Summaries of Benefits for large group plans — 2017

EPO plans

• EPO $20 $40 $250
• EPO $20/$40 $1,500/80%
• EPO $30 $50 $1500 Ded 70% Coins
• EPO $30 $50 $2500 Ded 80% Coins $100 ER
• EPO $30 $50 $2500 Ded 80% Coins 80% ER
• EPO $30 $50 $500
• EPO $30 50% $2500 Ded 50% Coins
• EPO $50/$75 $2,500/50%
• EPO $2,000/100%
• EPO HSA $1300 Ded 50% Coins w INT $7 50% $125 max RX
• EPO HSA $1300 Ded 80% Coins w INT $7 50% $125 max RX
• EPO HSA $1300 Ded 50% Coins w INT $10 $40 $60 RX
• EPO HSA $1300 Ded 80% Coins w INT $10 $40 $60 RX
• EPO HSA $1500 Ded 70% Coins w INT $10 $40 $60 RX
• EPO HSA $1500 Ded 70% Coins w INT $7 50% $125 max RX
• EPO HSA $2,500/100% w/ $25/$50/$75 Int RX

EPO Advantage plans

• AmeriHealth Advantage $15/$25
• AmeriHealth Advantage High Option $1000 Ded
• AmeriHealth Advantage Medium Option $2000 Ded
• AmeriHealth Advantage Low Option $2500 Ded
• AmeriHealth Advantage Economy Option $2500 Ded
• AmeriHealth Advantage Economy HSA Option
• Tier 1 Advantage High Option $1500 Ded
• Tier 1 Advantage Low Option $2500 Ded
• Tier 1 Advantage Low HSA Option

HMO plans

• HMO $15 $30 $0 Day
• HMO $20 $40 $0 Day
• HMO $20 $40 $1000 Ded 80% Coins Option 1
• HMO $20 $40 $300 Day
• HMO $25 $50 $1000 Ded 80% Coins Option 2
• HMO $30 $50 $0 Day
• HMO $30 $50 $1500 Ded 70% Coins Option 3
• HMO $30 $50 $400 Day
• HMO Public Sector $2
• HMO Select $10
• HMO Select $20
• HMO Select $30

HMO Plus plans

• HMO Plus $20 $40 $1000 Ded 80% Coins Option 1
• HMO Plus $20 $40 $300 Day
• HMO Plus $25 $50 $1000 Ded 80% Coins Option 2
• HMO Plus $30 $50 $1500 Ded 70% Coins Option 3
• HMO Plus $30 $50 $400 Day

POS plans

• POS $15 $30 $0 Day
• POS $15 $30 $200 Day
• POS $20 $40 $0 Day
• POS $20 $40 $1000 Ded 90% Coins
• POS $20 $40 $300 Day
• POS $30 $50 $1500 Ded 80% Coins
• POS $30 $50 $2000 Ded 70% Coins
• POS $30 $50 $400 Day
• POS Premium Select $15 H
• POS Premium Select $30 E
• POS Public Sector $5
• POS Select $20 H

POS Plus plans

• POS Plus $10 $20 $0 Day
• POS Plus $15 $30 $0 Day
• POS Plus $15 $30 $200 Day
• POS Plus $20 $40 $0 Day
• POS Plus $20 $40 $1000 Ded 90% Coins
• POS Plus $20 $40 $250 Day
• POS Plus $30 $40 $300 Day
• POS Plus $30 $50 $1500 Ded 80% Coins
• POS Plus $30 $50 $2000 Ded 70% Coins
• POS Plus $40 $50 $300 Day

PPO plans

• PPO $10
• PPO $10 $20
• PPO $15
• PPO $15 $25
• PPO $20
• PPO $20 $20 $300 Ded 90% Coins
• PPO $20 $30
• PPO $5
• PPO HDHP $2500 Ded 70% Coins
• PPO HSA $1,300 Ded 80% Coins w INT RX $10 $40 $60
• PPO HSA $1,300 Ded 100% Coins w INT RX $10 $40 $60
• PPO HSA $2000 Ded 90% Coins w INT RX $7 $35 $50
• PPO HSA $2500 Ded 70% Coins w INT RX $7 $35 $50
• PPO Public Sector $10

Vision

• Vision Care 100: 12/12/12*
• Vision Care 100: 12/12/24*
• Vision Care 100: 24/24/24
• Vision Care 100: 12/12/12 $25 Copay — Voluntary
• Vision Care 130: 12/12/12*
• Vision Care 130: 12/12/24*
• Vision Care 130: 12/12/24 $25 Copay*
• Vision Care 150: 12/12/12*
• Vision Care 150: 12/12/24 — Voluntary
• $35 Vision Program

  Benefits Available Every Two Calendar Years

• $100 Vision Program

  Benefits Available Once Every Calendar Year

• $100 Vision Program

  Benefits Available Every Two Calendar Years

• $200 Vision Program

  Benefits Available Once Every Calendar Year

• $200 Vision Program

  Benefits Available Every Two Calendar Years

• $35 Corrective Eyewear

  Benefits Available Every Two Calendar Years

• $100 Corrective Eyewear

  Benefits Available Every Two Calendar Years

Prescription benefits at a glance

• Standard Prescription Drug Program $7/50%
• Standard Prescription Drug Program 50%/50%
• Select Drug Program $7/$35/$50
• Select Drug Program $10/$40/$60
• Select Drug Program $15/$35/$50

*Voluntary option available.