|
| DISCONTINUED ANTHEM BLUE CROSS PLANS |
DISCONTINUED
Anthem Blue Cross PPO Plans |
Effective |
Network |
In-Network
(Ded Sgl/Fam) |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
2-2011
7-09 |
PPO |
750 / 1500 |
|
50% co-ins |
$15
na
no ded |
30%
30% / $0
30% / $0
AD |
2-2011
|
PPO |
1000 / 2000 |
|
50% co-ins |
$15
na
0 $ded |
30%
30% / $0
50% / $0
AD |
2-2011 |
PPO |
1250 / 2500 |
|
100% co-ins |
$15
na
0 $ded |
30%
30% / $0
50% / $0
AD |
10-2010 |
PPO |
5000 / 10000
aggregate |
5800 / 11600
aggregate |
0% co-ins
AD |
$10
$30
AD |
0%
0% / $0
0% / $0
AD |
10-2010 |
PPO |
3000 / 6000
aggregate |
5000 / 10000
aggregate |
0% co-ins
AD |
$10
$30
AD |
0%
0% / $0
0% / $0
AD |
10-2010 |
PPO |
2000 / 4000
aggregate |
4000 / 8000
aggregate |
0% co-ins
AD |
$10
$30
AD |
0%
0% / $0
0% / $0
AD |
7-09 |
PPO |
1500 / 3000
aggregate |
3000 / 6000
aggregate |
0% co-ins
AD |
$10
$30
AD |
0%
0% / $0
0% / $0
AD |
7-09 |
PPO |
3000 / 6000 aggregate
Health Incentive Plan Allocation
1000 / 2000 aggregate
|
3000 / 6000 aggregate |
0% co-ins
AD |
0%
0%
AD |
0%
0% / $0
0% / $0
AD |
7-09 |
PPO |
3500 / 7000
aggregate |
|
$35 copay
AD |
$10
$25
AD |
0%
0% / $0
0% / $0
AD |
7-09 |
PPO |
5500 / 11000 |
7000 / 14000 |
2 visits /
$20 copay |
$10
$25
AD |
20%
20% / $0
20% / $0
After $500 ded |
7-09 |
PPO |
1250 / 2500 |
3250 / 6500 |
not covered |
|
20%
20% / $0
20% / $0
AD |
7-09 |
PPO |
250 / 500 |
3600 / 7200 |
12 visits / $25 copay /
45% co-ins up to $900 and then 10% co-insurance from $901 to $3,600 |
$15
$25
AD |
30% up to $900, 10% from $901 to $3600
30% up to $900, 10% from $901 to $3600
/ $0
30% up to $900, 10% from $901 to $3600 / $0
|
7-09 |
PPO |
500 / 1000
First Dollar Coverage
750 / 1500
|
|
$35 copay |
$10
$30
$250 ded |
25%
25% / $0
25% / $0
AD
(when First Dollar Coverage is used up) |
7-09 |
PPO |
1000 / 2000
aggregate
First Dollar Coverage
$500 / $1000
|
|
$40 copay |
$10
$35
$350 ded |
40%
40% / $0
40% / $0
AD
(When First Dollar Coverage is used up)
|
2-08 |
PPO |
2400 / 4800
aggregate |
|
$35 copay
AD |
$10
$25
AD |
20%
20% / $0
20% / $0
AD |
DISCONTINUED
Anthem Blue Cross HMO Plans |
Effective |
Network |
In-Network
(Ded Sgl/Fam) |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
2-08 |
HMO |
500 / 1000 |
2250 / 4500 |
0 visits / $25 copay /
0% co-ins |
$15
$25
150 $ded |
0%
0% / $0
20% / $0 |
2-08 |
HMO |
1500 / 3000 |
2250 / 4500 |
0 visits / $20 copay /
0% co-ins |
$10
$25
150 $ded |
0%
0% / $0
0% / $0 |
2-08 |
HMO |
0 / 0 |
1750 / 3500 |
0 visits / $20 copay /
0% co-ins |
$10
$25
150 $ded |
0%
0% / $0
20% / $0 |
DISCONTINUED
Anthem Blue Cross HMO Plans |
Effective |
Network |
In-Network
(Ded Sgl/Fam) |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
|
| DISCONTINUED PLANS |
DISCONTINUED
