Consumers’ Choice Individual Health Plans
IN-NETWORK BENEFITS ONLY*
Plans effective January 1, 2014
Plan Name
Coinsurance
Federal Marketplace Plans
Gold
*Does not apply to emergency care
Individual
Deductible
PCP
Specialist
Urgent Care
Individual
Emergency
Total Out of
Care
Pocket
Pharmacy
Gold 1
20%
$600
$20
$50
$50
Ded/Coins
$4,500
$10/ $30/ $60
Gold 2
30%
$1,000
$20
$50
$50
Ded/Coins
$4,000
$10/ $30/ $60
Silver 1
30%
$2,000
$30
$60
$50
Ded/Coins
$6,350
$10/ $40/ $80
Silver 1 - 73 AV
30%
$2,000
$25
$55
$50
Ded/Coins
$5,200
$10/ $35/ $80
Silver 1 - 87 AV
20%
$250
$10
$25
$25
Ded/Coins
$2,250
$10/ $25/ $50
Silver 1 - 94 AV
10%
$75
$5
$10
$10
Ded/Coins
$1,000
$4/ $15/ $35
Silver 2
30%
$3,500
$25
$50
$50
Ded/Coins
$6,350
$10/ $40/ $75
Silver 2 - 73 AV
30%
$2,750
$20
$50
$50
Ded/Coins
$5,200
$10/ $35/ $60
Silver 2 - 87 AV
20%
$450
$10
$30
$30
Ded/Coins
$2,250
$10/ $25/ $50
Silver 2 - 94 AV
10%
$150
$5
$15
$15
Ded/Coins
$1,000
$4/ $15/ $35
Silver HDP 1
100%
NA
$3,500
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$3,500
Ded/Coins
100%
NA
$2,750
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$2,750
Ded/Coins
100%
NA
$1,000
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$1,000
Ded/Coins
100%
NA
$250
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$500
Ded/Coins
Bronze 1
40%
$4,000
$30
Ded/Coins
Ded/Coins
Ded/Coins
$6,350
Ded/Coins
Bronze HDP 1
NA
100%
$6,250
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$6,250
Ded/Coins
100%
NA
$6,350
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$6,350
Ded/Coins
Silver
Silver HDP 1 73 AV
Silver HDP 1 87 AV
Silver HDP 1 94 AV
Bronze
Catastrophic
Value Plan
Commercial Plans - Off Federal Marketplace
30%
$1,000
$20
$50
Ded/Coins
Ded/Coins
$4,500
$10/ $35/ $60
Silver 3
30%
$2,500
$25
$50
$50
Ded/Coins
$6,350
$10/ $40/ $75
Silver 4
30%
$4,750
$25
$50
$50
Ded/Coins
$6,350
$10/ $40/ $75
Silver 5
40%
$1,750
$35
$70
Ded/Coins
Ded/Coins
$6,250
$10/ $40/ $80
Silver 6
40%
$3,500
$30
$50
Ded/Coins
Ded/Coins
$6,350
$10/ $40/ $75
Silver 7
20%
$5,000
$20
$50
Ded/Coins
Ded/Coins
$6,350
$8/ $30/ $70
Silver 8
100%
NA
$5,500
$35
$65
Ded/Coins
Ded/Coins
$5,500
$10/ $50/ $100
Bronze 2
100%
NA
$6,350
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$6,350
$10/ $65/ $150
Gold HDP 1
NA
100%
$2,000
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$2,000
Ded/Coins
Silver HDP 2
20%
$2,000
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$6,000
Ded/Coins
Silver HDP 3
30%
$1,250
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$6,250
Ded/Coins
Silver HDP 4
NA
100%
$3,600
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$3,600
Ded/Coins
Bronze HDP 2
100%
NA
$5,500
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$5,500
Ded/Coins
Bronze HDP 3
50%
$2,750
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$6,350
Ded/Coins
Bronze HDP 4
100%
NA
$6,300
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$6,300
Ded/Coins
HDP indicates Qualified High Deductible Plan. Does not apply on Cost-Sharing Reduction Plans if deductible is less than $1250. HDP plans include an aggregate
family deductible of two times individual. All specialty drugs are processed under the deductible and coinsurance on all individual plans.
