Point-of-Service (POS) Plans
The plans listed below are for use with:
- Groups with between two (2) and nine (9) employees unless the group has opted for the federally-qualified mandated plans
- Groups with ten (10) or more employees until the group's plan renewal on or after 12/1/2010; after that renewal date, please refer to the federally-qualified mandated group plan descriptions
Please contact your broker or agent for more information.
| Plan Name | Deductible | Coinsurance | Out of Pocket | Office Visit | Prescription Benefit Plan Options | ||||||||
| In Network | Out of Network | In Network | Out of Network | In Network | |||||||||
| Single | Family | Single | Family | In Network | Out of Network | Single | Family | Single | Family | PCP | Specialist | ||
| POS1 | $250 | $500 | $250 | $500 | N/A | 20% | $250 | $500 | $2500 | $5000 | $15 | $30 |
50009 - Standard 5 Tier $10/25/50/50/80
|
| POS2 | $250 | $500 | $500 | $1000 | 20% | 30% | $1500 | $3000 | $3000 | $6000 | $20 | $40 | |
| POS3 | $500 | $1000 | $1000 | $2000 | 20% | 30% | $2500 | $5000 | $5000 | $1000 | $25 | $50 | |
| POS4 | $7500 | $2250 | $1750 | $5250 | 20% | 30% | $3000 | $6000 | $6000 | $12000 | $25 | $50 | |
| POS5 | $1000 | $3000 | $2000 | $6000 | 20% | 30% | $4000 | $8000 | $8000 | $16000 | $25 | $50 | |
| POS6 | $1500 | $4500 | $3500 | $10500 | 20% | 30% | $5000 | $10000 | $10000 | $20000 | $25 | $50 | |
| CDPOS1 | $1500 | $3000 | $3000 | $6000 | 0% | 30% | $1500 | $3000 | $4500 | $9000 | D/C | D/C | |
| CDPOS2 | $2500 | $5000 | $5000 | $10000 | 0% | 30% | $2500 | $5000 | $6500 | $13000 | D/C | D/C | |
| CDPOS3 | $3500 | $7000 | $7000 | $14000 | 0% | 30% | $3500 | $7000 | $8500 | $17000 | D/C | D/C | |
| P250 Co-choice | $250 | $500 | $500 | $1000 | 20% | 40% | $2250 | $4500 | $4500 | $9000 | $30 | $60 | |
| P500 Co-choice | $500 | $1000 | $1000 | $2000 | 20% | 40% | $2500 | $500 | $5000 | $10000 | $30 | $60 | |
| P750 Co-choice | $750 | $1500 | $1500 | $3000 | 20% | 40% | $2750 | $5500 | $5500 | $11000 | $30 | $60 | |
| P1000 Co-choice | $1000 | $2000 | $2000 | $4000 | 20% | 40% | $3000 | $6000 | $6000 | $12000 | $30 | $60 | |
| P1500 Co-choice | $1500 | $3000 | $3000 | $6000 | 20% | 40% | $3500 | $7000 | $7000 | $14000 | $30 | $60 | |
| P2000 Co-choice | $2000 | $4000 | $4000 | $8000 | 20% | 40% | $4000 | $8000 | $8000 | $16000 | $30 | $60 | |
| P2500 Co-choice | $2500 | $5000 | $5000 | $10000 | 20% | 40% | $4500 | $9000 | $9000 | $18000 | $30 | $60 | |
| P3000 Co-choice | $3000 | $6000 | $6000 | $12000 | 20% | 40% | $5000 | $10000 | $10000 | $20000 | $30 | $60 | |
| P3500 Co-choice | $3500 | $7000 | $7000 | $14000 | 20% | 40% | $5500 | $11000 | $11000 | $22000 | $30 | $60 | |
| P4000 Co-choice | $4000 | $8000 | $8000 | $16000 | 20% | 40% | $6000 | $12000 | $12000 | $24000 | $30 | $60 | |
| P4500 Co-choice | $4500 | $9000 | $9000 | $18000 | 20% | 40% | $6500 | $13000 | $13000 | $26000 | $30 | $60 | |
| P5000 Co-choice | $5000 | $10000 | $10000 | $20000 | 20% | 40% | $7000 | $14000 | $14000 | $28000 | $30 | $60 | |
| HSAP1500 - 0% | $1500 | $3000 | $2500 | $5000 | 0% | 20% | $1500 | $3000 | $4500 | $9000 | D | D | |
| HSAP2000 - 0% | $2000 | $4000 | $3000 | $6000 | 0% | 20% | $2000 | $4000 | $5000 | $10000 | D | D | 100% HSA POS |
