Group Forms SeeChange Health

APPLICATIONS AND FORMS

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SeeChange Plans 2014 Network Office Visits Prescriptions Deductible & Coinsurance Out-of-Pocket Limits
Gold Reward 80 Copay (S-1) CIgna $30/$50 $20/$50/$70/20% $0 + 20% $6350 Ind/$12,700 Family
Silver Reward 80 Copay (S-2) Cigna $45/$65 $25, $500 deductible, $50/$70/20% $1500 + 20% $6350 Ind/$12,700 Family
Silver Reward 70 Copay (S-3) Cigna $45/$65 $10, $250 deductible, $50/$70/30% $1750 + 30% $6350 Ind/$12,700 Family
Bronze Reward 80 (S-4) Cigna Deductible & Coinsurance Deductible, then $10/$25/$50/20% $5500 + 20% $6350 Ind/$12,700 Family
Bronze Reward 70 Copay (S-5) Cigna $60/$70 (limit 3) $25, Deductible, then $50/$70/30% $5000 + 30% $6350 Ind/$12,700 Family
Bronze Reward 50 (S-6) Cigna Deductible & Coinsurance $10, Deductible, then $50/$70/50% $5500 + 50% $6350 Ind/$12,700 Family
Bronze Reward 100 (S-7) Cigna Deductible Deductible $6200 + 0% $6200 Ind/$12,400 Family
Silver Reward HSA (S-8) Cigna Deductible & Coinsurance Deductible, then $10/$25/$50/20% $2000 + 20% $6350 Ind/$12,700 Family
Bronze Reward HSA (S-9) Cigna Deductible & Coinsurance Deductible then $10/$25/$50/20% $4500 + 50% $6350 Ind/$12,700 Family
 
Plan Description SBC Office Visit
Copay
Prescription Deductible &
Coinsurance
Out-of-Pocket
Limit
HRA 5000 SBC $40 (limit 3) $500 Deductible,
then $10/$50/Not Covered/30%
$5000 + 20% $9000
HSA 3000 SBC Deductible &
Coinsurance
Deductible &
Coinsurance
$3000 + 20% $5000
HSA 4000 SBC Deductible &
Coinsurance
Deductible &
Coinsurance
$4000 + 20% $5500
HSA 5000 SBC Deductible &
Coinsurance
Deductible &
Coinsurance
$5000 + 20% $5950
Classic 2200 SBC Deductible &
Coinsurance
$200 Deductible,
then $10/$35/50%/35%
$2200 + 20% $3200
Classic 3500 SBC Deductible &
Coinsurance
$200 Deductible,
then $10/$35/50%/35%
$3500 + 30% $5000
Classic 5000 SBC Deductible &
Coinsurance
$200 Deductible,
then $10/$35/50%/35%
$5000 + 40% $7000
Deluxe 500 Copay SBC $25/$50 $200 Deductible,
then $10/$35/50%/35%
$500 + 20% $1500
Deluxe 1000 Copay SBC $25/$50 $200 Deductible,
then $10/$35/50%/35%
$1000 + 20% $3000
Deluxe 2000 Copay SBC $25/$50 $200 Deductible,
then $10/$35/50%/35%
$2000 + 20% $4000
Deluxe 3000 Copay SBC $25/$50 $200 Deductible,
then $10/$35/50%/35%
$3000 + 20% $5000
Deluxe 4000 Copay SBC $25/$50 $200 Deductible,
then $10/$35/50%/35%
$4000 + 20% $6000
Standard PPO
Basic PPO