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", "*Deductible waived for generic drugs" ], "formulary": [ "Value" ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l97c/o8PZhbCmNPj_JECoZWfiz0KPQzMl0HyhRtmAfe9Irjk" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9Q0/Oy17hevAwE.uciYNfss5z2qAoz9tCuKv4oIc5yPZrGE" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9Vy/Pm1Tmum0ay94xF2R8rNftOkqydcGXMpR_zeUT8Zft9E" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=PPO&alphaPrefix=XXX&postalCode=" } ] } }, { "planName": "Gold QHDHP PPO Choice 1700/0/10", "PlanDetails": { "metalLevel": "Gold", "plantype": "medical", "productType": "PPO Choice", "dataCatProductType":"Choice", "deductible": [ "Choice 1 - $1,700/$3,400", "Choice 2 - $3,400/$6,800", "Non-embedded" ], "OOPmax": [ "$6,900 individual", "$13,800 family" ], "Exchange": [ "Off Pennie" ], "hsaeligible": "Yes- HSA account set up included with purchase of plan", "county": "Available in Lancaster", "Coinsurance": [ "Choice 1 - None", "Choice 2 - 30%" ], "PrimaryCare": [ "Choice 1 - $10 copay after deductible", "Choice 2 - $20 copay after deductible" ], "specialist": [ "Choice 1 - $20 copay after deductible", "Choice 2 - $40 copay after deductible" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/a9d21fca-894d-4ce3-abc2-00555919b1ac/images%252Fgold-plan.jpg?MOD=AJPERES", "emergencyroom": "$175 copay after deductible", "urgentcare": "$75 copay after deductible", "virtualcare": [ "Paid in full after deductible" ], "diagnosticlab": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% copay after deductible" ], "opdiagnostictest": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% copay after deductible" ], "ophightechimaging": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% copay after deductible" ], "opsurgery": [ "Choice 1 - $175 copay after deductible", "Choice 2 - $350 copay after deductible" ], "iphospitaladmission": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% after deductible" ], "retailrx": [ "Preferred generic - $7 copay after deductible", "Nonpreferred generic - $25 copay after deductible", "Preferred brand - $55 copay after deductible", "Nonpreferred brand - $80 copay after deductible" ], "homedeliveryrx": [ "Preferred generic - $18 copay after deductible", "Nonpreferred generic - $63 copay after deductible", "Preferred brand - $138 copay after deductible", "Nonpreferred brand - $200 copay after deductible" ], "formulary": [ "Value" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. " ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l98a/zwWwLpGT6FPzFn5zesJRkAORe4SUBPwAjbfKUhFDcI4" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9Qy/SPm6OoaT1zDc5GrP.wjxxs6BLQV.j2XSmlKLMAEwyFk" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9YJ/b.kpNI59P2i39Yk4ExnRM1Lu0FYjEHt1CUEZxfsqxJ4" }, { "docName": "HSA Information", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/3j00000096GO/nvegywFZNATkf_LlrypT4Rp20a_oLQzAx3adfhKTz_g" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=PPO&alphaPrefix=XXX&postalCode=" } ] } }, { "planName": "Gold PPO Choice 1800/0/25", "PlanDetails": { "metalLevel": "Gold", "productType": "PPO Choice", "deductible": [ "Choice 1 - $1,800/$3,600", "Choice 2 - $4,000/$8,000" ], "OOPmax": [ "$8,550 individual", "$17,100 family" ], "Exchange": [ "On Pennie", "Off Pennie" ], "hsaeligible": "No", "county": "Available in Lancaster", "Coinsurance": [ "Choice 1 - None", "Choice 2 - 30%" ], "PrimaryCare": [ "Choice 1 - $25 copay", "Choice 2 - $50 copay" ], "specialist": [ "Choice 1 - $50 copay", "Choice 2 - $75 copay" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/a9d21fca-894d-4ce3-abc2-00555919b1ac/images%252Fgold-plan.jpg?MOD=AJPERES", "emergencyroom": "$200 copay after Choice 1 deductible", "urgentcare": "$75 copay", "virtualcare": [ "$0 copay" ], "diagnosticlab": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% after deductible" ], "opdiagnostictest": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% after deductible" ], "ophightechimaging": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% after deductible" ], "opsurgery": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% after deductible" ], "iphospitaladmission": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% after deductible" ], "retailrx": [ "Preferred generic* - $10 copay", "Nonpreferred generic* - 25% ($250 max)", "Preferred brand - $25 copay after deductible", "Nonpreferred brand - $75 copay after deductible" ], "homedeliveryrx": [ "Preferred generic* - $25 copay", "Nonpreferred generic* - 25% ($500 max)", "Preferred brand - $63 copay after deductible", "Nonpreferred brand - $188 copay after deductible" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. ", "*Deductible waived for generic drugs" ], "formulary": [ "Value" ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l98f/67_dw6ds5gd1NWYw0udYjEFIyP1WkuNmWGCcY_loSGE" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9R3/UxIYodxVUi..X.tluTJxj.aLZvNzdiI.f5rlHfOqq04" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9YO/2KntDnW6niygrXLHBtn16EGCmlJ7gNDNp4YE5Cd6RxM" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=ICOM&alphaPrefix=XXX&postalCode=" } ] } }, { "planName": "Gold