Click
here to
link to our site
Pacificare
|
Click on the button below to obtain the appropriate forms. These are pdf files to be printed, completed, and faxed to our office.
| Employee Application Package for New Group | Add Employee to Existing Group Plan | Employee Change Form |
Other Forms:
Employee forms can be faxed to our office at (303) 721-1085. Please confirm that application was received by calling (303) 721-1145. Please call with any questions regarding eligibility or waiting periods.
HMO Plans
| Health Plan Name |
Office Visit Copay |
Hospital Copay |
Outpatient Copay |
| Basic HMO | $40 |
$500/day, max $2000 |
$300 |
| Standard HMO | $25 | $250/day, max $1000 | $100 |
| 15-35/200d | $15 | $200/day, max $1000 | $175 |
| 25-40/400d | $25 | $400/day, max $2000 | $250 |
| 30-50/500a | $30 | $500 + 20% to $30K | $250 + 20% to $30K |
| POS 15-30/300a | $15 | $300 | $100 |
PPO Plans
| Plan Name |
Office Visit Copay |
Deductible |
Coinsurance |
| $40 |
$3000 |
30% to $10K |
|
| $25 |
$1500 |
20% to $7500 |
|
$20 |
$1000 |
20% to $10K |
|
$25 |
$1500 |
20% to $15K |
|
$30 |
$2000 |
20% to $20K |
|
$20 |
$500 |
20% to $10K |
|
$30 |
$2000 |
30% to $17K |
|
| Self-Directed | Office Visit Copay | Hospital Copay | Outpatient Copay |
paid by SDA |
$1500 |
20% to $15K |
|
paid by SDA |
$2000 |
30% to $17K |
HSA Plans
Plan Name |
Deductible |
Coinsurance |
Max Out-of-Pocket |
| $2700/$5400 |
80/20 |
$5000/$10,000 |
|
$3500/$7000 |
70/30 |
$5000/$10,000 |
|
$5000/$10,000 |
100/0 |
$5000/$10,000 |
 |
Click
below for: Roper Individual Health Insurance Services |
 South Metro Denver Chamber of Commerce |
 |