Blue Shield PPO Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
01-2011 |
PPO
HSA |
4800 / 9600
embedded |
5900 indiv /
11800 family
embedded
6 Million
|
0% co-ins
AD |
$10
$30 or 30%
AD |
0%
0% / $0
0% / $0
AD |
PPO
HSA |
2500 / 5000
embedded |
4000 / 8000
embedded
6 million
|
20% co-ins
AD |
$10
$30 or 30%
AD |
20%
20% / $0
20% / $0
AD |
01-2011 |
PPO
HSA |
3000 / 6000 |
|
0% co-ins
AD |
$10
$30 or 30%
AD |
0%
0% / $0
0% / $0
AD |
01-2011 |
PPO
HSA |
2250 / 4500 |
|
20% co-ins
AD |
$10
$30 or 30%
AD |
20%
20% / $0
20% / $0
AD |
01-2011 |
PPO
HSA |
2000 / 4000 |
|
0% co-ins
AD |
$10
$30 or 30%
AD |
0%
0% / $0
0% / $0
AD |
01-2011 |
PPO
HSA |
1800 / 3600 |
|
0% co-ins
AD |
$10
$30 or 30%
AD |
0%
0% / $0
0% / $0
AD |
01-2011 |
PPO
HSA |
4800 /9600 |
|
20% co-ins
AD |
$10
$30 or 30%
AD |
20%
20% / $0
20% / $0
AD |
01-2011 |
PPO
HSA |
3000 / 6000 |
|
20% co-ins
AD |
$10
$30 or 30%
AD |
20%
20% / $0
20% / $0
AD |
01-2011 |
PPO
HSA |
2000 / 4000 |
|
20% co-ins
AD |
$10
$30 or 30%
AD |
20%
20% / $0
20% / $0
AD |
01-2011 |
PPO |
0 / 0
First Dollar Coverage
$750 / $1500
|
5000 / 10000 |
100% co-ins up to max copay then many benefits will be 0% co-ins |
$15
$30 or 30%
$250 ded |
20%
20% / $0
20% / $0 |
01-2011 |
PPO |
0 / 0
First Dollar Service
$500 / $1000
|
5000 / 10000 |
100% co-ins up to max copay then many benefits will be 0% co-ins |
$15
$30 or 30%
$500 ded |
30%
30% / $0
30% / $0 |
01-2011 |
POS |
0 / 0 |
|
$25 copay |
$15
$30
$150 ded |
0%
0% / $0
0% / $500 surgery |
01-2011 |
PPO |
3000 / 6000 |
|
20% co-ins |
$15
$30 or 30%
$500 ded |
20%
20% / $0
20% / $250 surgery
AD |
01-2011 |
PPO |
2000 per member |
7000 per member
6 million
|
2 visits / $40 copay /
after 2 visits 100% co-ins until max copay has been met - then 0% co-ins
|
$15
n/a |
35%
35% / $0
35% / $500 surgery
AD |
01-2011 |
PPO |
1000 / 2000 |
|
$45 copay |
$10
$30
$250 ded |
25%
25% / $0
25% / $500 surgery
AD |
01-2011 |
PPO |
500 / 1000 |
|
$35 copay |
$10
$30
$150 ded |
20%
20% / $0
20% / $150 surgery
AD |
01-2011 |
PPO |
500 / 1000 |
|
$40 copay |
$10
$30
250 $ded |
30%
30% / $0
30% / $250 surgery
AD |
01-2011 |
PPO |
500 indiv / 1000 2 pers / 1500 family |
5500 per mem /
11000 2 pers /
16500 family
6 million
|
$45 copay |
$15
$30 or 30%
$250 ded |
30%
30% / $0
30% / $250 surgery
AD |
01-2011 |
PPO |
250 / 500 |
2750 indiv /
5500 family
6 million
|
$15 copay |
$10
$25
0 $ded |
10%
10% / $0
10% / $0
AD |
01-2011 |
PPO |
250 / 500 |
|
$25 copay |
$10
$30
0 $ded |
20%
20% / $0
20% / $0
AD |
01-2011 |
PPO |
0 / 0 |
|
$10 copay |
$10
$25
0 $ded |
10%
10% / $0
10% / $0 |
PPO(SM) Savings Plan 3400*
Discontinued as of 2-08 |
2-08 |
PPO |
3400 / 6800 |
4500 / 9000 |
$0 copay /
30% co-ins |
$10
$30 or 30%
0 $ded |
|
DISCONTINUED