PPO Choice 2400/0/25", "PlanDetails": { "metalLevel": "Gold", "productType": "PPO Choice", "deductible": [ "Choice 1 - $2,400/$4,800", "Choice 2 - $4,800/$9,600" ], "OOPmax": [ "$8,550 individual", "$17,100 family" ], "Exchange": [ "On Pennie", "Off Pennie" ], "hsaeligible": "No", "county": "Available in Lancaster", "Coinsurance": [ "Choice 1 - None", "Choice 2 - 30%" ], "PrimaryCare": [ "Choice 1 - $25 copay", "Choice 2 - $50 copay" ], "specialist": [ "Choice 1 - $50 copay", "Choice 2 - $75 copay" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/a9d21fca-894d-4ce3-abc2-00555919b1ac/images%252Fgold-plan.jpg?MOD=AJPERES", "emergencyroom": "$250 copay after Choice 1 deductible", "urgentcare": "$75 copay", "virtualcare": [ "$0 copay" ], "diagnosticlab": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% after deductible" ], "opdiagnostictest": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% after deductible" ], "ophightechimaging": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% after deductible" ], "opsurgery": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% after deductible" ], "iphospitaladmission": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% after deductible" ], "retailrx": [ "Preferred generic* - $10 copay", "Nonpreferred generic* - 25% ($250 max)", "Preferred brand - $25 copay after deductible", "Nonpreferred brand - $75 copay after deductible" ], "homedeliveryrx": [ "Preferred generic* - $25 copay", "Nonpreferred generic* - 25% ($500 max)", "Preferred brand - $63 copay after deductible", "Nonpreferred brand - $188 copay after deductible" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. ", "*Deductible waived for generic drugs" ], "formulary": [ "Value" ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l98k/0qQFAazMMeb1Y2SSl8tJgdD2gFirEh2QWD9JNyYI8x8" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9R8/kcLxiXy9mu6ebgk5pWx6vIl5nQ6wChrvXNVEU3lnGEY" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9YY/CqOxDo5x2gVKE5X4.j4GK5fn15Y_EDYjHmhZ7rdsRfI" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=CAP&alphaPrefix=XXX&postalCode=" } ] } }, { "planName": "Gold PPO Choice Select 1800/0/25", "PlanDetails": { "metalLevel": "Gold", "productType": "PPO Choice Select", "deductible": [ "Choice 1 - $1,800/$3,600", "Choice 2 - $4,000/$8,000" ], "OOPmax": [ "$8,550 individual", "$17,100 family" ], "Exchange": [ "On Pennie", "Off Pennie" ], "hsaeligible": "No", "county": "Available in Cumberland, Dauphin and Perry Counties", "Coinsurance": [ "Choice 1 - None", "Choice 2 - 30%" ], "PrimaryCare": [ "Choice 1 - $25 copay", "Choice 2 - $50 copay" ], "specialist": [ "Choice 1 - $50 copay", "Choice 2 - $75 copay" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/a9d21fca-894d-4ce3-abc2-00555919b1ac/images%252Fgold-plan.jpg?MOD=AJPERES", "emergencyroom": "$200 copay after deductible", "urgentcare": "$75 copay", "virtualcare": [ "$0 copay" ], "diagnosticlab": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% after deductible" ], "opdiagnostictest": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% after deductible" ], "ophightechimaging": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% after deductible" ], "opsurgery": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% after deductible" ], "iphospitaladmission": [ "Choice 1 - Paid in full after deductible", "Choice 2 - 30% after deductible" ], "retailrx": [ "Preferred generic* - $10 copay", "Nonpreferred generic* - 25% ($250 max)", "Preferred brand - $25 copay after deductible", "Nonpreferred brand - $75 copay after deductible" ], "homedeliveryrx": [ "Preferred generic* - $25 copay", "Nonpreferred generic* - 25% ($500 max)", "Preferred brand - $63 copay after deductible", "Nonpreferred brand - $188 copay after deductible" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. 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", "*Deductible waived for generic drugs" ], "formulary": [ "Value" ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9C8/9tme74mju_J3iKmmWYWE2mul1pwbB215NHQLPArvPwQ" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9Ts/X6CNjqqKvja8A7bvRx7zaY.gUCqSNAd6kexP0vujY98" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9bw/.qErSQFNlFaUftpo6Iu2p2qXzTHb5qsbCqCnFH22rZs" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=CAP&alphaPrefix=XXX&postalCode=" } ] } }, { "planName": "Silver QHDHP PPO 2900/10/40", "PlanDetails": { "metalLevel": "Silver", "plantype": "medical", "productType": "PPO", "deductible": [ "$2,900 individual", "$5,800 family", "Non-embedded" ], "OOPmax": [ "$7,450 individual", "$14,900 family" ], "Exchange": [ "Off Pennie" ], "hsaeligible": "Yes - HSA account set up included with purchase of plan", "county": "Available in all counties except Lancaster", "Coinsurance": [ "10%" ], "PrimaryCare": [ "$40 copay after deductible" ], "specialist": [ "$85 copay after