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2015 Individual Medical Bronze and Catastrophic Plans (p. 1 of 2)
Plan ID/ Form Schedue # Issuer
Plan Name
Metal Level Product Type Network Coverage Deductible-Individual/Family Coinsurance Max Out of Pocket-Individual/Family Preventive Care PCP Visits (not wellness)
Specialist Visits
Urgent Care Outpatient Facility/Surgical Center
Emergency Room
Inpatient Hospital Services
Generic Drugs Preferred Brand Drugs Durable Medical Equipment Chiropractic Care Adult Dental Embedded? Routine Dental Adult Pediatric Dental Embedded? Dental Check-Up for Children
No Charge $40 for first 2 visits, thereafter 10% Coinsurance after deductible
No Charge
25% Coinsurance after deductible
No Charge $35 for first 2 visits, thereafter 20% Coinsurance after deductible
10% Coinsurance after deductible
Not Covered
Not Covered
10% Coinsurance after deductible
25% Coinsurance after deductible $50 Copay and 25% Coinsurance after deductible 25% Coinsurance after deductible
No Coinsurance after deductible $50 Copay after deductible No Coinsurance after deductible
20% Coinsurance after deductible $50 Copay and 20% Coinsurance after deductible 20% Coinsurance after deductible
10% Coinsurance after deductible $50 Copay and 10% Coinsurance after deductible 10% Coinsurance after deductible
$200 Copay after deductible
$200 Copay and 20% Coinsurance after deductible
$200 Copay and 10% Coinsurance after deductible
$200 Copay and 25% Coinsurance after deductible
$500 Copay per Stay, and 25% Coinsurance $500 Copay per Stay after deductible after deductible 25% Coinsurance after No Coinsurance after deductible deductible 25% Coinsurance after No Coinsurance after deductible deductible 25% Coinsurance after No Coinsurance after deductible deductible 25% Coinsurance after No Coinsurance after deductible deductible No No Not Covered No Not Covered
Not Covered No Not Covered
25% Coinsurance after deductible
$
40
25% Coinsurance after deductible
$
100
50% Coinsurance after 60% Coinsurance after deductible deductible
50% Coinsurance after 60% Coinsurance after deductible deductible
50% Coinsurance after 60% Coinsurance after deductible deductible
10% Coinsurance after deductible
$125 Copay after deductible 25% Coinsurance after deductible
$ 125 20% Coinsurance after deductible
50% Coinsurance after 60% Coinsurance after deductible deductible 50% Coinsurance after 60% Coinsurance after deductible deductible
60% Coinsurance after $ 140 deductible 50% Coinsurance after 60% Coinsurance after deductible deductible
60% Coinsurance after $ 140 deductible 50% Coinsurance after 60% Coinsurance after deductible deductible
10% Coinsurance after deductible 10% Coinsurance after deductible
25% Coinsurance after deductible
$300 Copay after deductible
50% Coinsurance after 50% Coinsurance after deductible deductible
$
$
10% Coinsurance after deductible
$500 Copay per Stay, $500 Copay per Stay, and 20% Coinsurance and 10% Coinsurance 25% Coinsurance after after deductible after deductible deductible 20% Coinsurance after 10% Coinsurance after 25% Coinsurance after deductible deductible deductible 20% Coinsurance after 10% Coinsurance after 25% Coinsurance after deductible deductible deductible 20% Coinsurance after 10% Coinsurance after 25% Coinsurance after deductible deductible deductible 20% Coinsurance after 10% Coinsurance after 25% Coinsurance after deductible deductible deductible No No No Not Covered No Not Covered
Not Covered No Not Covered
$5800 / $11600 10%
Not Covered No Not Covered
20% Coinsurance after deductible
50% Coinsurance after deductible 10% Coinsurance after 20% deductible 50% Coinsurance after 20% deductible 20% Coinsurance after 50% Coinsurance after deductible deductible 50% Coinsurance after $ 40 deductible No No Not Covered No Not Covered
Not Covered No Not Covered
$
45
825 $
60% Coinsurance after 50% Coinsurance after deductible deductible 30% Coinsurance after deductible $ 30 60% Coinsurance after 50% Coinsurance after deductible deductible 60% Coinsurance after 50% Coinsurance after deductible deductible 60% Coinsurance after 50% Coinsurance after deductible deductible No No Not Covered No Not Covered
Not Covered
Not Covered No Not Covered
$
825
45
825 $
60% Coinsurance after 50% Coinsurance after deductible deductible 60% Coinsurance after deductible $ 30 60% Coinsurance after 50% Coinsurance after deductible deductible 60% Coinsurance after 50% Coinsurance after deductible deductible 60% Coinsurance after 50% Coinsurance after deductible deductible No No Not Covered No Not Covered
Not Covered Yes No Charge
825