Blue Shield HMO Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
01-2011 |
HMO |
0 / 0 |
|
$40 copay |
$15
$30
250 $ded |
0%
0% / $0
40% / $0 |
01-2011 |
HMO |
0 / 0 |
|
$30 copay |
$15
$30
$150 ded |
0%
0% / $0
0% / $500 surgery |
01-2011 |
HMO |
0 / 0 |
|
$25 copay |
$15
$30
$250 ded |
0%
0% / $0
25% / $0 |
01-2011 |
HMO |
0 / 0 |
|
$20 copay |
$15
$30
$150 ded |
0%
0% / $0
0% / $500 surgery |
01-2011 |
HMO |
0 / 0 |
|
$15 copay |
$15
$30
0 $ded |
0%
0% / $0
0% / $250 surgery |
1-2011 |
HMO |
0 / 0 |
2000 / 4000
None |
$10 copay |
$10
$25
0 $ded |
0%
0% / $0
0% / $50 surgery |
01-2011 |
HMO |
0 / 0 |
|
$5 copay |
$10
$25
0 $ded |
0%
0% / $0
0% / $0 |
01-2011 |
HMO |
0 / 0 |
|
$20 copay |
$15
$30
$150 ded |
0%
0% / $0
0% / $500 surgery |
01-2011 |
HMO |
0 / 0 |
|
$30 copay |
$15
$30
$150 ded |
0%
0% / $0
0% / $500 surgery |
01-2011 |
HMO |
0 / 0 |
|
$20 copay |
$15
$30
$150 ded |
0%
0% / $0
0% / $500 surgery |
01-2011 |
HMO |
0 / 0 |
1000 / 2000
None |
$5 copay
|
$5
$5
0 $ded
|
0%
0% / $0
0% / $25
|
DISCONTINUED
Blue Shield HMO Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
|
| DISCONTINUED UHC PLANS |
| DISCONTINUED UHC Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| Choice Plus Balanced Value 20/3000/90% Plan D6L |
3-09 |
PPO |
3000 / 9000 |
6000 / 12000
5 Million per covered person |
$20 copay |
$10
$35
$250 ded |
10%
10% / $500
10% / $250
AD |
| Choice Plus Balanced Value 30/2500/80% Plan D6N |
3-09 |
PPO |
2500 / 7500 |
4500 / 9000
5 Million per covered person |
$30 copay |
$10
$35
$250 ded |
20%
20% / $500
20% / $250
AD |
| Choice Plus Definity HSA 2850/80% Plan D6I |
3-09 |
PPO |
2850 / 5600 |
3500 / 7000
5 Million per covered person |
20% co-ins
AD |
$10
$30
AD |
20%
20% / $0
20% / $0
AD |
| Choice Plus Definity HSA 2850/80% Plan D6J |
3-09 |
PPO |
2850 / 5600 |
3500 / 7000
5 Million per covered person |
20% co-ins
AD |
$10
$30
AD |
20%
20% / $0
20% / $0
AD |
| Choice Plus Definity HSA 3000/70% Plan C3X |
3-09 |
PPO |
3000 / 6000 |
5000 / 10000
5 Million per covered person |
30% co-ins
AD |
$10
$30
AD |
30%
30% / $0
30% / $0
AD |
| Choice Plus Definity HSA 3500/70% Plan C3Y |
3-09 |
PPO |
3500 / 7000 |
5000 / 10000
5 Million per covered person |
30% co-ins
AD |
$10
$30
AD |
30%
30% / $0
30% / $0
AD |
| Choice Plus Definity HRA 2000/90% Plan C3W |
3-09 |
PPO |
2000 / 4000 |
5000 / 10000
5 Million per covered person |
10% co-ins
AD |
$10
$35
$250 ded on tiers II & III |
10%
10% / $0
10% / $0
AD |
| DISCONTINUED UHC Plans |
Effective
|
Network
|
In-Network
Ded Sgl/Fam
|
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| Non Differential PPO 2000/80% Plan 6HE |
7-08 |
PPO |
2000 / 6000 |
4000 / 12000 |
20% co-ins |
|
|
| Choice Plus Balanced 100 30/3000/100% Plan 6CX |
7-08 |
PPO |
3000 / 9000 |
3000 / 9000 |