deductible" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/58e247c4-1137-4b2c-a09c-b43bc1ae4089/images%252Fsilver-plan.jpg?MOD=AJPERES", "emergencyroom": "$400 copay after deductible", "urgentcare": "$100 copay after deductible", "virtualcare": [ "Paid in full after deductible" ], "diagnosticlab": [ "$25 copay after deductible at independent labs", "$75 copay after deductible at hospital owned labs" ], "opdiagnostictest": [ "10% coinsurance after deductible" ], "ophightechimaging": [ "25% coinsurance after deductible" ], "opsurgery": [ "10% coinsurance after deductible" ], "iphospitaladmission": [ "10% coinsurance after deductible" ], "retailrx": [ "Preferred generic - $10 copay after deductible", "Nonpreferred generic - 25% ($250 max) after deductible", "Preferred brand - $25 copay after deductible", "Nonpreferred brand - $75 copay after deductible" ], "homedeliveryrx": [ "Preferred generic - $25 copay after deductible", "Nonpreferred generic - 25% ($500 max) after deductible", "Preferred brand - $63 copay after deductible", "Nonpreferred brand - $188 copay after deductible" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. " ], "formulary": [ "Value" ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l97h/lOgeCfj0cGG6mmMrEhezVkgbGOhh9mKhyhC64HJ.HHA" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9Q5/qoS_OC3XT615fVASFPhl6X7alVkt4hdH1xE7EJUdYzw" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9W8/FOeueRyQgfHEgbHFBO3EaXHsjnwxcjFxZXp2S_rIZPI" }, { "docName": "HSA Information", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/3j00000096GO/nvegywFZNATkf_LlrypT4Rp20a_oLQzAx3adfhKTz_g" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=PPO&alphaPrefix=XXX&postalCode=" } ] } }, { "planName": "Silver PPO 3450/0/40 Rx 250", "PlanDetails": { "metalLevel": "Silver", "plantype": "medical", "productType": "PPO", "dataCatProductType":"PPO", "deductible": [ "Medical -$3,450 Individual/$6,900 Family", "Prescription - $250 individual/$500 family" ], "OOPmax": [ "$8,700 individual", "$17,400 Family" ], "Exchange": [ "Off Pennie" ], "hsaeligible": "No", "county": "Available in all counties except Lancaster", "Coinsurance": [ "None" ], "PrimaryCare": [ "$40 copay" ], "specialist": [ "$75 copay" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/58e247c4-1137-4b2c-a09c-b43bc1ae4089/images%252Fsilver-plan.jpg?MOD=AJPERES", "emergencyroom": "$400 copay after deductible", "urgentcare": "$100 copay", "virtualcare": [ "$0 copay" ], "diagnosticlab": [ "$40 copay(deductible waived) at independent labs", "$75 copay after deductible at hospital owned labs" ], "opdiagnostictest": [ "Paid in full after deductible" ], "ophightechimaging": [ "300 coinsurance after deductible" ], "opsurgery": [ "400 coinsurance after deductible" ], "iphospitaladmission": [ "$125/ day copay x 5 days after deductible" ], "retailrx": [ "Preferred generic* - $7 copay", "Nonpreferred generic* - $25 copay", "Preferred brand - $55 copay after deductible", "Nonpreferred brand - $80 copay after deductible" ], "homedeliveryrx": [ "Preferred generic* - $18 copay", "Nonpreferred generic* - $63 copay", "Preferred brand - $138 copay after deductible", "Nonpreferred brand - $200 copay after deductible" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. ", "*Deductible waived for generic drugs" ], "formulary": [ "Value" ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l97m/AdoPYSd1D8WDhQFuTJwRwCjEsaAvad.vCLzYaXrPMq0" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9QF/HYodp8UeEJTZ7_sXdihnA8t9OPMRh.ikIt6dKW7YBsA" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9WD/LUavQ_hPj2pMPvaNxZu2R_BTOePauRide.IWocL3gbI" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=PPO&alphaPrefix=XXX&postalCode=" } ] } }, { "planName": "Silver PPO 3500/0/40 Rx 250", "PlanDetails": { "metalLevel": "Silver", "plantype": "medical", "productType": "PPO", "dataCatProductType":"PPO", "deductible": [ "Medical -$3,500 Individual/$7,000 Family", "Prescription - $250 individual/$500 family" ], "OOPmax": [ "$8,700 individual", "$17,400 Family" ], "Exchange": [ "On Pennie", "Off Pennie" ], "hsaeligible": "No", "county": "Available in all counties except Lancaster", "Coinsurance": [ "None" ], "PrimaryCare": [ "$40 copay" ], "specialist": [ "$75 copay" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/58e247c4-1137-4b2c-a09c-b43bc1ae4089/images%252Fsilver-plan.jpg?MOD=AJPERES", "emergencyroom": "$400 copay after deductible", "urgentcare": "$100 copay", "virtualcare": [ "$0 copay" ], "diagnosticlab": [ "$40 copay(deductible waived) at independent labs", "$75 copay after deductible at hospital owned labs" ], "opdiagnostictest": [ "Paid in full after deductible" ], "ophightechimaging": [ "300 coinsurance after deductible" ], "opsurgery": [ "400 coinsurance after deductible" ], "iphospitaladmission": [ "$125/ day copay x 5 days after deductible" ], "retailrx": [ "Preferred generic* - $7 copay", "Nonpreferred generic* - $25 copay", "Preferred brand - $55 copay after deductible", "Nonpreferred brand - $80 copay after deductible" ], "homedeliveryrx": [ "Preferred generic* - $18 copay", "Nonpreferred generic* - $63 copay", "Preferred brand - $138 copay after deductible", "Nonpreferred brand - $200 copay after deductible" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. ", "*Deductible waived for generic drugs" ], "formulary": [ "Value" ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l97r/rg44ctZ5Ak8j5TWXSyVCRK47WYizu6CJRrQ1LauDngU" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9QK/YUEICnezg_8zAKuuhSq5hsTgzzDSvMjcACxBJ1zz1z4" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9WS/dtdVq20lcdYaxJrUtJt8TupnZPdqXpp9DOB8bjYM_FY" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=PPO&alphaPrefix=XXX&postalCode=" } ] } }, { "planName": "Silver PPO 3400/0/30 Rx 200 CSR73", "PlanDetails": { "metalLevel": "Silver", "plantype": "medical", "productType": "PPO", "dataCatProductType":"PPO", "deductible": [ "Medical -$3,400 Individual/$6,800 Family", "Prescription - $250 individual/$500 family" ], "OOPmax": [ "$7,350 individual", "$14,700 family" ], "Exchange": [ "On Pennie" ], "hsaeligible": "No", "county": "Available in all counties except Lancaster", "Coinsurance": [ "None" ], "PrimaryCare": [ "$30 copay" ], "specialist": [ "$60 copay" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/58e247c4-1137-4b2c-a09c-b43bc1ae4089/images%252Fsilver-plan.jpg?MOD=AJPERES", "emergencyroom": "$350 copay after deductible", "urgentcare": "$50 copay", "virtualcare": [ "$0 copay" ], "diagnosticlab": [ "$30 copay(deductible waived) at independent labs", "$60 copay after deductible at hospital owned labs" ], "opdiagnostictest": [ "Paid in full after deductible" ], "ophightechimaging": [ "$250 copay after deductible" ], "opsurgery": [ "$350 copay after deductible" ], "iphospitaladmission": [ "$125/ day copay x 5 days after deductible" ], "retailrx": [ "Preferred generic* - $5 copay", "Nonpreferred generic* - $15 copay", "Preferred brand - $25 copay after deductible", "Nonpreferred brand - $55 copay after deductible" ], "homedeliveryrx": [ "Preferred generic* - $13 copay", "Nonpreferred generic* - $38 copay", "Preferred brand - $63 copay after deductible", "Nonpreferred brand - $138 copay after deductible" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. ", "*Deductible waived for generic drugs", "Available only if you qualify for cost-share reductions on Pennie." ], "formulary": [ "Value" ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l97w/Qlc1uP04inQKcApmZOY8zkbd4InQWkglO91OWhpHSq4" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9QP/4jIuEs56CXqt.uHSoNT5riU7gZ1G2ncT7IpHUPWgIoo" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9Wr/rtil9rfRvhgUmtOigBnbrT9mckIY45rlY0EYcjOJ.9k" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=PPO&alphaPrefix=XXX&postalCode=" } ] } }, { "planName": "Silver PPO 1400/0/5 Rx 150 CSR87", "PlanDetails": { "metalLevel": "Silver", "plantype": "medical", "productType": "PPO", "dataCatProductType":"PPO", "deductible": [ "Medical -$1,400 Individual/$2,800 Family", "Prescription - $150 individual/$300 family" ], "OOPmax": [ "$3,050 individual", "$6,100 family" ], "Exchange": [ "On Pennie" ], "hsaeligible": "No", "county": "Available in all counties except Lancaster", "Coinsurance": [ "None" ], "PrimaryCare": [ "$5 copay" ], "specialist": [ "$10 copay" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/58e247c4-1137-4b2c-a09c-b43bc1ae4089/images%252Fsilver-plan.jpg?MOD=AJPERES", "emergencyroom": "$75 copay after deductible", "urgentcare": "$35 copay", "virtualcare": [ "$0 copay" ], "diagnosticlab": [ "$15 copay(deductible waived) at independent labs", "$40 copay after deductible at hospital owned labs" ], "opdiagnostictest": [ "Paid in full after deductible" ], "ophightechimaging": [ "$200 copay after deductible" ], "opsurgery": [ "$250 copay after deductible" ], "iphospitaladmission": [ "$100/ day copay x 5 days after deductible" ], "retailrx": [ "Preferred generic* - $3 copay", "Nonpreferred generic* - $10 copay", "Preferred brand - $15 copay after deductible", "Nonpreferred brand - $40 copay after deductible" ], "homedeliveryrx": [ "Preferred generic* - $8 copay", "Nonpreferred generic* - $25 copay", "Preferred brand - $38 copay after deductible", "Nonpreferred brand - $100 copay after deductible" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. ", "*Deductible waived for generic drugs", "Available only if you qualify for cost-share reductions on Pennie." ], "formulary": [ "Value" ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l981/uIJBLx2pjGNc3PC.fe_uWbJ5jWpr2myxrNoNPk76FoA" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9QU/JYHC3XtUnqv7g60XHdtiUK5G8kTYNlTvw94_jtwegQo" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9Wr/rtil9rfRvhgUmtOigBnbrT9mckIY45rlY0EYcjOJ.9k" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=PPO&alphaPrefix=XXX&postalCode=" } ] } }, { "planName": "Silver PPO 450/0/3 Rx 100 CSR94", "PlanDetails": { "metalLevel": "Silver", "plantype": "medical", "productType": "PPO", "dataCatProductType":"PPO", "deductible": [ "Medical -$450 Individual/$900 Family", "Prescription - $100 individual/$200 family" ], "OOPmax": [ "$1,000 individual", "$2,000 family" ], "Exchange": [ "On Pennie" ], "hsaeligible": "No", "county": "Available in all counties except Lancaster", "Coinsurance": [ "None" ], "PrimaryCare": [ "$3 copay" ], "specialist": [ "$5 copay" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/58e247c4-1137-4b2c-a09c-b43bc1ae4089/images%252Fsilver-plan.jpg?MOD=AJPERES", "emergencyroom": "$50 copay after deductible", "urgentcare": "$20 copay", "virtualcare": [ "$0 copay" ], "diagnosticlab": [ "$10 copay(deductible waived) at independent labs", "$20 copay after deductible at hospital owned labs" ], "opdiagnostictest": [ "Paid in full after deductible" ], "ophightechimaging": [ "$150 copay after deductible" ], "opsurgery": [ "$150 copay after deductible" ], "iphospitaladmission": [ "$75/ day copay x 5 days after deductible" ], "retailrx": [ "Preferred generic* - $2 copay", "Nonpreferred generic* - $5 copay", "Preferred brand - $10 copay after deductible", "Nonpreferred brand - $25 copay after deductible" ], "homedeliveryrx": [ "Preferred generic* - $5 copay", "Nonpreferred generic* - $13 copay", "Preferred brand - $25 copay after deductible", "Nonpreferred brand - $63 copay after deductible" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. ", "*Deductible waived for generic drugs", "Available only if you qualify for cost-share reductions on Pennie." ], "formulary": [ "Value" ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l986/wPRxFk6MEeEIGksnLVxhYP5oxypfEqqVqBZKSdyV52E" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9QZ/frtFFB02Csm3U58y5KyburnDVmr4FBUyF0QeBrVAA_M" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9Ww/7FLw3xXUZBE4n2KB2O65ynwYeWFHD_GuIoQgaNtqFmI" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=PPO&alphaPrefix=XXX&postalCode=" } ] } }, { "planName": "Silver QHDHP PPO Choice 3000/10/35", "PlanDetails": { "metalLevel": "Silver", "plantype": "medical", "productType": "PPO Choice", "deductible": [ "Choice 1 - $3,000/$6,000", "Choice 2 - $6,000/$12,000", "Non-embedded" ], "OOPmax": [ "$7,450 individual", "$14,900 family" ], "Exchange": [ "Off Pennie" ], "hsaeligible": "Yes- HSA account set up included with purchase of plan", "county": "Available in Lancaster county", "Coinsurance": [ "Choice 1 - 10%", "Choice 2 - 30%" ], "PrimaryCare": [ "Choice 1 - $35 copay after deductible", "Choice 2 - $60 copay after deductible" ], "specialist": [ "Choice 1 - $65 copay after deductible", "Choice 2 - $85 copay after deductible" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/58e247c4-1137-4b2c-a09c-b43bc1ae4089/images%252Fsilver-plan.jpg?MOD=AJPERES", "emergencyroom": "$400 copay after Choice 1 deductible", "urgentcare": "$100 copay after Choice 1 deductible", "virtualcare": [ "Paid in full after Choice 1 deductible" ], "diagnosticlab": [ "Choice 1 - 10% after deductible", "Choice 2 - 30% after deductible" ], "opdiagnostictest": [ "Choice 1 - 10% after deductible", "Choice 2 - 30% after deductible" ], "ophightechimaging": [ "Choice 1 - 10% after deductible", "Choice 2 - 30% after deductible" ], "opsurgery": [ "Choice 1 - 10% after deductible", "Choice 2 - 30% after deductible" ], "iphospitaladmission": [ "Choice 1 - 10% after deductible", "Choice 2 - 30% after deductible" ], "retailrx": [ "Preferred generic - $10 copay after deductible", "Nonpreferred generic - 25% ($250 max) after deductible", "Preferred brand - $50 copay after deductible", "Nonpreferred brand - $100 copay after deductible" ], "homedeliveryrx": [ "Preferred generic - $25 copay after deductible", "Nonpreferred generic - 25% ($500 max) after deductible", "Preferred brand - $125 copay after deductible", "Nonpreferred brand - $250 copay after deductible" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. " ], "formulary": [ "Value" ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l98p/wTwKVtUkv48IG.KJ5YcuUlBZRuGvZ9MDkds23kt5esY" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9RD/8nqcG68RQA7m8FpZmH7BsIA4vmAXN6HgG3MegrVaQGg" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9Yi/qbtYiYhEGzIwq6uU4D81eXakhVS17Wl0yPpUjL7Oaa8" }, { "docName": "HSA Information", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/3j00000096GO/nvegywFZNATkf_LlrypT4Rp20a_oLQzAx3adfhKTz_g" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=ICOM&alphaPrefix=XXX&postalCode=" } ] } }, { "planName": "Silver PPO Choice 4450/20/35", "PlanDetails": { "metalLevel": "Silver", "productType": "PPO Choice", "deductible": [ "Choice 1 - $4,450/$8,900", "Choice 2 - $8,550/$17,100" ], "OOPmax": [ "$8,550 individual", "$17,100 family" ], "Exchange": [ "Off Pennie" ], "hsaeligible": "No", "county": "Available in Lancaster county", "Coinsurance": [ "Choice 1 - 20%", "Choice 2 - None" ], "PrimaryCare": [ "Choice 1 - $35 copay", "Choice 2 - $60 copay" ], "specialist": [ "Choice 1 - $65 copay", "Choice 2 - $85 copay" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/58e247c4-1137-4b2c-a09c-b43bc1ae4089/images%252Fsilver-plan.jpg?MOD=AJPERES", "virtualcare": [ "$0 