SCHEDULE OF BENEFITS (SOB)
2018 INDIVIDUAL & FAMILY PLANS
SILVER CSR
Silver 5500/80
73% – 2700/Copay 35 CSR
87% – $50 Ded/Copay 25 CSR
94% – $0 Ded/Copay 0 CSR
Silver 4000/75
73% – 2850/80/Copay 35 CSR
87% – $150 Ded/80/Copay 25 CSR
94% – $50 Ded/80/Copay 0 CSR
Silver HSA 3200/75
73% – 2000/80 CSR
87% – 200/80 CSR
94% – $50 Ded/80 CSR
Silver 3000/75/Copay 40
73% – 2750/Copay 35 CSR
87% – $100 Ded/Copay 25 CSR
94% – $25 Ded/Copay 5 CSR
2017 INDIVIDUAL & FAMILY PLANS
SILVER
SILVER CSR
Silver 5200/80
73% – 2600/Copay 30 CSR
87% – $0 Ded/Copay 25 CSR
94% – $0 Ded/Copay 0 CSR
Silver 3800/80
73% – 2550/80/Copay 35 CSR
87% – $0 Ded/80/Copay 30 CSR
94% – $0 Ded/80/Copay 5 CSR
Silver HSA 3000/80
73% – 1900/80 CSR
87% – 250/80 CSR
94% – $50 Ded/80 CSR
Silver 2500/80/Copay 35
73% – 2500/Copay 30 CSR
87% – $0 Ded/Copay 25 CSR
94% – $0 Ded/Copay 5 CSR
Silver 2400/80
73% – 1700/80 CSR
87% – 200/80 CSR
94% – $0 Ded/80 CSR
Silver 2000/70
73% – 1200/10Rx CSR
87% – 175/10Rx CSR
94% – $0 Ded/5Rx CSR
Silver 3500/80
73% – 3000/80 Standard CSR
87% – 700/80 Standard CSR
94% – 250/80 Standard CSR