$30 copay |
|
|
| Choice Plus Balanced 25/1000/80% Plan 6CW |
7-08 |
PPO |
1000 / 3000 |
3500 / 7000 |
$25 copay |
|
|
| Choice Plus Balanced 25/2500/80% Plan 6CV |
7-08 |
PPO |
2500 / 7500 |
4500 / 9000 |
$25 copay |
|
|
| DISCONTINUED UHC Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| Choice Plus Balanced 35/2000/50% Plan 6CN |
5-08 |
PPO |
2000 / 6000 |
6000 / 12000 |
$35 copay |
|
|
| Choice Plus Balanced Value 25/1000/80% Plan 6CP |
5-08 |
PPO |
1000 / 3000 |
3500 / 7000 |
$25 copay |
|
|
| Choice Plus Balanced Value 25/2500/80% Plan 6CQ |
5-08 |
PPO |
2500 / 7500 |
4500 / 9000 |
$25 copay |
|
|
| Choice Plus Balanced Value 35/1000/50% Plan 6CT |
5-08 |
PPO |
1000 / 3000 |
5000 / 10000 |
$35 copay |
|
|
| Choice Plus Balanced Value 35/1000/70% Plan 6CR |
5-08 |
PPO |
1000 / 3000 |
5000 / 10000 |
$35 copay |
|
|
| Choice Plus Balanced Value 35/2000/50% Plan 6CU |
5-08 |
PPO |
2000 / 6000 |
6000 / 12000 |
$35 copay |
|
|
| Choice Plus Balanced Value 40/1500/70% Plan 6CS |
5-08 |
PPO |
1500 / 4500 |
5000 / 10000 |
$40 copay |
|
|
| DISCONTINUED UHC Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| Choice Plus Definity HSA 1500/80% Plan U1O |
12-07 |
PPO |
1500 / 3000 |
3000 / 6000 |
20% co-ins |
|
|
| Non Differential PPO 2000/80% Plan 7CB |
12-07
rev 02 |
PPO |
2000 / 6000 |
4000 / 12000 |
20% co-ins |
|
|
| Choice Plus Balanced 100 30/3000/100% Plan 6CO |
12-07 |
PPO |
3000 / 9000 |
3000 / 9000 |
$30 copay |
|
|
| Choice Plus Balanced 100 30/3000/100% Plan 7AQ |
12-07 |
PPO |
3000 / 9000 |
3000 / 9000 |
$30 copay |
|
|
| Choice Plus Balanced 100 Value 30/3000/100% Plan 6CO |
12-07 |
PPO |
3000 / 9000 |
4000 / 12000 |
$30 copay |
|
|
| Choice Plus Balanced 25/1000/80% Plan 7AB |
12-07 |
PPO |
1000 / 3000 |
3500 / 7000 |
$25 copay |
|
|
| Choice Plus Balanced 25/2500/80% Plan 2AQ |
12-07 |
PPO |
2500 / 7500 |
4500 / 9000 |
$25 copay |
|
|
| Choice Plus Balanced 35/1000/50% Plan 6CE |
12-07 |
PPO |
1000 / 3000 |
5000 / 10000 |
$35 copay |
|
|
| Choice Plus Balanced 35/1000/70% Plan 6CC |
12-07 |
PPO |
1000 / 3000 |
5000 / 10000 |
$35 copay |
|
|
| Choice Plus Balanced 40/1500/70% Plan 6CF |
12-07 |
PPO |
1500 / 4500 |
5000 / 10000 |
$40 copay |
|
|
| Choice Plus Consumer 1500/80% Plan 6CH |
12-07 |
PPO |
1500 / 3000 |
3000 / 6000 |
20% co-ins |
|
|
| Choice Plus Consumer 1500/100% Plan 7AL |
12-07 |
PPO |
1500 / 4500 |
1500 / 4500 |
0% co-ins |
|
|
| Choice Plus Consumer 2000/100% Plan 7AM |
12-07 |
PPO |
2000 / 6000 |
2000 / 6000 |
0% co-ins |
|
|
| Choice Plus Consumer 2500/80% Plan S1Y |
12-07 |
PPO |
2500 / 5000 |
5000 / 10000 |
20% co-ins |
|
|
| Choice Plus Consumer 3000/70% Plan 6CG |
12-07 |
PPO |
3000 / 6000 |
5000 / 10000 |
30% co-ins |
|
|
| Choice Plus Traditional 20/250/90% Plan 6CM |
