2014 Small Group Health Options Program (SHOP)
The Small Group Health Option Program (SHOP) plans are part of our 2014 Exchange portfolio for small businesses with 2 to 50 employees, designed to deliver clear and simple healthcare coverage options.
SHOP Plan Categories:
Platinum plans
| Benefits |
Ultimate Exclusive HMO for SHOP |
Ultimate Full HMO for SHOP |
|---|---|---|
| Calendar year medical deductible | None | None |
| Calendar year out-of-pocket maximum |
$4,000 per individual/ $8,000 per family |
$4,000 per individual/ $8,000 per family |
|
Office visit - primary care doctor (First 3 visits per calendar year are covered prior to meeting the calendar year medical deductible combined with physician office visits, urgent care, outpatient mental health, outpatient substance abuse, and postnatal visits) |
$20 per visit | $20 per visit |
|
Urgent care visit (First 3 visits per calendar year are covered prior to meeting the calendar year medical deductible combined with physician office visits, urgent care, outpatient mental health, outpatient substance abuse, and postnatal visits) |
$40 per visit | $40 per visit |
|
Calendar year brand drug deductible (Brand drugs are subject to the calendar year medical deductible) |
None | None |
| Generic drugs1 | $5 per prescription | $5 per prescription |
| Preferred brand drugs1 | $15 per prescription | $15 per prescription |
| Non-preferred brand drugs1 | $25 per prescription | $25 per prescription |
Gold plans
| Benefits |
Ultimate Exclusive HMO for SHOP |
Ultimate Full HMO for SHOP |
|---|---|---|
| Calendar year medical deductible | None | None |
| Calendar year out-of-pocket maximum |
$6,350 per individual/ $12,700 per family |
$6,350 per individual/ $12,700 per family |
|
Office visit - primary care doctor (First 3 visits per calendar year are covered prior to meeting the calendar year medical deductible combined with physician office visits, urgent care, outpatient mental health, outpatient substance abuse, and postnatal visits) |
$30 per visit | $30 per visit |
|
Urgent care visit (First 3 visits per calendar year are covered prior to meeting the calendar year medical deductible combined with physician office visits, urgent care, outpatient mental health, outpatient substance abuse, and postnatal visits) |
$60 per visit | $60 per visit |
|
Calendar year brand drug deductible (Brand drugs are subject to the calendar year medical deductible) |
None | None |
| Generic drugs1 | $20 per prescription | $20 per prescription |
| Preferred brand drugs1 | $50 per prescription | $50 per prescription |
| Non-preferred brand drugs1 | $70 per prescription | $70 per prescription |
Silver plans
| Benefits |
Ultimate Exclusive HMO for SHOP |
Ultimate Full HMO for SHOP |
|---|---|---|
| Calendar year medical deductible | $1,500 | $1,500 |
| Calendar year out-of-pocket maximum |
$6,350 per individual/ $12,700 per family |
$6,350 per individual/ $12,700 per family |
|
Office visit - primary care doctor (First 3 visits per calendar year are covered prior to meeting the calendar year medical deductible combined with physician office visits, urgent care, outpatient mental health, outpatient substance abuse, and postnatal visits) |
$452 per visit | $452 per visit |
|
Urgent care visit (First 3 visits per calendar year are covered prior to meeting the calendar year medical deductible combined with physician office visits, urgent care, outpatient mental health, outpatient substance abuse, and postnatal visits) |
$902 per visit | $902 per visit |
|
Calendar year brand drug deductible (Brand drugs are subject to the calendar year medical deductible) |
$500 | $500 |
| Generic drugs1 | $20 per prescription2 | $20 per prescription2 |
| Preferred brand drugs1 | $50 per prescription | $50 per prescription |
| Non-preferred brand drugs1 | $70 per prescription | $70 per prescription |
Bronze plans
| Benefits |
Basic Exclusive PPO for SHOP |
|---|---|
| Calendar year medical deductible |
$5,000 per individual/ $10,000 per family |
| Calendar year out-of-pocket maximum |
$6,350 per individual/ $12,700 per family |
|
Office visit - primary care doctor (First 3 visits per calendar year are covered prior to meeting the calendar year medical deductible combined with physician office visits, urgent care, outpatient mental health, outpatient substance abuse, and postnatal visits) |
$60 per visit |
|
Urgent care visit (First 3 visits per calendar year are covered prior to meeting the calendar year medical deductible combined with physician office visits, urgent care, outpatient mental health, outpatient substance abuse, and postnatal visits) |
$120 per visit |
|
Calendar year brand drug deductible (Brand drugs are subject to the calendar year medical deductible) |
All drugs including specialty drugs are subject to the medical deductible. |
| Generic drugs1 | $25 per prescription |
| Preferred brand drugs1 | $50 per prescription |
| Non-preferred brand drugs1 | $75 per prescription |
1 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation.
2 Not subject to the calendar-year medical deductible.