| HSAP2500 - 0% | $2500 | $5000 | $3500 | $7000 | 0% | 20% | $2500 | $5000 | $5500 | $11000 | D | D | |
| HSAP3000 - 0% | $3000 | $6000 | $4000 | $8000 | 0% | 20% | $3000 | $6000 | $6000 | $12000 | D | D | |
| HSAP3500 - 0% | $3500 | $7000 | $4500 | $9000 | 0% | 20% | $3500 | $7000 | $6500 | $13000 | D | D | |
| HSAP4000 - 0% | $4000 | $8000 | $5000 | $10000 | 0% | 20% | $4000 | $8000 | $7000 | $14000 | D | D | |
| HSAP4500 - 0% | $4500 | $9000 | $5500 | $11000 | 0% | 20% | $500 | $9000 | $7500 | $15000 | D | D | |
| HSAP5000 - 0% | $5000 | $10000 | $6000 | $12000 | 0% | 20% | $5000 | $10000 | $8000 | $16000 | D | D | |
| HSAP1500 - 10% | $1500 | $3000 | $2500 | $5000 | 10% | 30% | $2000 | $4000 | $5500 | $11000 | D/C | D/C | 50015 - 5 Tier $10/25/50/50/80 50201 - 5 Tier $20/40/60/60/100 50501 - Deductible then 50% Co-insurance |
| HSAP2000 - 10% | $2000 | $4000 | $3000 | $6000 | 10% | 30% | $2500 | $5000 | $6000 | $12000 | D/C | D/C | 50013 - 5 Tier $10/25/50/50/80 50203 - 5 Tier $20/40/60/60/100 50503 - Deductible then 50% Co-insurance |
| HSAP2500 - 10% | $2500 | $5000 | $3500 | $7000 | 10% | 30% | $3000 | $6000 | $6500 | $13000 | D/C | D/C | 50017 - 5 Tier $10/25/50/50/80 50205 - 5 Tier $20/40/60/60/100 50505 - Deductible then 50% Co-insurance |
| HSAP3000 - 10% | $3000 | $6000 | $4000 | $8000 | 10% | 30% | $3500 | $7000 | $7000 | $14000 | D/C | D/C | 50011 - 5 Tier $10/25/50/50/80 50207 - 5 Tier $20/40/60/60/100 50507 - Deductible then 50% Co-insurance |
| HSAP1500 - 20% | $1500 | $3000 | $2500 | $5000 | 20% | 40% | $2500 | $5000 | $6500 | $13000 | D/C | D/C | 50019 - 5 Tier $10/25/50/50/80 50217 - 5 Tier $20/40/60/60/100 50509 - Deductible then 50% Co-insurance |
| HSAP2000 - 20% | $2000 | $4000 |
$3000 |
$6000 | 20% | 40% | $3000 | $6000 | $7000 | $14000 | D/C | D/C | 50021 - 5 Tier $10/25/50/50/80 50219 - 5 Tier $20/40/60/60/100 50511 - Deductible then 50% Co-insurance |
| HSAP2500 - 20% | $2500 | $5000 | $3500 | $7000 | 20% | 40% | $3500 | $7000 | $7500 | $15000 | D/C | D/C | 50023 - 5 Tier $10/25/50/50/80 50221 - 5 Tier $20/40/60/60/100 50513 - Deductible then 50% Co-insurance |
| HSAP3000 - 20% | $3000 | $6000 | $4000 | $8000 | 20% | 40% | $4000 | $8000 | $8000 | $16000 | D/C | D/C | 50025 - 5 Tier $10/25/50/50/80 50223 - 5 Tier $20/40/60/60/100 50515 - Deductible then 50% Co-insurance |
| HSAP3500 - 20% | $3500 | $7000 | $4500 | $9000 | 20% | 40% | $4000 | $8000 | $9000 | $18000 | D/C | D/C | 50045 - 5 Tier $10/25/50/50/80 50225 - 5 Tier $20/40/60/60/100 50525 - Deductible then 50% Co-insurance |
| HSAP4000 - 20% | $4000 | $8000 | $5000 | $10000 | 20% | 40% | $5000 | $10000 | $10000 | $20000 | D/C | D/C | 50047 - 5 Tier $10/25/50/50/80 50227 - 5 Tier $20/40/60/60/100 50527 - Deductible then 50% Co-insurance |
| HSAP4500 - 20% | $4500 | $9000 | $5500 | $11000 | 20% | 40% | $5500 | $11000 | $11000 | $22000 | D/C | D/C | 50049 - 5 Tier $10/25/50/50/80 50229 - 5 Tier $20/40/60/60/100 50529 - Deductible then 50% Co-insurance |
| HSAP5000 - 20% | $5000 | $10000 | $5600 | $11200 | 20% | 40% | $5600 | $11200 | $11200 | $22400 | D/C | D/C | 50051 - 5 Tier $10/25/50/50/80 50231 - 5 Tier $20/40/60/60/100 50531 - Deductible then 50% Co-insurance |