12-07 |
PPO |
250 / 750 |
3000 / 6000 |
$20 copay |
|
|
| Choice Plus Traditional 30/500/70% Plan 6CB |
12-07 |
PPO |
500 / 1500 |
3000 / 6000 |
$30 copay |
|
|
| Choice Plus Traditional 35/500/80% Plan 6CD |
12-07 |
PPO |
500 / 1500 |
5000 / 10000 |
$35 copay |
|
|
| DISCONTINUED UHC Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| Choice Plus Plan QPA |
5-07 |
PPO |
1000 / 3000 |
3500 / 7000 |
$25 copay |
|
|
| Choice Plus Plan QPB |
5-07 |
PPO |
3000 / 9000 |
3000 / 9000 |
$30 copay |
|
|
| DISCONTINUED UHC Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| HSA Options PPO Plan LDD |
4-06 |
PPO |
2000 / 4000 |
2000 / 4000 |
0% co-ins |
|
|
| HSA Options PPO Plan LDE |
4-06 |
PPO |
2000 / 4000 |
4000 / 8000 |
20% co-ins |
|
|
| HSA Options PPO Plan LDF |
4-06 |
PPO |
2850 / 5600 |
2850 / 5600 |
0% co-ins |
|
|
| HSA Options PPO Plan LDG |
4-06 |
PPO |
2850 / 5600 |
5000 / 10000 |
20% co-ins |
|
|
| HSA Options PPO Plan LDH |
4-06 |
PPO |
2850 / 5600 |
5000 / 10000 |
20% co-ins |
|
|
| HSA Options PPO Plan LDI |
4-06 |
PPO |
3500 / 7000 |
3500 / 7000 |
0% co-ins |
|
|
| HSA Options PPO Plan LDJ |
4-06 |
PPO |
3500 / 7000 |
5000 / 10000 |
20% co-ins |
|
|
| HSA Options PPO Plan LDK |
4-06 |
PPO |
3500 / 7000 |
5000 / 10000 |
20% co-ins |
|
|
| DISCONTINUED UHC Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| HSA Options PPO Plan LDL |
4-06 |
PPO |
5000 / 10000 |
5000 / 10000 |
0% co-ins |
|
|
| HSA Options PPO Plan LDM |
4-06 |
PPO |
5000 / 10000 |
5000 / 10000 |
0% co-ins |
|
|
| HSA Options PPO Plan LDN |
4-06 |
PPO |
1500 / 3000 |
1500 / 3000 |
0% co-ins |
|
|
| HSA Options PPO Plan LDO |
4-06 |
PPO |
1500 / 3000 |
3000 / 6000 |
20% co-ins |
|
|
| HSA Options PPO Plan LYA |
4-06 |
PPO |
2500 / 5000 |
2500 / 5000 |
0% co-ins |
|
|
| HSA Options PPO Plan LYB |
4-06 |
PPO |
2500 / 5000 |
5000 / 10000 |
20% co-ins |
|
|
| HSA Options PPO Plan LYC |
4-06 |
PPO |
5000 / 10000 |
5000 / 10000 |
0% co-ins |
|
|
| DISCONTINUED UHC Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| Options PPO Plan LKA |
4-06 |
PPO |
1500 / 4500 |
1500 / 4500 |
$25 copay |
|
|
| Options PPO Plan LKB |
4-06 |
PPO |
2500 / 7500 |
2500 / 7500 |
$25 copay |
|
|
| Options PPO Plan LKC |
4-06 |
PPO |
3000 / 9000 |
3000 / 9000 |
$25 copay |
|
|
| Options PPO Plan LKD |
4-06 |
PPO |
4000 / 12000 |
4000 / 12000 |
$25 copay |
|
|
| Options PPO Plan LKE |
4-06 |
PPO |
5000 / 15000 |
5000 / 15000 |
$25 copay |
|
|
| Options PPO Plan LKF |
4-06 |
PPO |
1000 / 3000 |
1000 / 3000 |
$25 copay |
|
|
| Options PPO Plan LKG |
4-06 |
PPO |
500 / 1500 |
3000 / 6000 |
$25 copay |
|
|
| Options PPO Plan LKH |
4-06 |
PPO |
1000 / 3000 |
3500 / 7000 |
$25 copay |
|
|
| DISCONTINUED UHC Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| Options PPO Plan LKI |
