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Group Name:
Prepared By:
TRADITIONAL PLANS
Carrier
Plans
Tier(s)
Atlantis
HMO 25/40A (New)
HMO 20A
HMO 25/40 (New)
HMO 20
HMO 25/40 Plus (New)
HMO 20 Plus
POS 25/40 2000A (New)
POS 20/2000
POS 25/40 2000 (New)
POS 20/1000
POS 25/40 1000 Plus (New)
POS 20/500
GHI
CS EPO 40/2000 (New)
CS EPO 40/2000A (New)
CS EPO 30/2000A (New)
CS EPO 40/1000C (New)
CS EPO 30/1000A (New)
CS EPO 40/1000A (New)
CS EPO 30/2000 (New)
CS EPO 40/1000B (New)
CS EPO 30/1000B (New)
CS EPO 30/1000 (New)
CS EPO 40/1000 (New)
CS EPO 30/500A (New)
CS EPO 30/500 (New)
CS PPO 30/1000 (New)
CS PPO 30/1000A (New)
EPO 30/500 (New)
EPO 40/1000 (New)
PPO 25/3000 (New)
PPO 30/1000 (New)
PPO 25/1000
Renewals Only
EPO 30/2000 (For Renewals Only)
EPO 30/1000 (For Renewals Only)
EPO 30/1000A (For Renewals Only)
EPO 30/500 (For Renewals Only)
EPO 30/500A (For Renewals Only)
PPO 30/2000 (For Renewals Only)
EPO 30/1000B (For Renewals Only)
EPO 30/1000C (For Renewals Only)
EPO 30/750 (For Renewals Only)
EPO 30/750 Plus (For Renewals Only)
EPO 30A (For Renewals Only)
EPO 30 (For Renewals Only)
EPO 20 (For Renewals Only)
EPO 15 (For Renewals Only)
HIP
EPO Super Value
EPO 30/45 2000 Select (New)
EPO 20/1000 Select
PPO 15 IN 1000
PPO 30/45 3000 Select (New)
PPO 30/1000 Select (New)
HMO Super Value
HMO 25/40A
HMO 25/40
HMO Value
HMO 20
HMO 5
HMO 15
HMO 10
POS 20
POS 15
POS 10
HIP
with Vytra Premium
EPO Smart Start
EPO 30/45 2000 Select (New)
PPO 30/45 3000 Select (New)
PPO 30/1000 Select (New)
PPO 20/IN 1000
PPO 20/IN 500
HMO Super Value
Direct Access HMO 20
Direct Access HMO 15
Direct Access HMO 10
POS 20/1000
POS 15/500
POS 10/250
MDNY
HMO 20A
HMO 20B
HMO 20
HMO 25/40A
HMO 25/40
HMO 15
HMO 10
POS 20
POS 10
CONSUMER DRIVEN PLANS
Atlantis
POS 20/2000 HRA Option #1
POS 20/2000 HRA Option #2
POS 20/2000 HRA Option #3
POS 20/2000 HRA Option #4
GHI
HSA High Deductible EPO Option #1
HSA High Deductible EPO Option #2
HSA High Deductible EPO Option #3
HSA High Deductible EPO Option #4
HSA High Deductible PPO Option #1
HSA High Deductible PPO Option #2
HSA High Deductible PPO Option #3
HSA High Deductible PPO Option #4
Perfect Health
PPO HSA PLAN 27
PPO HSA PLAN 28
PPO HSA PLAN 29
PPO HSA PLAN 30
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# Employees
Monthly Employer Contribution
EE Only:
EE + Spouse /EE + One:
EE + Child(ren):
Family:
 
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Proposal
Rate Sheet
Proposal & Rate Sheet
Show Money Funded into HSA: yes    no

 
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