Group Forms Rocky Mountain

APPLICATIONS AND FORMS

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Rocky Mountain 2014 Plans Network Office Visit Copays Prescriptions Deductible & Coinsurance Out-of-Pocket Limits
Gold 500/80 $35 Copay (R-1) PPO $35/$50 $15/$40/$55/30%/40% $500 + 20% $3000 Ind/$6000 Family
Gold 650/850 $35 Copay (R-2) PPO $35/$55 $15/$40/$55/30%/40% $650 + 20% $4000 Ind/$8000 Family
Silver 1500/70 $35 Copay (R-3) PPO $35/$50 $15/$40/$55/30%/40% $1500 + 30% $6350 Ind/$12,700 Family
Silver 2000/70 $40 Copay (R-4) PPO $40/$60 $15/$40/$55/30%/40% $2000 + 30% $6000 Ind/$12,000 Family
Silver 2000/70 $45 Copay (R-5) PPO $45/$65 $15/$40/$55/30%/40% $2000 + 30% $6350 Ind/$12,700 Family
Bronze 4500/60 $55 Copay (R-6) PPO $55/Ded & Coinsurance $20/40%/40%/50%/50% $4500 + 40% $6350 Ind/$12,700 Family
Bronze HSA 3250 $45 Copay (R-7) PPO Deductible then $45/$65 Deductible, $15/$40/$55/30%/40% $3250 + 30% $6350 Ind/$12,700 Family
Gold HMO 500/80 $35 Copay (R-8) HMO $35/$50 $15/$40/$55/30%/40% $500 + 20% $3000 Ind/$6000 Family
Gold HMO 650/80 $35 Copay (R-9) HMO $35/$55 $15/$40/$55/30%/40% $650 + 20% $4000 Ind/$8000 Family
Silver HMO 1500/70 $35 Copay (R-10) HMO $35/$50 $15/$40/$55/30%/40% $1500 + 30% $6350 Ind/$12,700 Family
Silver HMO 2000/70 $40 Copay (R-11) HMO $40/$60 $15/$40/$55/30%/40% $2000 + 30% $6000 Ind/$12,000 Family
Silver HMO 2000/70 $45 Copay (R-12) HMO $45/$65 $15/$40/$55/30%/40% $2000 + 30% $6350 Ind/$12,700 Family
Bronze HMO 4500/60 $55 Copay (R-13) HMO $55/Ded & Coinsurance $20/40%/40%/50%/50% $4500 + 40% $6350 Ind/$12,700 Family
Bronze HMO HSA 3250 $45 Copay (R-14) HMO Deductible then $45/$65 Deductible, $15/$40/$55/30%/40% $3250 + 30% $6350 Ind/$12,700 Family
NEW WEST PHYSICIAN DENVER METRO
New West HMO Gold 500/80 $35 Copay (RNW-1) New West HMO $35/$50 $15/$40/$55/30%/40% $500 + 20% $3000 Ind/$6000 Family
New West HMO Silver 1500/70 $35 Copay (RNW-2) New West HMO $35/$50 $15/$40/$55/30%/40% $1500 + 30% $6350 Ind/$12,700 Family
New West HMO Silver 2000/70 $45 Copay (RNW-3) New West HMO $45/$65 $15/$40/$55/30%/40% $2000 + 30% $6350 Ind/$12,700 Family
New West HMO Bronze HSA 3250 $45 Copay (RNW-4) New West HMO Deductible then $45/$65 Deductible,$15/$40/$55/30%/40% $3250 + 30% $6350 Ind/$12,700 Family
CS HEALTH PARTNERS COLORADO SPRINGS
CSHP HMO Gold 500/80 $35 Copay (RCS-1) Colo Spr Health Partners HMO $35/$50 $15/$40/$55/30%/40% $500 + 20% $3000 Ind/$6000 Family
CSHP HMO Silver 1500/70 $35 Copay (RCS-2) Colo Spr Health Partners HMO $35/$50 $15/$40/$55/30%/40% $1500 + 30% $6350 Ind/$12,700 Family
CSHP HMO Silver 2000/70 $45 Copay (RCS-3) Colo Spr Health Partners HMO $45/$65 $15/$40/$55/30%/40% $2000 + 30% $6350 Ind/$12,700 Family
CSHP HMO Bronze HSA 3250 $45 Copay (RCS-4) Colo Spr Health Partners HMO Deductible then $45/$65 Deductible, $15/$40/$55/30%/40% $3250 + 30% $6350 Ind/$12,700 Family
 
HMO Plans
Health Plan Name Office Visit Copay Prescriptions Deductible &
Coinsurance
Out-of-Pocket
Limit
500/80 $35/$50 $15 Generic Only or
$15/$50/$65/20%/30%
$500 + 20% $3500
1000/70 $45/$60 $15 Generic Only or
$15/$50/$65/20%/30%
$1000 + 30% $4500
1500/75 $45/$65 $15 Generic Only or
$15/$50/$65/20%/30%
$1500 + 25% $5000
2000/70 $45/$65 $15 Generic Only or
$15/$50/$65/20%/30%
$2000 + $30% $6000
3000/70 $35/$50 $15 Generic Only or
$15/$50/$65/20%/30%
$3000 + 30% $8000
4000/70 $35$50 $15 Generic Only or
$15/$50/$65/20%/30%
$4000 + 30% $9000
Basic HMO
Standard HMO
 
PPO Plans
Plan Name Office Visit Copay Pharmacy Deductible &
Coinsurance
Out-of-Pocket
Limit
500/80 $35/$50 $15 Generic Only or
$15/$50/$65/20%/30%
$500 + 20% $3500
1000/70 $45/60 $15 Generic Only or
$15/$50/$65/20%/30%
$1000 + 30% $4500
1500/75 $45/$65 $15 Generic Only or
$15/$50/$65/20%/30%
$1500 + 25% $5000
2000/70 $45/$65 $15 Generic Only or
$15/$50/$65/20%/30%
$2000 + 30% $6000
3000/65 $45/$65 $15 Generic Only or
$15/$50/$65/20%/30%
$3000 + 35% $6000
3000/100 $35/$60 $15 Generic Only or
$15/$50/$65/20%/30%
$3000 + 0% $3000
4000/100 $40/$65 $15 Generic Only or
$15/$50/$65/20%/30%
$4000 + 0% $4000
5000/100 $45/$65 $15 Generic Only or
$15/$50/$65/20%/30%
$5000 + 0% $5000
Core Plus Not covered $15 Generic Only $1500 + 25% $5000
Vista 500/70 $35 $15 Generic Only or
$15/$50/$65/20%/30%
$500 + 30% $3500
Vista 1000/70 $35 $15 Generic Only or
$15/$50/$65/20%/30%
$1000 + 30% $3000
Vista 1500/70 $35 $15 Generic Only or
$15/$50/$65/20%/30%
$1500 + 30% $4500
Basic PPO
Standard PPO
 
HSA Plans
Plan Name Deductible Coinsurance Max Out-of-Pocket
HSA PPO 2650 $2650-$4000 0% $2650-$4000
HSA PPO 3250 $3250-$6000 0% $3250-$6000
HSA PPO 5000 $5000-$1000 0% $5000-$10000