4-06 |
PPO |
2000 / 6000 |
2000 / 6000 |
$25 copay |
|
|
| Options PPO Plan LKJ |
4-06 |
PPO |
500 / 1500 |
3000 / 6000 |
$25 copay |
|
|
| Options PPO Plan LKK |
4-06 |
PPO |
250 / 750 |
2500 / 5000 |
$25 copay |
|
|
| Options PPO Plan LKL |
4-06 |
PPO |
1500 / 4500 |
4500 / 9000 |
$25 copay |
|
|
| Options PPO Plan NAA |
4-06 |
PPO |
250 / 750 |
1500 / 3000 |
$20 copay |
|
|
| Options PPO Plan NAB |
4-06 |
PPO |
250 / 750 |
1500 / 3000 |
$20 copay |
|
|
| Options PPO Plan NAC |
4-06 |
PPO |
500 / 1500 |
2000 / 4000 |
$20 copay |
|
|
| Options PPO Plan NAD |
4-06 |
PPO |
500 / 1500 |
2000 / 4000 |
$20 copay |
|
|
| DISCONTINUED UHC Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| Options PPO Plan NAE |
4-06 |
PPO |
1000 / 3000 |
2500 / 5000 |
$20 copay |
|
|
| Options PPO Plan NAF |
4-06 |
PPO |
1000 / 3000 |
2500 / 5000 |
$20 copay |
|
|
| Options PPO Plan NAG |
4-06 |
PPO |
1500 / 4500 |
3500 / 7000 |
10% co-ins |
|
|
| Options PPO Plan NAH |
4-06 |
PPO |
1500 / 4500 |
3500 / 7000 |
$25 copay |
|
|
| Options PPO Plan NAI |
4-06 |
PPO |
1500 / 4500 |
3500 / 7000 |
20% co-ins |
|
|
| Options PPO Plan NAJ |
4-06 |
PPO |
1500 / 4500 |
3500 / 7000 |
$25 copay |
|
|
| Options PPO Plan NAK |
4-06 |
PPO |
2000 / 6000 |
4000 / 8000 |
10% co-ins |
|
|
| Options PPO Plan NAL |
4-06 |
PPO |
2000 / 6000 |
4000 / 8000 |
$25 copay |
|
|
| DISCONTINUED UHC Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| Options PPO Plan NAM |
4-06 |
PPO |
2000 / 6000 |
4000 / 8000 |
20% co-ins |
|
|
| Options PPO Plan NAN |
4-06 |
PPO |
2000 / 6000 |
4000 / 8000 |
$25 copay |
|
|
| Options PPO Plan NAO |
4-06 |
PPO |
2500 / 7500 |
4500 / 9000 |
10% co-ins |
|
|
| Options PPO Plan NAP |
4-06 |
PPO |
2500 / 7500 |
4500 / 9000 |
$25 copay |
|
|
| Options PPO Plan NAQ |
4-06 |
PPO |
2500 / 7500 |
4500 / 9000 |
20% co-ins |
|
|
| Options PPO Plan NAR |
4-06 |
PPO |
2500 / 7500 |
4500 / 9000 |
$25 copay |
|
|
| Options PPO Plan NAS |
4-06 |
PPO |
3000 / 9000 |
5000 / 10000 |
10% co-ins |
|
|
| Options PPO Plan NAT |
4-06 |
PPO |
3000 / 9000 |
5000 / 10000 |
$30 copay |
|
|
| DISCONTINUED UHC Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| Options PPO Plan NAU |
4-06 |
PPO |
3000 / 9000 |
5000 / 10000 |
20% co-ins |
|
|
| Options PPO Plan NAV |
4-06 |
PPO |
3000 / 9000 |
5000 / 10000 |
$30 copay |
|
|
| Options PPO Plan NAW |
4-06 |
PPO |
5000 / 15000 |
7500 / 15000 |
10% co-ins |
|
|
| Options PPO Plan NAX |
4-06 |
PPO |
5000 / 15000 |
7500 / 15000 |
$30 copay |
|
|
| Options PPO Plan NAY |
4-06 |
PPO |
5000 / 15000 |
7500 / 15000 |
20% co-ins |
|
|
| Options PPO Plan NAZ |
4-06 |
PPO |
5000 / 15000 |
7500 / 15000 |
$30 copay |
|
|
| Options PPO Plan NDA |
4-06 |
PPO |
1000 / 3000 |
1000 / 3000 |
