393 $15.00 $10.00 $15.00 $15.00
BA394 $15.00 $5.00 $15.00 $15.00
BA395 $15.00 $10.00 $15.00 $15.00
BA396 $15.00 $5.00 $10.00 $10.00
BA397 $15.00 $5.00 $15.00 $15.00
BA398 $15.00 $10.00 $15.00 $15.00
BA399 $15.00 $5.00 $15.00 $15.00
BA400 $15.00 $10.00 $15.00 $15.00
BA401 $15.00 $10.00 $15.00 $15.00
BA402 $15.00 $5.00 $15.00 $15.00
BA403 $15.00 $8.00 $12.00 $15.00
BA404 $15.00 $10.00 $15.00 $15.00
BA405 $15.00 $10.00 $15.00 $15.00
BA406 $15.00 $5.00 $15.00 $15.00
BA407 $15.00 $10.00 $15.00 $15.00
BA408 $15.00 $10.00 $15.00 $15.00
BA409 $15.00 $10.00 $15.00 $15.00
BA410 $15.00 $8.00 $12.00 $15.00
BA411 $15.00 $10.00 $15.00 $15.00
BA412 $15.00 $10.00 $15.00 $15.00
BA413 N/C $5.00 $10.00 $15.00
BA414 N/C $10.00 $15.00 $20.00
BA415 $15.00 $5.00 $10.00 $10.00
BA416 $15.00 $8.00 $12.00 $15.00
BA417 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
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VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
BA418 $15.00 $10.00 $15.00 $15.00
BA419 $15.00 $10.00 $15.00 $15.00
BA420 $15.00 $8.00 $12.00 $15.00
BA421 $15.00 $10.00 $15.00 $15.00
BA422 $15.00 $5.00 $15.00 $15.00
BA423 $15.00 $10.00 $15.00 $15.00
BA424 $15.00 $8.00 $12.00 $15.00
BA425 N/C $5.00 $10.00 $15.00
BA426 $15.00 $10.00 $15.00 $15.00
BA427 N/C $10.00 $15.00 $20.00
BA428 N/C $5.00 $10.00 $15.00
BA429 $15.00 $5.00 $10.00 $10.00
BA430 $15.00 $5.00 $10.00 $10.00
BA431 $15.00 $5.00 $10.00 $10.00
BA432 $15.00 $10.00 $15.00 $15.00
BA433 $15.00 $5.00 $10.00 $10.00
BA434 $15.00 $10.00 $15.00 $15.00
BA435 $15.00 $5.00 $15.00 $15.00
BA436 $15.00 $8.00 $12.00 $15.00
BA437 $15.00 $10.00 $15.00 $15.00
BA438 $15.00 $5.00 $10.00 $10.00
BA439 $15.00 $10.00 $15.00 $15.00
BA440 $15.00 $8.00 $12.00 $15.00
BA441 $15.00 $5.00 $10.00 $10.00
BA442 $15.00 $5.00 $15.00 $15.00
BA443 $15.00 $10.00 $15.00 $15.00
BA444 $15.00 $10.00 $15.00 $15.00
BA445 $15.00 $5.00 $15.00 $15.00
BA446 $15.00 $8.00 $12.00 $15.00
BA447 $15.00 $5.00 $10.00 $10.00
BA448 $15.00 $10.00 $15.00 $15.00
BA449 $15.00 $10.00 $15.00 $15.00
BA450 $15.00 $10.00 $15.00 $15.00
BA451 $15.00 $8.00 $12.00 $15.00
BA452 $15.00 $5.00 $15.00 $15.00
BA453 $15.00 $6.00 $8.00 $8.00
BA454 $15.00 $6.00 $8.00 $8.00
BA455 $15.00 $8.00 $12.00 $15.00
BA456 $15.00 $6.00 $8.00 $8.00
BA457 $15.00 $5.00 $15.00 $15.00
BA458 $15.00 $5.00 $10.00 $10.00
BA459 $15.00 $5.00 $15.00 $15.00
