2016 Small Group Medical Network Plan Benefits Carrier
Network Limited Limited Limited Limited Limited Limited Limited
Product EPO EPO HMO HMO HMO HMO HMO
Metal Tier Gold Silver Bronze Gold Platinum Silver Gold
Plan Name PureCare 80 EPO 1000/20 Alternate PureCare 70 EPO 1800/30 Alternate PureCare 60 HSP 6000/70 PureCare 80 HSP 0/35 PureCare 90 HSP 0/20 PureCare 70 HSP 1500/45 Salud HMO y Mas $30
Plan Ded. $1,000 $1,800 $6,000 $0 $0 $1,500 $0
Limited
HMO
Gold
Salud HMO y Mas $40
$0
Limited
HMO
Gold
Salud HMO y Mas $50
$0
Limited
HMO
Platinum
Salud HMO y Mas $10
$0
Limited
HMO
Platinum
Salud HMO y Mas $20
$0
Limited Limited Limited Limited Limited Limited Limited Limited Limited Limited Full Full Full Full Full Full Full Full Full Full
HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO HMO PPO PPO PPO PPO PPO
Gold Gold Gold Platinum Platinum Gold Gold Gold Platinum Platinum Platinum Platinum Gold Gold Gold Platinum Gold Silver Bronze Bronze
SmartCare HMO $30 SmartCare HMO $40 SmartCare HMO $50 SmartCare HMO $10 SmartCare HMO $20 WholeCare HMO $30 WholeCare HMO $40 WholeCare HMO $50 WholeCare HMO $10 WholeCare HMO $20 Platinum $10 Platinum $20 Gold $30 Gold $40 Gold $50 Platinum 90 0/20 Gold 80 0/35 Silver 70 1500/45 Bronze 60 6000/70 Bronze 60 4750/15 Alternate HSA
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $1,500 $6,000 $4,750
OOP Max. $4,500 $6,500 $6,500 $6,200 $4,000 $6,500 $1,500 Mex $6,000 CA $1,500 Mex $6,500 CA $1,500 Mex $6,850 CA $1,500 Mex $3,000 CA $1,500 Mex $4,250 CA $6,000 $6,500 $6,850 $3,000 $4,250 $6,000 $6,500 $6,850 $3,000 $4,250 $3,000 $4,250 $6,000 $6,500 $6,850 $4,000 $6,200 $6,500 $6,500 $6,550
Office Visit $20/$30 $30/$50 $70/$90⁺ $35/$55 $20/$40 $45/$70 $5/$5 Mex $30/$50 CA $5/$5 Mex $40/$60 CA $5/$5 Mex $50/$70 CA $5/$5 Mex $10/$30 CA $5/$5 Mex $20/$40 CA $30/$50 $40/$60 $50/$70 $10/$30 $20/$40 $30/$50 $40/$60 $50/$70 $10/$30 $20/$40 $10/$30 $20/$40 $30/$50 $40/$60 $50/$70 $20 / $40 $35 / $55 $45 / $70 $70/$90 $15 / $30
⁺ Deductible waived for first three (3) office visits * Rx deductible applies only to tiers 2 & 3
This is an overview for comparison purposes only. Please refer to carrier benefit summaries for full details.
Inpatient 20% 50% 0% after OOP 20% 10% 20% $0 Mex $600/admit CA $0 Mex $800/admit CA $0 Mex $1,200/admit CA $0 Mex $300/admit CA $0 Mex $500/admit CA $600/admit $800/admit $1,200/admit $300/admit $500/admit $600/admit $800/admit $1,200/admit $300/admit $500/admit $300/admit $500/admit $600/admit $800/admit $1,200/admit 10% 20% 20% 100% 20%
Rx $5/$15/20% $10/$55/50% 0% after OOP $15/$50/$70 $5/$15/$25 $15/$55/$75 $5/$5/$5 Mex $15/$50/$70 CA $5/$5/$5 Mex $15/$50/$70 CA $5/$5/$5 Mex $20/$50/$70 CA $5/$5/$5 Mex $5/$30/$50 CA $5/$5/$5 Mex $5/$30/$50 CA $15/$50/$70 $15/$50/$70 $20/$50/$70 $5/$30/$50 $5/$30/$50 $15/$50/$70 $15/$50/$70 $20/$50/$70 $5/$30/$50 $5/$30/$50 $5/$30/$50 $5/$30/$50 $15/$50/$70 $15/$50/$70 $20/$50/$70 $5/$15/$25 $15/$50/$70 $15/$55/$75 100% $5/$15/$40
Rx Ded. *$250 *$350 $500 $0 $0 *$250 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $250 $500 Plan ded
