On Exchange Plans (as of January, 2015)
Plan Name
Blue Choice Gold PPO 002
Blue Choice Gold PPO 001
Blue Choice Silver PPO 027
Blue Choice Silver PPO 004
Blue Choice Silver PPO 003
Blue Choice Bronze PPO 005
Blue Choice Bronze PPO 006
Blue Advantage Gold HMO 002
Blue Advantage Gold HMO 001
Blue Advantage Silver HMO 020
Blue Advantage Silver HMO 004
Blue Advantage Silver HMO 003
Blue Advantage Bronze HMO 005
Blue Advantage Bronze HMO 006
7-Char Marketing
Plan Name
Formulary
Deductible
(Individual)
Deductible
(Family)
G646CHC
G645CHC
S640CHC
S639CHC
S638CHC
B649CHC
B650CHC
G646ADT
G645ADT
S640ADT
S639ADT
S638ADT
B651ADT
B650ADT
Standard
Standard
Standard
Standard
Standard
Standard
Standard
Generics Plus
Generics Plus
Generics Plus
Generics Plus
Generics Plus
Generics Plus
Generics Plus
$1,500
$3,250
$2,000
$3,000
$6,000
$5,000
$6,000
$1,500
$3,250
$2,000
$3,000
$6,000
$5,000
$6,000
$4,000
$9,750
$4,000
$9,000
$12,700
$12,700
$12,700
$4,000
$9,750
$4,000
$9,000
$12,700
$12,700
$12,700
OPX
(Individual
Inc. Ded)
$3,500
$3,250
$6,350
$6,350
$6,000
$6,600
$6,000
$3,500
$3,250
$6,350
$6,350
$6,000
$6,600
$6,000
OPX
(Family Inc.
Ded)
$10,500
$9,750
$12,700
$12,700
$12,700
$13,200
$12,700
$10,500
$9,750
$12,700
$12,700
$12,700
$13,200
$12,700
Coins
PCP
Copay
SPC Copay
80%
100%
70%
80%
100%
80%
100%
80%
100%
70%
80%
100%
80%
100%
$10
$30
$40
$30
$30
$30*
NA
$10
$30
$40
$30
$30
$40*
NA
$60
$50
$60
$50
$50
$60*
NA
$60
$50
$60
$50
$50
$60*
NA
Urgent
Care
Copay
$75
$75
$75
$75
$75
$75
NA
$75
$75
$75
$75
$75
$75
$75
ER Per
Occurrence
Deductible
$400
$400
$500
$500
$500
NA
NA
$400
$400
$500
$500
$500
NA
NA
Drug Plan
$0/$10/$35/$75/$150
$0/$10/$35/$75/$150
$0/$10/$50/$100/$150
$0/$10/$50/$100/$150
$0/$10/$50/$100/$150
80%
100%
$0/$10/$35/$75/$150
$0/$10/$35/$75/$150
$0/$10/$50/$100/$150
$0/$10/$50/$100/$150
$0/$10/$50/$100/$150
90%/90%/80%/70%/60%
100%

Attachment A-Kaiser, WHA, SutterPlus Rates

REGION 4 1ST QTR 2015 v2