copay" ], "emergencyroom": "$400 copay after Choice 1 deductible", "urgentcare": "$100 copay", "diagnosticlab": [ "Choice 1 - 20% after deductible", "Choice 2 - Paid in full after deductible" ], "opdiagnostictest": [ "Choice 1 - 20% after deductible", "Choice 2 - Paid in full after deductible" ], "ophightechimaging": [ "Choice 1 - 20% after deductible", "Choice 2 - Paid in full after deductible" ], "opsurgery": [ "Choice 1 - 20% after deductible", "Choice 2 - Paid in full after deductible" ], "iphospitaladmission": [ "Choice 1 - 20% after deductible", "Choice 2 - Paid in full after deductible" ], "retailrx": [ "Preferred generic* - $10", "Nonpreferred generic* - 25% ($250 max)", "Preferred brand - $50 copay after deductible", "Nonpreferred brand - $100 copay after deductible" ], "homedeliveryrx": [ "Preferred generic* - $25", "Nonpreferred generic* - 25% ($500 max)", "Preferred brand - $125 copay after deductible", "Nonpreferred brand - $250 copay after deductible" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. ", "*Deductible waived for generic drugs" ], "formulary": [ "Value" ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l98u/o0fyHmETB8Sn1ClVQLP6h64slm.aYh4UJsQi2c.1tRc" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9RI/zTw2Ku6d1u6vEfftX.Kb6iY.XGAipGaduqio_U4ob8Y" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9Ys/41hgV0A4qTMumQTUM2mPFbIppA.Y9_Jz_IRpMmRSiBw" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=ICOM&alphaPrefix=XXX&postalCode=" } ] } }, { "planName": "Silver PPO Choice 4500/20/35", "PlanDetails": { "metalLevel": "Silver", "plantype": "medical", "productType": "PPO Choice", "deductible": [ "Choice 1 - $4,500/$9,000", "Choice 2 - $8,550/$17,100" ], "OOPmax": [ "$8,550 individual", "$17,100 family" ], "Exchange": [ "On Pennie", "Off Pennie" ], "hsaeligible": "No", "county": "Available in Lancaster county", "Coinsurance": [ "Choice 1 - 20%", "Choice 2 - None" ], "PrimaryCare": [ "Choice 1 - $35 copay", "Choice 2 - $60 copay" ], "specialist": [ "Choice 1 - $65 copay", "Choice 2 - $85 copay" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/58e247c4-1137-4b2c-a09c-b43bc1ae4089/images%252Fsilver-plan.jpg?MOD=AJPERES", "virtualcare": [ "$0 copay" ], "emergencyroom": "$400 copay after Choice 1 deductible", "urgentcare": "$100 copay", "diagnosticlab": [ "Choice 1 - 20% after deductible", "Choice 2 - Paid in full after deductible" ], "opdiagnostictest": [ "Choice 1 - 20% after deductible", "Choice 2 - Paid in full after deductible" ], "ophightechimaging": [ "Choice 1 - 20% after deductible", "Choice 2 - Paid in full after deductible" ], "opsurgery": [ "Choice 1 - 20% after deductible", "Choice 2 - Paid in full after deductible" ], "iphospitaladmission": [ "Choice 1 - 20% after deductible", "Choice 2 - Paid in full after deductible" ], "retailrx": [ "Preferred generic* - $10", "Nonpreferred generic* - 25% ($250 max)", "Preferred brand - $50 copay after deductible", "Nonpreferred brand - $100 copay after deductible" ], "homedeliveryrx": [ "Preferred generic* - $25", "Nonpreferred generic* - 25% ($500 max)", "Preferred brand - $125 copay after deductible", "Nonpreferred brand - $250 copay after deductible" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. 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", "*Deductible waived for generic drugs" ], "formulary": [ "Value" ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9BZ/x7FaAbjeukAdgy6JRNmOoKp8zTg1Bh3Sjo04xGKuLbc" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9T9/1pItfVfPOBSTzb4Siz0PjVkB3BQm9dDO3USbW2SZTaY" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9aF/X2bc15b7yl_FMC3TM61kgJjtQ3T2ojFYavblvfeMCeM" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=ICOM&alphaPrefix=XXX&postalCode=" } ] } }, {"planName": "Silver PPO Choice Select 4000/15/25 CSR73", "PlanDetails": { "metalLevel": "Silver", "plantype": "medical", "productType": "PPO Choice Select", "dataCatProductType":"Select", "deductible": [ "Choice 1 - $4,000/$8,000", "Choice 2 - $7,350/$14,700" ], "OOPmax": [ "$7,350 individual", "$14,700 family" ], "Exchange": [ "On Pennie" ], "hsaeligible": "No", "county": "Available in Cumberland, Dauphin and Perry Counties", "Coinsurance": [ "Choice 1 - 15%", "Choice 2 - None" ], "PrimaryCare": [ "Choice 1 - $25 copay", "Choice 2 - $50 copay" ], "specialist": [ "Choice 1 - $55 copay", "Choice 2 - $75 copay" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/58e247c4-1137-4b2c-a09c-b43bc1ae4089/images%252Fsilver-plan.jpg?MOD=AJPERES", "virtualcare": [ "$0 copay" ], "emergencyroom": "$200 copay after Choice 1 deductible", "urgentcare": "$45 copay", "diagnosticlab": [ "Choice 1 - 15% after deductible", "Choice 2 - Paid in full after deductible" ], "opdiagnostictest": [ "Choice 1 - 15% after deductible", "Choice 2 - Paid in full after deductible" ], "ophightechimaging": [ "Choice 1 - 15% after deductible", "Choice 2 - Paid in full after deductible" ], "opsurgery": [ "Choice 1 - 15% after deductible", "Choice 2 - Paid in full after deductible" ], "iphospitaladmission": [ "Choice 1 - 15% after deductible", "Choice 2 - Paid in full after deductible" ], "retailrx": [ "Preferred generic* - $5 copay", "Nonpreferred generic* - 18% ($200 max)", "Preferred brand - $25 copay after deductible", "Nonpreferred brand - $55 copay after deductible" ], "homedeliveryrx": [ "Preferred generic* - $13", "Nonpreferred generic* - 18% ($400 max)", "Preferred brand - $63 copay after deductible", "Nonpreferred brand - $138 copay after deductible" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. 