Ulster 2015 Insurance Brochure Template Final.xlsx

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Platinum 100 (Replacing 104 & 105)

Gold 221 (Replacing 203)

Gold 222 (Replacing 204)

Silver 320 (Replacing 302)

Silver 322 (Replacing 305)

Bronze 400 (NEW)

EPO Copay Embedded

EPO Copay ‐ Embrace  Health Embedded

EPO Hybrid Embedded

HDEPO Qualified Aggregate

EPO Hybrid  Embedded

HDEPO  Non‐Qualified Embedded

 

 

 

(2015 Plan Mapping:  Silver 302 will map into this  plan)

(2015 Plan Mapping:  Silver 305 will map into this  plan)

 

SMALL GROUP  OPTIONS

(2015 Plan Mapping:      both Platinum plans moved into  (2015 Plan Mapping:  (2015 Plan Mapping:  this Platinum plan) Gold 203 will map into this plan) Gold 204 will map into this plan)

 Preventative   Care

Bronze 421 (Replacing 407)

Bronze 422 (Replacing 409)

HDEPO Qualified Aggregate HDEPO Qualified Aggregate  

 

(2015 Plan Mapping:  Bronze 407 will mapinto this  plan)

(2015 Plan Mapping:  Bronze 407 will mapinto this  plan)

Qualified services are covered in full.

 Physician /    Specialist

 $15 / $35 

Deductible then $30/$50

$20 / $40

Deductible then $25/$40

$40 / $60

 Deductible then 50% 

Deductible then 0%

 Deductible then 50% 

 Hospital Stay

$500

Deductible then $1000

Deductible then 20%

Deductible then $0

Deductible then 20%

 Deductible then 50% 

Deductible then 0%

 Deductible then 50% 

 Outpatient   Surgery

$100

Deductible then $100

Deductible then 20%

Deductible then $100

Deductible then 20%

 Deductible then 50% 

Deductible then 0%

 Deductible then 50% 

 Emergency   Room

$100

Deductible then $100

Deductible then 20%

Deductible then $50

Deductible then 20%

 Deductible then 50% 

Deductible then 0%

 Deductible then 50% 

$10 / $30 / $60

$10/$50/$80 NOT subject to deductible

$10/$50/$80 NOT subject to deductible

 Deductible then  $10/50%/50%

$10/50%/50% NOT subject to deductible

 Deductible then  $10/$35/$70

 Deductible then  $10/50%/50%

 Deductible then  50%/50%/50%

 Prescriptions  Dependent Rider

 Deductible

 In‐Network Coinsurance

 Out of Pocket  Maximum

     In Network:           $0 Single           $0 Family

     In Network:           $250 Single           $500 Family

     In Network:           $600 Single           $1200 Family

     In Network:           $1500 Single           $3000 Family

     In Network:           $2000 Single           $4000 Family

     In Network:           $3500 Single           $7000 Family

     In Network:           $5250 Single           $10500 Family

     In Network:           $4500 Single           $9000 Family

     Out of Network:           N/A

     Out of Network:           N/A

     Out of Network:           N/A

     Out of Network:           N/A

     Out of Network:           N/A

     Out of Network:           N/A

     Out of Network:           N/A

     Out of Network:           N/A

   N/A

   N/A

20%

   N/A

20%

50%

0%

50%

   In Network:         $2000 Single         $4000 Family

   In Network:         $6850 Single         $13700 Family

   In Network:         $5000 Single         $10000 Family

   In Network:         $6550 Single         $13100 Family

   In Network:         $6850 Single         $13700 Family

   In Network:         $6850 Single         $13700 Family

   In Network:         $6550 Single         $13100 Family

   In Network:         $6550 Single         $13100 Family

     Out of Network:           N/A

     Out of Network:           N/A

     Out of Network:           N/A

     Out of Network:           N/A

     Out of Network:           N/A

     Out of Network:           N/A

     Out of Network:           N/A

     Out of Network:           N/A

$824.03

$694.85

$677.62

$591.01

$561.29

$496.70

$491.68

$484.78

EE+Spouse

$1,648.06

$1,389.71

$1,355.24

$1,182.02

$1,122.57

$993.40

$983.36

$969.55

EE+Children

$1,456.02

$1,236.42

$1,207.12

$1,059.89

$1,009.36

$899.56

$891.03

$879.29

Family

$2,403.66

$2,035.50

$1,986.38

$1,739.55

$1,654.83

$1,470.77

$1,456.46

$1,436.78

Single

SMALL  GROUP  RATES

Up to age 26 on all plans regardless of student status; Domestic partner covered.

Please note‐‐‐ Employee+Children and Family Rates include the Mandatory Pediatric Dental Charge ‐ your actual rate may be less depending on the number of qualifying dependents. Please note ‐‐‐ Please check your doctors as these are all EPO plans.  EPO ‐ National Network w/First Health & Magnacare.  Doctors can be found on www.cdphp.org