2015 HDHP POS Plan Designs
Small group, Non-grandfathered plans
BRONZE
SILVER
GOLD
In-Network
2015
HDHP
Plans
Individual
Deductible/
Out-of-Pocket
Maximum
Family
Deductible/
Out-of-Pocket
Maximum
Coinsurance
Level
Individual
Deductible/Outof-Pocket
Maximum
Family
Deductible/
Out-of-Pocket
Maximum
Coinsurance
Level
Office Visit
QPC1815*
QPC4815
$2,000/$2,000**
$4,000/$4,000
100%
$4,000/$8,000**
$8,000/$16,000
70%
QPC1915*
QPC4915
$2,000/$5,000** $4,000/$10,000
80%
$4,000/$10,000** $8,000/$20,000
$6,000/$6,000
100%
$3,000/$5,000** $6,000/$10,000
QPC2115*
QPC5115
QPC2215*
QPC5215
$3,000/$3,000
Emergency
Room
Pharmacy
Generic/Formulary/
Non-Formulary/
Specialty
100%/100%
100%
100%
50%
80%/80%
80%
80%
$6,000/$12,000 $12,000/$24,000
70%
100%/100%
100%
100%
100%
$6,000/$12,000** $12,000/$24,000
70%
$20/$40***
$300***
$10/$25/$50/$250***
Primary
Care/
Specialist
QPC2315*
QPC5315
$3,500/$3,500
$7,000/$7,000
100%
$7,000/$14,000 $14,000/$28,000
70%
100%/100%
100%
100%
QPC2415*
QPC5415
$3,500/$6,450
$7,000/$12,900
70%
$7,000/$12,900 $14,000/$25,800
50%
70%/70%
70%
70%
QPC2515*
QPC5515
$4,000/$6,000
$8,000/$12,000
80%
$8,000/$12,000 $16,000/$24,000
50%
80%/80%
80%
80%
$4,000/$6,450** $8,000/$12,900
80%
$8,000/$12,900** $16,000/$25,800
50%
80%/80%
80%
80%
$10,000/$12,000
100%
$10,000/$20,000 $20,000/$40,000
70%
100%/100%
100%
$15/$35/$65/$250***
$5,000/$6,450** $10,000/$12,900
100%
$10,000/$20,000** $20,000/$40,000
70%
$30/$60***
$300***
$15/$35/$65/$250***
QPC2615*
QPC5615
QPC2715*
QPC5715
QPC2815*
QPC5815
$5,000/$6,000
QPC2915*
QPC5915
$5,250/$5,250
$10,500/$10,500
100%
$10,500/$21,000 $21,000/$42,000
70%
100%/100%
100%
100%
QPC3015*
QPC6015
$6,300/$6,300
$12,600/$12,600
100%
$12,600/$25,200 $25,200/$50,400
70%
100%/100%
100%
100%
Key:
QPC plans = PHP Classic network
* = Includes Pediatric Dental coverage
** = Non-embedded deductible plans
*** = Copays apply after deductible
October 2014
Out-of-Network
NOTE: This summary is not intended to provide a full description of eligible benefits,
requirements and limitations. Additional benefit plans, options, and products are
available, and can be accessed online at www.phpni.com. Call a PHP Sales Representative today at (260) 432-6690 or toll free at 1-800-982-6257 for more information.

4th Qtr 2014 ACA Cheapest to Highest charts MD, DC and VA,7-8

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