| Plan #
| Plan/deductible/out-of-pocket maximum
| Office call copay
| Price relationship factor
|
| AwareŽ
|
| 1
| Aware GoldŽ plan
| N/A
| 1.00
|
| 4
| Aware Gold with copay plan
| $25
| .86
|
| Comprehensive Major Medical (CMM) plans
|
| 113
| No deductible, OOP $1,100/$5,000
| $25
| .77
|
| 118
| $300/$900, OOP $1,500/$5,000
| $25
| .72
|
| 120
| $500/$1,000, OOP $1,800/$5,000
| $25
| .70
|
| 121
| $750/$1,500, OOP $2,000/$5,000
| $25
| .68
|
| 122
| $1,000/$2,000, OOP $2,250/$5,000
| $30
| .66
|
| 123
| $2,000/$4,000, OOP $2,500/$5,000
| $30
| .64
|
| Blue ValueSM plans
|
| 131
| $1,500/$4,500, OOP $3,000/$6,000
| $40
| .59
|
| 132
| $2,500/$7,500, OOP $4,000/$8,000
| $40
| .55
|
| 133
| $3,500/$8,500, OOP $5,000/$10,000
| $50
| .52
|
| Freedom 1-2-3 plans
|
| 40
| Freedom 1-2-3 Accord Network
$750/$1,500, OOP $2,250/$4,500
| N/A
| .62
|
| 42
| Freedom 1-2-3 Accord Network
$1,500/$3,000, OOP $4,500/$7,500
| N/A
| .56
|
| 43
| Freedom 1-2-3 Accord Network
$2,500/ $5,000, OOP $6,500/$13,000
| N/A
| .50
|
| 44
| $750/$1,500, OOP $2,250/$4,500
| N/A
| .58
|
| 46
| Freedom 1-2-3 Value Network
$1,500/$3,000, OOP $4,500/$7,500
| N/A
| .52
|
| 47
| Freedom 1-2-3 Value Network
$2,500/ $5,000, OOP $6,500/$13,000
| N/A
| .47
|
| 48
| Freedom 1-2-3 Aware Network
$750/$1,500, OOP $2,250/$4,500
| N/A
| .66
|
| 49
| Freedom 1-2-3 Aware Network
$1,500/ $3,000, OOP $4,500/$7,500
| N/A
| .60
|
| 50
| Freedom 1-2-3 Aware Network
$2,500/ $5,000, OOP $6,500/$13,000
| N/A
| .54
|
| Options BlueSM compatible with (HRA)
|
| 161
| Options Blue 80
$1,500/$3,000, OOP $2,750/$7,000
| N/A
| .59
|
| 165
| Options Blue 80
$2,500/$5,000, OOP $3,500/$7,000
| N/A
| .51
|
| 167
| Options Blue 100
$3,000/$6,000, OOP equal to deductible
| N/A
| .56
|
| 169
| Options Blue 100
$5,000/$10,000, OOP equal to deductible
| N/A
| .47
|
|
| Plan #
| Plan/deductible/out-of-pocket maximum
| Office call copay
| Price relationship factor
|
| Options Blue compatible with (HSA)
|
| 170
| Options Blue 80
$1,600/$3,200, OOP $3,200/$6,400
| N/A
| .59
|
| 172
| Options Blue 80
$2,100/$4,200, OOP $4,200/$8,400
| N/A
| .53
|
| 174
| Options Blue 80
$3,000/$6,000, OOP $5,800/$11,600
| N/A
| .46
|
| 175
| Options Blue 80
$3,000/$6,000 embedded deductible OOP $5,800/$11,600
| N/A
| .47
|
| 176
| Options Blue 100
$1,600/$3,200, OOP equal to the deductible
| N/A
| .66
|
| 178
| Options Blue 100
$2,100/$4,200, OOP equal to deductible
| N/A
| .61
|
| 180
| Options Blue 100
$3,000/$6,000, OOP equal to deductible
| N/A
| .53
|
| 181
| Options Blue 100
$3,000/$6,000 embedded deductible OOP equal to deductible
| N/A
| .55
|
| 182
| Options Blue 100
$5,800/$11,600, OOP equal to deductible
| N/A
| .39
|
| 183
| Options Blue 100
$5,800/$11,600 embedded deductible OOP equal to deductible
| N/A
| .43
|
| Blue Plus plans
|
| 27
| Preferred Gold
| $25
| .77
|
| 31
| Preferred Gold
$500/$1,000, OOP $1,800/$5,000
| $25
| .71
|
| 32
| Preferred Gold
$1,000/$2,000, OOP $2,250/$5,000
| $30
| .67
|
| 33
| Preferred Gold Ltd
$2,000/$4,000, OOP $2,250/$5,000
| $30
| .64
|
| Blue Plus mandated plans
|
| 25
| Blue Plus with deductible
$2,250/$4,500, OOP $3,000/$6,000
| N/A
| .59
|
| 26
| Blue Plus with copay
No deductible, OOP $3,000/$6,000
| $15
| .75
|
| Blue Cross mandated plans
|
| 23
| Blue Cross with deductible
$2,250/$4,500, OOP $3,000/$6,000
| N/A
| .59
|
| 24
| Blue Cross with copay
No deductible, OOP $3,000/$6,000
| $15
| .75
|
|
Effective October 1, 2010
* This plan design does not comply with federal mental health parity regulations that are applicable to groups
with 51 or more employees.
|