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", "*Deductible waived for generic drugs", "Available only if you qualify for cost-share reductions on Pennie." ], "formulary": [ "Value" ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9Cc/dRu18f2mv6tqD_s2kaPb3oGIkVhZ701r4cgneNbzWPk" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9UC/oZqx9VWitqV_dhLVIzyr.N4MM44EE4nzuEqwF0Qg41c" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9cQ/G0oMfSImF.YdEvfUBnHEkdpHCVDs4mG.FlOlRCphudY" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=ICOM&alphaPrefix=XXX&postalCode=" } ] } }, { "planName": "Silver Performance PPO 1200/0/15 CSR87", "PlanDetails": { "metalLevel": "Silver", "plantype": "medical", "productType": "Performance PPO", "dataCatProductType":"Performance", "deductible": [ "Performance Plus - $1,200/$2,400", "Performance Select - $3,050/$6,100" ], "OOPmax": [ "$3,050 individual", "$6,100 family" ], "Exchange": [ "On Pennie" ], "hsaeligible": "No", "county": "Available in Adams, Franklin, Lebanon, Lehigh, Northampton, and York Counties", "Coinsurance": [ "Performance Plus - None", "Performance Select - None" ], "PrimaryCare": [ "Performance Plus - $15 copay", "Performance Select - $30 copay" ], "specialist": [ "Performance Plus - $30 copay", "Performance Select - $60 copay" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/58e247c4-1137-4b2c-a09c-b43bc1ae4089/images%252Fsilver-plan.jpg?MOD=AJPERES", "virtualcare": [ "$0 copay" ], "emergencyroom": "$75 copay after Performance Plus deductible", "urgentcare": "$35 copay", "diagnosticlab": [ "Performance Plus - Paid in full after deductible", "Performance Select - Paid in full after deductible" ], "opdiagnostictest": [ "Performance Plus - Paid in full after deductible", "Performance Select - Paid in full after deductible" ], "ophightechimaging": [ "Performance Plus - Paid in full after deductible", "Performance Select - Paid in full after deductible" ], "opsurgery": [ "Performance Plus - Paid in full after deductible", "Performance Select - Paid in full after deductible" ], "iphospitaladmission": [ "Performance Plus - Paid in full after deductible", "Performance Select - Paid in full after deductible" ], "retailrx": [ "Preferred generic* - $3 copay", "Nonpreferred generic* - 15% ($150 max)", "Preferred brand - $15 copay after deductible", "Nonpreferred brand - $40 copay after deductible" ], "homedeliveryrx": [ "Preferred generic* - $8 copay", "Nonpreferred generic* - 15% ($300 max)", "Preferred brand - $38 copay after deductible", "Nonpreferred brand - $100 copay after deductible" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. ", "*Deductible waived for generic drugs", "Available only if you qualify for cost-share reductions on Pennie." ], "formulary": [ "Value" ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9Ch/RXF1MPZzChbrVeqnK9Yy9nmAhojupyvqaYckRwVP9GY" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9UH/2TvweOJvO5y95CP8jWN15lDAuXwAbY9mYKAHUaFBd0w" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9cV/Xp_QOJNqIHZMpVsgvdciH6CElBtNUggjZEChIr4StJ0" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=ICOM&alphaPrefix=XXX&postalCode=" } ] } }, { "planName": "Silver Performance PPO 475/0/5 CSR94", "PlanDetails": { "metalLevel": "Silver", "plantype": "medical", "productType": "Performance PPO", "deductible": [ "Performance Plus - $475/$950", "Performance Select - $1,000/$2,000" ], "OOPmax": [ "$1,000 individual", "$2,000 family" ], "Exchange": [ "On Pennie" ], "hsaeligible": "No", "county": "Available in Adams, Franklin, Lebanon, Lehigh, Northampton, and York Counties", "Coinsurance": [ "Performance Plus - None", "Performance Select - None" ], "PrimaryCare": [ "Performance Plus - $5 copay", "Performance Select - $20 copay" ], "specialist": [ "Performance Plus - $10 copay", "Performance Select - $30 copay" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/58e247c4-1137-4b2c-a09c-b43bc1ae4089/images%252Fsilver-plan.jpg?MOD=AJPERES", "virtualcare": [ "$0 copay" ], "emergencyroom": "$50 copay after Performance Plus deductible", "urgentcare": "$20 copay", "diagnosticlab": [ "Performance Plus - Paid in full after deductible", "Choice 2 - Paid in full after deductible" ], "opdiagnostictest": [ "Performance Plus - Paid in full after deductible", "Performance Select - Paid in full after deductible" ], "ophightechimaging": [ "Performance Plus - Paid in full after deductible", "Performance Select - Paid in full after deductible" ], "opsurgery": [ "Performance Plus - Paid in full after deductible", "Performance Select - Paid in full after deductible" ], "iphospitaladmission": [ "Performance Plus - Paid in full after deductible", "Performance Select - Paid in full after deductible" ], "retailrx": [ "Preferred generic* - $2 copay", "Nonpreferred generic* - 10% ($100 max)", "Preferred brand - $10 copay after deductible", "Nonpreferred brand - $25 copay after deductible" ], "homedeliveryrx": [ "Preferred generic* - $5 copay", "Nonpreferred generic* - 10% ($200 max)", "Preferred brand - $25 copay after deductible", "Nonpreferred brand - $63 copay after deductible" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. 