$20 copay |
|
|
| Options PPO Plan NDB |
4-06 |
PPO |
1000 / 3000 |
1000 / 3000 |
0% co-ins |
|
|
| DISCONTINUED UHC Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| Options PPO Plan NDC |
4-06 |
PPO |
2000 / 6000 |
2000 / 6000 |
$25 copay |
|
|
| Options PPO Plan NDD |
4-06 |
PPO |
2000 / 6000 |
2000 / 6000 |
0% co-ins |
|
|
| Options PPO Plan RUA |
4-06 |
PPO |
1100 / 2200 |
1100 / 2200 |
0% co-ins |
|
|
| Options PPO Plan RUB |
4-06 |
PPO |
2000 / 4000 |
2000 / 4000 |
0% co-ins |
|
|
| Options PPO Plan RUC |
4-06 |
PPO |
2850 / 5600 |
2850 / 5600 |
0% co-ins |
|
|
| Options PPO Plan TEA |
4-06 |
PPO |
500 / 1500 |
2000 / 4000 |
$20 copay |
|
|
| Options PPO Plan TEB |
4-06 |
PPO |
1000 / 3000 |
2500 / 5000 |
$20 copay |
|
|
| Options PPO Plan TEC |
4-06 |
PPO |
1500 / 4500 |
3500 / 7000 |
$25 copay |
|
|
| Options PPO Plan TED |
4-06 |
PPO |
1000 / 3000 |
1000 / 3000 |
$20 copay |
|
|
| Options PPO Plan TEE |
4-06 |
PPO |
2000 / 6000 |
2000 / 6000 |
$25 copay |
|
|
DISCONTINUED PacifiCare
POS Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| SignaturePOS 15/80-60 |
7-09 |
POS |
0 / 0 |
2500 / 7500
None |
$15 copay |
$10
$25
$0 ded |
0%
0% / $250 per admit
0% / $250 per admit |
DISCONTINUED PacifiCare
PPO Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| SV 10-30/500d |
3-09 |
HMO |
0 / 0 |
2000 / 6000
None |
$10 copay |
$15
$35
150 $ded |
0%
0% / $500 per day, 2 day max per admit
0% / $400 per admit |
| SV Advantage 10-30/500d |
3-09 |
HMO |
0 / 0 |
2000 / 6000
None |
$10 copay |
$15
$35
150 $ded |
0%
0% / $500 per day, max 2 days per admit
0% / $400 per admit |
| SV 20-40/500d |
3-09 |
HMO |
0 / 0 |
3000 / 9000
None |
$20 copay |
$20
$35
150 $ded |
0%
0% / $500 per day, 4 days max per admit
0% / $400 per admit |
| SV Advantage 20-40/500d |
3-09 |
HMO |
0 / 0 |
3000 / 9000
None |
$20 copay |
$20
$35
150 $ded |
0%
0% / $500 per day, max 4 days per admit
0% / $400 per admit |
| SV 35-45/600d |
3-09 |
HMO |
0 / 0 |
5000 / 15000
None |
$35 copay |
$20
$35
150 $ded |
0%
0% / $600 per day, 4 days max per admit
0% / $500 per admit |
| SV Advantage 35-45/600d |
3-09 |
HMO |
0 / 0 |
5000 / 15000
None |
$35 copay |
$20
$35
150 $ded |
0%
0% / $600 per day, max 4 days per admit
0% / $500 per admit |
| SignatureElite 20/90-50/250 |
3-09 |
PPO |
250 / 500 |
3250 / 6500
5 Million |
$20 copay |
$10
$35
$150 ded |
10%
10% / $0
10% / $0
AD |
| SignatureElite 30/80-60/250 |
3-09 |
PPO |
250 / 500 |
3250 / 6500
5 Million |
$30 copay |
$10
$35
$150 ded |
20%
20% / $0
20% / $0
AD |
| SignatureElite 30/80-60/500 |
3-09 |
PPO |
500 / 1000 |
5500 / 11000
5 Million |
$30 copay |
$10
$35
$150 ded |
20%
20% / $0
20% / $0
AD |
| SignatureElite 40--50-50--1000 |
3-09 |
PPO |
1000 / 2000 |
4000 / 8000
5 Million |
$40 copay |
