Off Exchange Plans (as of January, 2015)
Plan Name
Blue Choice Platinum PPO 013
Blue Choice Platinum PPO 010
Blue Choice Gold PPO 023
Blue Choice Gold PPO 020
Blue Choice Platinum PPO 011
Blue Choice Gold PPO 022
Blue Choice Silver PPO 027
Blue Choice Silver PPO 028
Blue Choice Silver PPO 029
Blue Choice Gold PPO 019
Blue Choice Silver PPO 024
Blue Choice Silver PPO 004
Blue Choice Gold PPO 021
Blue Choice Gold PPO 001
Blue Choice Gold PPO 030
Blue Choice Silver PPO 025
Blue Choice Bronze PPO 005
Blue Choice Silver PPO 003
Blue Choice Bronze PPO 006
Blue Advantage Platinum HMO 010
Blue Advantage Gold HMO 022
Blue Advantage Gold HMO 023
Blue Advantage Platinum HMO 007
Blue Advantage Gold HMO 017
Blue Advantage Gold HMO 014
Blue Advantage Platinum HMO 008
Blue Advantage Gold HMO 016
Blue Advantage Gold HMO 012
Blue Advantage Silver HMO 020
Blue Advantage Silver HMO 021
Blue Advantage Silver HMO 018
Blue Advantage Silver HMO 004
Blue Advantage Gold HMO 015
Blue Advantage Gold HMO 001
Blue Advantage Bronze HMO 005
Blue Advantage Silver HMO 003
Blue Advantage Bronze HMO 006
7-Char Marketing
Plan Name
Formulary
Deductible
(Individual)
Deductible
(Family)
P603CHC
P600CHC
G623CHC
G620CHC
P601CHC
G622CHC
S610CHC
S611CHC
S612CHC
G619CHC
S608CHC
S607CHC
G621CHC
G617CHC
G613CHC
S609CHC
B633CHC
S606CHC
B634CHC
P603ADT
G632ADT
G633ADT
P600ADT
G623ADT
G620ADT
P601ADT
G622ADT
G618ADT
S610ADT
S611ADT
S608ADT
S607ADT
G621ADT
G617ADT
B636ADT
S606ADT
B634ADT
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Generics Plus
Generics Plus
Generics Plus
Generics Plus
Generics Plus
Generics Plus
Generics Plus
Generics Plus
Generics Plus
Generics Plus
Generics Plus
Generics Plus
Generics Plus
Generics Plus
Generics Plus
Generics Plus
Generics Plus
Generics Plus
$0
$250
$1,000
$1,000
$1,250
$1,250
$2,000
$2,500
$2,600
$3,000
$3,000
$3,000
$3,125
$3,250
$4,000
$5,000
$5,000
$6,000
$6,000
$0
$0
$0
$250
$1,000
$1,000
$1,250
$1,250
$2,000
$2,000
$2,500
$3,000
$3,000
$3,125
$3,250
$5,000
$6,000
$6,000
$0
$750
$3,000
$3,000
$3,750
$3,750
$4,000
$7,500
$7,800
$9,000
$9,000
$9,000
$9,375
$9,750
$12,000
$12,700
$12,700
$12,700
$12,700
$0
$0
$0
$750
$3,000
$3,000
$3,750
$3,750
$4,000
$4,000
$7,500
$9,000
$9,000
$9,375
$9,750
$12,700
$12,700
$12,700
OPX
(Individual Inc.
Ded)
$1,250
$1,250
$3,500
$3,900
$1,250
$3,500
$6,350
$6,600
$4,400
$3,000
$6,000
$6,350
$3,125
$3,250
$4,000
$5,000
$6,600
$6,000
$6,000
$1,250
$6,000
$6,600
$1,250
$3,500
$3,900
$1,250
$3,500
$2,000
$6,350
$6,600
$6,000
$6,350
$3,125
$3,250
$6,600
$6,000
$6,000
OPX
(Family Inc. Ded)
$3,750
$3,750
$10,500
$11,700
$3,750
$10,500
$12,700
$13,200
$12,900
$9,000
$12,700
$12,700
$9,375
$9,750
$12,000
$12,700
$13,200
$12,700
$12,700
$3,750
$12,700
$13,200
$3,750
$10,500
$11,700
$3,750
$10,500
$6,000
$12,700
$13,200
$12,700
$12,700
$9,375
$9,750
$13,200
$12,700
$12,700
Coins PCP Copay SPC Copay
100%
80%
100%
80%
100%
80%
70%
80%
80%
100%
70%
80%
100%
100%
100%
100%
80%
100%
100%
100%
100%
100%
80%
100%
80%
100%
80%
100%
70%
80%
70%
80%
100%
100%
80%
100%
100%
$25
$25
$15
$20
$25
$30
$40
$40
NA
NA
$40
$30
$30
$30
NA
NA
$30*
$30
NA
$25
$30
$30
$25
$15
$20
$25
$30
NA
$40
$40
$40
$30
$30
$30
$40*
$30
NA
$45
$45
$40
$40
$45
$50
$60
$60
NA
NA
$60
$50
$50
$50
NA
NA
$60*
$50
NA
$45
$50
$60
$45
$40
$40
$45
$50
NA
$60
$60
$60
$50
$50
$50
$60*
$50
NA
Urgent Care
Copay
ER Per Occurrence
Deductible
Drug Plan
$75
$75
$75
$75
$75
$75
$75
$75
NA
NA
$75
$75
$75
$75
NA
NA
$75
$75
NA
$75
$75
$75
$75
$75
$75
$75
$75
$75
$75
$75
$75
$75
$75
$75
$75
$75
$75
$300
$300
$300
$400
$300
$400
$500
$500
NA
NA
$500
$500
$400
$400
NA
NA
NA
$500
NA
$300
$400
$400*
$300
$300
$400
$300
$400
NA
$500
$500
$500
$500
$400
$400
NA
$500
NA
$0/$10/$35/$75/$150
$0/$10/$35/$75/$150
$0/$10/$35/$75/$150
$15/$40/$55
$0/$10/$35/$75/$150
$15/$30/$45
$0/$10/$50/$100/$150
$0/$10/$50/$100/$150
80%
100%
$20/$40/$60
$0/$10/$50/$100/$150
$10/$40/$60
$0/$10/$35/$75/$150
100%
100%
80%
$0/$10/$50/$100/$150
100%
$0/$10/$35/$75/$150
$0/$10/$50/$100/$150
$0/$10/$35/$75/$150
$0/$10/$35/$75/$150
$0/$10/$35/$75/$150
$15/$40/$55
$0/$10/$35/$75/$150
$15/$30/$45
100%
$0/$10/$50/$100/$150
$0/$10/$50/$100/$150
$20/$40/$60
$0/$10/$50/$100/$150
$10/$40/$60
$0/$10/$35/$75/$150
90%/90%/80%/70%/60%
$0/$10/$50/$100/$150
100%