Click on plan name link to view full benefit summary.
| Plan Name |
Deductible |
Description |
Summary of Benefit Design |
| CH-CH-5188 |
0 |
Deductible, Co-pay and Coinsurance
with added out of network benefit |
Choice 4BB-08; RX$10/$30/$50/$75 w/OC |
| CH-CH-3703 |
250 |
Deductible, Co-pay and Coinsurance with added out of network benefit |
Choice 1BB; Rx $10/25/40/75 OC |
| CH-CH-3704 |
500 |
Deductible, Co-pay and Coinsurance with added out of network benefit |
Choice 2BB; Rx $15/30/50/75 OC |
| CH-CH-3706 |
500 |
Deductible, Co-pay and Coinsurance with added out of network benefit |
Choice 5B; Rx $10/25/40/75 OC |
| CH-CH-5189 |
500 |
Deductible, Co-pay and Coinsurance
with added out of network benefit |
Choice 5BB-08; RX$20/$40/$60/$75 w/
OC |
| CH-CH-3705 |
750 |
Deductible, Co-pay and Coinsurance with added out of network benefit |
Choice 3BB; Rx $15/30/50/75 OC |
| CD-CH-3702 |
1000 |
Coinsurance after deductible is met, out of network benefits |
Choice CDHP 3A; Rx $15/30/50/75 OC |
| CH-CH-5190 |
1000 |
Deductible, Co-pay and Coinsurance with added out of network benefit |
Choice 6BB-08; RX$20/$40/$60/$75 w/ OC |
| CH-CH-5485 |
1000 |
Deductible, Co-pay and Coinsurance with added out of network benefit |
Rx $15/30/50/75 OC |
| CH-CH-5191 |
1500 |
Deductible, Co-pay and Coinsurance with added out of network benefit |
Choice 7BB-08; RX$20/$40/$60/$75 w/ OC |
| CH-CH-5196 |
1500 |
Deductible, Co-pay and Coinsurance with added out of network benefit |
Choice 11BB-08; RX$20/$40/$60/$75 w/ OC |
| HD-CH-3692 |
1500 |
Co-pay and Coinsurance after deductible is met, out of network benefits, HSA-qualified |
HDHP CHOICE 1A; Rx $10/20/30/75 OC |
| HD-CH-3693 |
1500 |
100% after deductible is met, out of network benefits, HSA-qualified |
HDHP CHOICE 1B; Rx - No Charge after Ded |
| HD-CH-5277 |
1750 |
100% after deductible is met, out of network benefits, HSA-qualified |
AV-SG-HDHP-CHOICE-1E-09; RX - No Charge after Ded |
| CH-CH-5484 |
2000 |
Deductible, Co-pay and Coinsurance with added out of network benefit |
RX$20/$40/$60/$75 w/ OC |
| HD-CH-4079 |
2000 |
100% after deductible is met, out of network benefits, HSA-qualified |
HD-CH-4079 - POS12 - HDHP-CHOICE-1D; RX - NO CHARGE AFTER DED |
| CH-CH-5192 |
2500 |
Deductible, Co-pay and Coinsurance
with added out of network benefit |
Choice 8BB-08; RX$20/$40/$60/$75 w/
OC |
| CH-CH-5194 |
3000 |
Deductible, Co-pay and Coinsurance
with added out of network benefit |
Choice 9BB-08; RX$20/$40/$60/$75 w/
OC |
| HD-CH-3694 |
3000 |
100% after deductible is met, out of network benefits, HSA-qualified |
HDHP CHOICE 1C; Rx - No Charge after Ded |
| CH-CH-5195 |
5000 |
Deductible, Co-pay and Coinsurance
with added out of network benefit |
Choice 10BB-08; RX$20/$40/$60/$75 w/
OC |
| HD-CH-5186 |
5000 |
100% after deductible is met, out of
network benefits, HSA-qualified |
HDHP-CHOICE-4DD-08; RX - No Charge
after Ded |