$10
$35
$150 ded |
50%
50% / $0
50% / $0
AD |
| SignatureElite 40--70-50--1000 |
3-09 |
PPO |
1000 / 2000 |
6000 / 12000
5 Million |
$40 copay |
$10
$35
$150 ded |
30%
30% / $0
30% / $0
AD |
| SignatureElite 40--70-50--250 |
3-09 |
PPO |
250 / 500 |
3250 / 6500
5 Million |
$40 copay |
$10
$35
$150 ded |
30%
30% / $0
30% / $0
AD |
| SignatureElite 70-50/2000 |
3-09 |
PPO |
2000 / 4000 |
5000 / 10000
5 Million |
30% co-ins
AD |
$10
$35
250 $ded |
30%
30% / $0
30% / $0
AD |
| SignatureElite 70-50/3500 |
3-09 |
PPO |
3500 / 7000 |
5500 / 11000
5 Million |
30% co-ins
AD |
$10
$35
250 $ded |
30%
30% / $0
30% / $0
AD |
DISCONTINUED PacifiCare
PPO Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| SignatureElite 30/70-50/250 |
7-07 |
PPO |
250 / 500 |
3000 / 6000 |
0 visits / $20 copay /
0% co-ins |
$10
$35
150 $ded |
|
| SignatureElite 35/80-60/500 |
7-07 |
PPO |
500 / 1000 |
5000 / 10000 |
0 visits / $35 copay /
0% co-ins |
$10
$35
0 $ded |
|
| SignatureElite 35/70-50/1000 |
7-07 |
PPO |
1000 / 2000 |
5000 / 10000 |
0 visits / $35 copay /
0% co-ins |
$10
$35
0 $ded |
|
| SignatureElite 35/50-50/1000 |
7-07 |
PPO |
1000 / 2000 |
3000 / 6000 |
0 visits / $35 copay /
0% co-ins |
$10
$35
0 $ded |
|
| DISCONTINUED HMO Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| 15/90-50/250 |
3-07 |
PPO |
250 / 500 |
3000 / 6000 |
0 visits / $15 copay /
0% co-ins |
$10
$25
0 $ded |
|
| 20/80-60/250 |
3-07 |
PPO |
250 / 500 |
3000 / 6000 |
0 visits / $20 copay /
0% co-ins |
$10
$25
0 $ded |
|
| DISCONTINUED HMO Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| SV Advantage 20/1500ded |
7-06 |
HMO |
1500 / 3000 |
4000 / 8000 |
0 visits / $20 copay /
0% co-ins |
$20
$35
0 $ded |
|
| SV Advantage 35/600d |
7-06 |
HMO |
0 / 0 |
5000 / 15000 |
0 visits / $35 copay /
0% co-ins |
$15
$35
0 $ded |
|
| DISCONTINUED HMO Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| SV Advantage 10-30/100 |
6-06 |
HMO |
0 / 0 |
1500 / 4500 |
0 visits / $10 copay /
0% co-ins |
$10
$25
0 $ded |
|
| SV Advantage 15-30/250a |
6-06 |
HMO |
0 / 0 |
1500 / 4500 |
0 visits / $15 copay /
0% co-ins |
$10
$25
0 $ded |
|
| DISCONTINUED PacifCare HMO Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |
| SV 15-30/250a |
2-06 |
HMO |
0 / 0 |
1500 / 4500 |
0 visits / $15 copay /
0% co-ins |
$10
$25
0 $ded |
|
| SV Advantage 10/500d |
2-06 |
HMO |
0 / 0 |
2000 / 6000 |
0 visits / $10 copay /
0% co-ins |
$15
$35
0 $ded |
|
DISCONTINUED PacifiCare
HMO Plans |
Effective |
Network |
In-Network
Ded Sgl/Fam |
In-Network
Out/pocket max
Lifetime Max |
In-Network
Office visits
(AD = after deductible) |
Rx Drugs...
Generic
Brand Name
Deductible
(AD = after deductible) |
Professional Services...
CoInsurance
InP CoIns/Copay
OutP CoIns/Copay
(AD = after deductible) |