Region 4 Rates - 1/1/2015 - 3/1/2015
Rockland
Four Tier
Platinum
Employee
Emp/Spouse
Emp/Child(ren)
Family
Health Republic TotalFreedom Platinum PPO
$15 PRIMARY/$35 SPECIALIST/$500 HOSPITAL COPAY,
MAX OOP $2,000. OON DED $4,000, OON MAX OOP
$5,000, Rx: $10/30/60/60*
$763.25
$1,520.53
$1,294.31
$2,165.58
Health Republic EssentialCare Platinum EPO
$15 PRIMARY/$35 SPECIALIST/$500 HOSPITAL COPAY,
Rx: $10/30/60/60*
$589.51
$1,173.05
$998.96
$1,670.43
Health Republic PrimarySelect Platinum EPO
$0 PRIMARY/$75 SPECIALIST, HOSPITAL DED & COINS,
OVERALL DED $0, COINS: 80/20, MAX OOP $1,400, Rx:
$0/35/70/70*
$565.64
$1,125.31
$958.38
$1,602.40
Employee
Emp/Spouse
Emp/Child(ren)
Family
Gold
Health Republic PrimarySelect Gold EPO
$0 PRIMARY/$75 SPECIALIST, HOSPITAL DED & COINS,
OVERALL DED $250, COINS: 80/20, MAX OOP $3,500, Rx:
$0/35/70/70 (DED N/A FOR GENERIC)*
$502.75
$999.53
$851.46
$1,423.16
Oxford Liberty Gold EPO 30/60
GATED. $30 PRIMARY/$60 SPECIALIST/$500 HOSPITAL
COPAY PER DAY ($2,000 MAX), OVERALL DED $1,000,
Rx:$15/35/75 ($100 Rx DED, N/A TIER 1)*
$695.71
$1,386.71
$1,181.66
$1,974.82
Employee
Emp/Spouse
Emp/Child(ren)
Family
Silver
Health Republic PrimarySelect Silver EPO
$0 PRIMARY/$75 SPECIALIST/HOSPITAL DED & COINS,
OVERALL DED $2,000, COINS 80/20, MAX OOP $6,350, Rx:
$0/35/70/70 (DED N/A FOR GENERIC)*
$431.98
$857.99
$731.15
$1,221.46
Oxford Liberty Silver PPO 40/70
$40 PRIMARY/$70 SPECIALIST/HOSPITAL DED & COINS,
DED $2,000, COINS: 70/30, MAX OOP $6,350, OON DED
$4,000, OON MAX $10,000, Rx: $15/35/75 ($100 Rx DED,
N/A TIER 1)*
$679.68
$1,354.66
$1,154.42
$1,929.14
Oxford Liberty Silver EPO 40/70
$40 PRIMARY/$70 SPECIALIST, HOSPITAL DED & COINS,
OVERALL DED $2,000, COINS: 70/30, MAX OOP $6,350, Rx:
$15/35/75 ($100 Rx DED, N/A TIER 1)*
$621.96
$1,239.23
$1,056.30
$1,764.65
Oxford Liberty Silver EPO 25/50
GATED. $25 PRIMARY/$50 SPECIALIST, HOSPITAL DED &
COINS, OVERALL DED $2,000, COINS: 70/30, MAX OOP
$5,600, Rx: $10/65/50% COINS MAX $800*
$605.69
$1,206.68
$1,028.63
$1,718.27
Employee
Emp/Spouse
Emp/Child(ren)
Family
Bronze
Health Republic EssentialCare Bronze EPO HSA 50%
50% PRIMARY/50% SPECIALIST, HOSPITAL 50% COINS,
MAX OVERALL DED $3,000,OOP $6,350, Rx:10/35/70/70
AFTER DED*
$355.74
$705.51
$601.55
$1,004.18
Oxford Liberty Bronze EPO HSA 80%
$5,000 OVERALL DED, COINS: 80/20 MAX OOP $6,350, Rx:
$20/40/80 AFTER DED*
$471.51
$938.32
$800.53
$1,335.85
All rates include $4.95 for HealthPass Program benefits that are not included as a part of normal carrier or agent services. Rates are subject to NYS Department of Financial Services approval and final verification at the time of enrollment.
The following billing and administrative fees apply: Oxford plans: EE $14.75, EE/Spouse $29.75, EE+Child(ren) $27.50, Family $43.25.
CareConnect and Health Republic plans: EE $6.75, EE/Spouse $12.50, EE+Child(ren) $11.75, Family $18.75.
The Oxford Liberty Gold EPO 30/60 and Oxford Liberty Silver EPO 25/50 plans are gated and require the selection of a Primary Care Physician (PCP).
Domestic Partner coverage is available through all carriers. Rates for Domestic Partners will be the same as rates for Employee/Spouse and Family.
Health Republic PrimarySelect plans have a $0 PCP copay if a PCP is selected in advance.
Health Republic 2015 plans do not include ACA required pediatric dental benefit
*Please refer to the official SBC for summary of coverage
1.1.2015

Heritage Product Grid - Tennessee (2-50)

On Exchange Plans (as of January, 2015)

directie per fte OP per fte oop