Medical Coverage Form Builder Comprehensive Medical Coverage Model Language Form Builder v0.015a What market is the plan offered on? Individual Small Group Large Group Under what type of license is this plan offered? EPO PPO HMO EPO w/ Gatekeeper Do you have a two-tier provider network? Yes No Does your plan require preauthorization? Yes No Do you have an Out-of-Network option? Yes No Do you cover Urgent Care Out-of-Network? Yes No Do you cover Ambulance Services Out-of-Network? Yes No Generate Form