60% Coinsurance after 10% Coinsurance after deductible deductible 60% Coinsurance after No Copay after deductible deductible 60% Coinsurance after No Copay after deductible deductible 60% Coinsurance after 20% Coinsurance after deductible deductible 60% Coinsurance after 10% Coinsurance after deductible deductible No No Not Covered Yes No Charge
Not Covered No Not Covered
2015 Individual Medical Bronze and Catastrophic Plans (p. 2 of 2)
Plan ID/ Form Schedue # Issuer
Plan Name
Metal Level Product Type Network Coverage Deductible-Individual/Family Coinsurance Max Out of Pocket-Individual/Family Preventive Care PCP Visits (not wellness)
Specialist Visits
Urgent Care Outpatient Facility/Surgical Center
Emergency Room
Inpatient Hospital Services
Generic Drugs Preferred Brand Drugs Durable Medical Equipment Chiropractic Care Adult Dental Embedded? Routine Dental Adult Pediatric Dental Embedded? Dental Check-Up for Children
25% Coinsurance after 45% Coinsurance after deductible deductible 25% Coinsurance after 45% Coinsurance after deductible deductible $100 Copay before $100 Copay before deductible and 25% deductible and 25% Coinsurance after Coinsurance after deductible deductible
No Charge $35 for first 4 visits, thereafter 25% coinsurance after deductible $35 for first 4 visits, thereafter 25% coinsurance after deductible
No Charge after deductible No Coinsurance after deductible
$50 Copay after deductible 15% Coinsurance after deductible
30% Coinsurance after deductible 30% Coinsurance after deductible
No Charge after deductible
$750 Copay after deductible
$200 Copay and 30% Coinsurance after deductible
$750 Copay per Stay after deductible
30% Coinsurance after deductible
Not Covered No Not Covered
Not Covered No Not Covered
No Coinsurance after deductible No Copay after deductible No Copay after deductible No Coinsurance after deductible No Coinsurance after deductible No Not Covered No Not Covered
25% Coinsurance after deductible 25% Coinsurance after $ 30 $ 30 deductible $60 Copay after $60 Copay after 25% Coinsurance after deductible deductible deductible 20% Coinsurance after 30% Coinsurance after 25% Coinsurance after deductible deductible deductible $30 Copay after $50 Copay after 25% Coinsurance after deductible deductible deductible No No No Not Covered Yes No Charge
19304NH0010001
61163NH0370001
Maine CHO
Minuteman Health
Community Safe Harbor
MyDoc HMO Simple Care
Anthem Anthem Catastrophic Pathway X Enhanced HMO 6600 0
$40 for first 3 visits, thereafter no charge after deductible
No Copay for first three visits, thereafter subject to deductible
Not Covered
$35 Copay for first 3 visits, then $35 after deductible
No Coinsurance after deductible
No Coinsurance after deductible
No Coinsurance after deductible
No Coinsurance after 50% Coinsurance after deductible deductible
No Coinsurance after deductible
No Coinsurance after deductible No Coinsurance after deductible
No Coinsurance after deductible No Coinsurance after deductible
No Coinsurance after deductible No Coinsurance after deductible
No Coinsurance after 50% Coinsurance after deductible deductible No Coinsurance after 50% Coinsurance after deductible deductible
No Coinsurance after deductible No Coinsurance after deductible
$100 Copay before deductible
$100 Copay before deductible
No Coinsurance after deductible
No Coinsurance after deductible
No Coinsurance after deductible
No Coinsurance after deductible No Coinsurance after deductible No Coinsurance after deductible No Coinsurance after deductible No Coinsurance after deductible No
No Coinsurance after deductible No Coinsurance after deductible No Coinsurance after deductible No Coinsurance after deductible No Coinsurance after deductible No
Not Covered No Not Covered
Not Covered No Not Covered
45% Coinsurance after No Coinsurance after No Coinsurance after deductible deductible deductible 45% Coinsurance after No Coinsurance after No Coinsurance after deductible deductible deductible 45% Coinsurance after No Coinsurance after No Coinsurance after deductible deductible deductible 45% Coinsurance after No Coinsurance after No Coinsurance after deductible deductible deductible 45% Coinsurance after No Coinsurance after No Coinsurance after deductible deductible deductible No No No Not Covered Yes No Charge
96751NH0150024
Not Covered Yes No Charge
Not Covered Yes No Charge
Catastrophic HMO NHN002
No Coinsurance after deductible
Catastrophic HMO NHN001 $6600 / $13200 0%
50% Coinsurance after No Coinsurance after deductible deductible 50% Coinsurance after No Coinsurance after deductible deductible 50% Coinsurance after No Coinsurance after deductible deductible 50% Coinsurance after No Coinsurance after deductible deductible 50% Coinsurance after No Coinsurance after deductible deductible No No Not Covered No Not Covered