BA460 $15.00 $5.00 $15.00 $15.00
BA461 $15.00 $10.00 $15.00 $15.00
BA462 $15.00 $5.00 $15.00 $15.00
BA463 $15.00 $10.00 $15.00 $15.00
BA464 $15.00 $8.00 $12.00 $15.00
BA465 $15.00 $10.00 $15.00 $15.00
BA466 $15.00 $10.00 $15.00 $15.00
BA467 $15.00 $5.00 $15.00 $15.00
BA468 $15.00 $10.00 $15.00 $15.00
BA469 $15.00 $10.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
184
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
BA470 $15.00 $10.00 $15.00 $15.00
BA471 $15.00 $5.00 $10.00 $10.00
BA472 $15.00 $5.00 $10.00 $10.00
BA473 $15.00 $10.00 $15.00 $15.00
BA474 $15.00 $10.00 $15.00 $15.00
BA475 $15.00 $10.00 $15.00 $15.00
BA476 $15.00 $5.00 $15.00 $15.00
BA477 $15.00 $5.00 $15.00 $15.00
BA478 $15.00 $10.00 $15.00 $15.00
BA479 $15.00 $5.00 $15.00 $15.00
BA480 $15.00 $5.00 $15.00 $15.00
BA481 $15.00 $10.00 $15.00 $15.00
BA482 $15.00 $10.00 $15.00 $15.00
BA483 $15.00 $5.00 $15.00 $15.00
BA484 $15.00 $8.00 $12.00 $15.00
BA485 $15.00 $10.00 $15.00 $15.00
BA486 $15.00 $10.00 $15.00 $15.00
BA487 $15.00 $5.00 $15.00 $15.00
BA488 $15.00 $10.00 $15.00 $15.00
BA489 $15.00 $6.00 $8.00 $8.00
BA490 $15.00 $5.00 $15.00 $15.00
BA491 $15.00 $5.00 $15.00 $15.00
BA492 $15.00 $10.00 $15.00 $15.00
BA493 $15.00 $10.00 $15.00 $15.00
BA494 $15.00 $10.00 $15.00 $15.00
BA495 $15.00 $10.00 $15.00 $15.00
BA496 $15.00 $4.00 $15.00 $20.00
BA497 $15.00 $5.00 $15.00 $15.00
BA498 $15.00 $5.00 $15.00 $15.00
BA499 $15.00 $5.00 $10.00 $10.00
BA500 $15.00 $5.00 $10.00 $10.00
BA501 N/C $5.00 $10.00 $15.00
BA502 N/C $5.00 $10.00 $15.00
BA503 N/C $5.00 $10.00 $15.00
BA504 N/C $5.00 $10.00 $15.00
BA505 N/C $5.00 $10.00 $15.00
BA506 N/C $10.00 $15.00 $20.00
BA507 N/C $10.00 $15.00 $20.00
BA508 N/C $10.00 $15.00 $20.00
BA509 N/C $10.00 $15.00 $20.00
BA510 N/C $10.00 $15.00 $20.00
BA511 N/C $5.00 $10.00 $15.00
BA512 N/C $5.00 $10.00 $15.00
BA513 N/C $5.00 $10.00 $15.00
BA514 N/C $5.00 $10.00 $15.00
BA515 N/C $5.00 $10.00 $15.00
BA516 N/C $10.00 $15.00 $20.00
BA517 $15.00 $10.00 $15.00 $15.00
BA518 $15.00 $10.00 $15.00 $15.00
BA519 $15.00 $5.00 $15.00 $15.00
BA520 $15.00 $10.00 $15.00 $15.00
BA521 $15.00 $5.00 $15.00 $15.00
CÓDIGOS DE CUBIERTAS / COPAGOS
08/13/2015
185
VISITAS A DOMICILIO VISITAS A LA OFICINA
CUBIERTA COPAGO GENERALISTA ESPECIALISTA SUBESPECIALISTA
BA522 $15.00 $5.00 $10.00 $10.00
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