CCHP_CR_PlanGridBroker_01172014
Gold 3
Consumers’ Choice Group Health Plans
Plans effective January 1, 2014
Plan
Coinsurance
Deductible
PCP
Specialist Urgent Care
Emergency Total Out of
Care
Pocket
Pharmacy
Federal Marketplace SHOP Plans
EPO - IN-NETWORK BENEFITS ONLY *Does not apply to emergency care
Platinum
CCHP 1
10%
$250
$15
$40
$50
$250
$2,250
$10 /$25 /$50/ Coins
CCHP 2
20%
$500
$25
$65
$50
$100+Coins
$4,750
$10/ $30/ $60/ Coins
CCHP 3
20%
$1,250
$20
$50
$50
$100+Coins
$4,500
$10/ $30/ $60/ Coins
CCHP HDP 1
10%
$1,500
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$3,000
Ded/Coins
CCHP 4
30%
$2,200
$30
$60
$55
Ded/Coins
$6,350
$10/ $35 /$65/ Coins
CCHP 5
40%
$2,000
$35
Ded/Coins
Ded/Coins
$150+Coins
$6,350
$10/ $40/ $75/ Coins
CCHP HDP 2
20%
$1,750
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$5,250
Ded/Coins
40%
$4,250
$30
Ded/Coins
Ded/Coins
Ded/Coins
$6,350
Ded/Coins
Gold
Silver
Bronze
CCHP 6
Commercial Plans - Off Marketplace Commercial PPO Plans
Out-of-network services covered at a lower benefit level. Pharmacy covered in-network only.
Co-Pay Plans
CCHP Plus 1
20%
$1,000
$20
$45
$50
$100+Coins
$4,000
$10/ $25/ $55/ Coins
CCHP Plus 2
30%
$1,000
$20
$50
$50
$100+Coins
$4,000
$10/ $30/ $60/ Coins
CCHP Plus 3
30%
$1,000
$20
$50
$50
$100+Coins
$4,500
$10/ $30/ $60/ Coins
CCHP Plus 5
40%
$2,000
$35
$65
$65
$150+ Coins
$6,350
$10/ $40/ $75/ Coins
CCHP Plus 7
30%
$500
$20
$50
$50
$100+Coins
$4,000
$10/ $30/ $60/ Coins
CCHP Plus 8
20%
$1,250
$20
$50
$50
$100+Coins
$4,750
$10/ $30/ $60/ Coins
CCHP Plus 9
30%
$1,750
$40
$80
$65
$150+Coins
$6,350
$10/ $45/ $80/ Coins
CCHP Plus 10
30%
$2,000
$25
$50
$50
$150+ Coins
$6,350
$10/ $35/ $60/ Coins
CCHP Plus 11
30%
$1,500
$35
$65
$65
$150+Coins
$6,350
$10/ $45/ $80/ Coins
CCHP Plus 12
NA
NA%
$6,350
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$6,350
$10/ $65/ $150/
Ded/Coins
Qualified High Deductible Plans - Off Marketplace
CCHP Plus HDP 1
100%
NA
$2,000
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$2,000
Ded/Coins
CCHP Plus HDP 2
20%
$2,000
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$6,000
Ded/Coins
CCHP Plus HDP 3
100%
NA
$5,500
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$5,500
Ded/Coins
CCHP Plus HDP 4
30%
$1,250
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$6,250
Ded/Coins
CCHP Plus HDP 5
50%
$2,750
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$6,250
Ded/Coins
CCHP Plus HDP 6
100%
NA
$6,300
Ded/Coins
Ded/Coins
Ded/Coins
Ded/Coins
$6,300
Ded/Coins
HDP plans include an aggregate family deductible of two times individual.
CCHP_CR_PlanGridBroker_01172014
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