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", "*Deductible waived for generic drugs" ], "formulary": [ "Value" ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l98L/SE31MgoH4CvYHRqUsSJ1rZN.GaoKehhGDNqh6cuo20I" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9Qj/cOXAM_oj35fRlZQdXQGJGpElST6RcBJ_M0DZCk5bWgg" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9XB/RyqNeESuvQ3wLII0e.HRnD833EeOpvczN1iJ19_YCec" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=PPO&alphaPrefix=XXX&postalCode=" } ] } }, { "planName": "Bronze QHDHP PPO Choice 6400/0/50", "PlanDetails": { "metalLevel": "Bronze", "plantype": "medical", "productType": "PPO Choice", "deductible": [ "Choice 1 - $6,400/$12,800", "Choice 2 - $7,450/$14,900", "Non-embedded" ], "OOPmax": [ "$7,450 individual", "$14,900 family" ], "Exchange": [ "On Pennie", "Off Pennie" ], "hsaeligible": "Yes- HSA account set up included with purchase of plan", "county": "Available in Lancaster", "Coinsurance": [ "Choice 1- None", "Choice 2- None" ], "PrimaryCare": [ "Choice 1 - $50 copay after deductible", "Choice 2 - Paid in full after deductible" ], "specialist": [ "Choice 1 - $85 copay after deductible", "Choice 2 - Paid in full after deductible" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/b2d110c7-15e4-411d-bfe2-109c70083ea0/images%252Fbronze-plan.jpg?MOD=AJPERES", "emergencyroom": "$400 copay after Choice 1 deductible", "urgentcare": "$100 copay after Choice 1 deductible", "virtualcare": [ "Paid in full after Choice 1 deductible" ], "diagnosticlab": [ " Paid in full after deductible" ], "opdiagnostictest": [ "Paid in full after deductible " ], "ophightechimaging": [ "Paid in full after deductible" ], "opsurgery": [ "Paid in full after deductible" ], "iphospitaladmission": [ "Paid in full after deductible" ], "retailrx": [ "Paid in full after deductible" ], "homedeliveryrx": [ "Paid in full after deductible" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. " ], "formulary": [ "Value" ], "PlanDocuments": [ { "docName": "Highlight sheet", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l99Y/bW3WyfbViJsK0iIRVfJIrepHBWgwNcwLzMCBVSIwtpM" }, { "docName": "Summary of benefits and coverage", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9Sa/XrvoFyTzCcjjnqxoCYe.NXbzCUwPQdgJNrJjFEpDwPA" }, { "docName": "Benefit contract", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/8Z000000l9ZM/B.k6QIhOQC647_vSYxTetnGgadpRH_blulh6fkoupFI" }, { "docName": "HSA Information", "docurl": "https://capbluecross1.my.salesforce.com/sfc/p/#3j000000hUJ1/a/3j00000096GO/nvegywFZNATkf_LlrypT4Rp20a_oLQzAx3adfhKTz_g" }, { "docName": "MyCare Finder", "docurl": "https://capitalbluecross.healthsparq.com/healthsparq/public/#/one/insurerCode=CAPBC_I&brandCode=CAPBC&productCode=ICOM&alphaPrefix=XXX&postalCode=" } ] } }, { "planName": "Bronze PPO Choice 7100/0/50", "PlanDetails": { "metalLevel": "Bronze", "productType": "PPO Choice", "deductible": [ "Choice 1 - $7,100/$14,200", "Choice 2 - $9,100/$18,200" ], "OOPmax": [ "$9,100 individual", "$18,200 family" ], "Exchange": [ "On Pennie", "Off Pennie" ], "hsaeligible": "No", "county": "Available in Lancaster county", "Coinsurance": [ "Choice 1-None", "Choice 2 -None" ], "PrimaryCare": [ "Choice 1 - $50 copay", "Choice 2 - Paid in full after deductible" ], "specialist": [ "Choice 1 - $85 copay", "Choice 2 - Paid in full after deductible" ], "planimgurl": "/wps/wcm/connect/prod_nws.capblue.com29556/b2d110c7-15e4-411d-bfe2-109c70083ea0/images%252Fbronze-plan.jpg?MOD=AJPERES", "emergencyroom": "$400 copay after Choice 1 deductible", "urgentcare": "$100 copay", "virtualcare": [ "$0 copay" ], "diagnosticlab": [ " Paid in full after deductible" ], "opdiagnostictest": [ "Paid in full after deductible " ], "ophightechimaging": [ "Paid in full after deductible" ], "opsurgery": [ "Paid in full after deductible" ], "iphospitaladmission": [ "Paid in full after deductible" ], "retailrx": [ "Preferred generic* - $10 copay", "Nonpreferred generic* - $30 copay", "Preferred brand - Paid in full after deductible", "Nonpreferred brand -Paid in full after deductible" ], "homedeliveryrx": [ "Preferred generic* - $25 copay", "Nonpreferred generic* - $75 copay", "Preferred brand - Paid in full after deductible", "Nonpreferred brand -Paid in full after deductible" ], "prescdisclaimer": [ "Cost Share amounts listed in the chart are for service performed at in-network providers. 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