Product Portfolio

Washington Large Group Plans

Large Group Plans
Product Type	Annual Deductible	Benefit (personal physician-provider copayment/other provider coinsurance/out-of-pocket maximum)
Providence Personal Option
Personal Option	NA	PE 10/10/1200
Personal Option w/ Deductible	$250	PE 10/10/1200 + 250D
	$250	PE 15/20/1700 + 250D
	$500	PE 15/20/2000 + 500D
	$500	PE 25/30/2000 + 500D
	$1000	PE 15/30/2000 + 1000D
	$1000	PE 25/30/2000 + 1000D
	$1500	PE 15/30/2000 + 1500D
	$1500	PE 25/30/2000 + 1500D
	$2000	PE 25/30/2000 + 2000D
Providence Open Option
Open Option	NA	OP 10/10/30/1200
Open Option w/ Out-of-Plan Deductible	$500	OP 10/10/30/1200 + 500D
Open Option w/ Out-of-Plan Deductible	$250	OP 15/20/40/2000 + 250D
Open Option w/ Common Deductible	$250	OP 10/10/20/1200 + 250CD
	$250	OP 15/20/40/1700 + 250CD
	$500	OP 15/20/40/2000 + 500CD
	$250	OP 20/30/40/2000 + 250CD
	$500	OP 25/20/30/2000 + 500CD
	$1000	OP 15/20/30/2000 + 1000CD
	$1000	OP 25/20/30/2000 + 1000CD
	$1000	OP 15/30/50/2000 + 1000CD
	$1500	OP 15/30/50/2000 + 1500CD
	$1500	OP 25/20/30/2000 + 1500CD
	$2000	OP 20/20/30/2000 + 2000CD
	$3000	OP 25/20/40/3000 + 3000CD
HSA Qualified	$1200	HSA OP 20/20/40/2000 + 1200CD
	$1500	HSA OP 20/20/40/3000 + 1500CD
	$2000	HSA OP 20/20/40/4000 + 2000CD
	$2600	HSA OP 20/20/40/5000 + 2600CD
Providence Traditional Option
Traditional Option	$200	TO 20/1000 + 200D
	$250	TO 20/1000 + 250D
	$250	TO 20/2500 + 250D
	$500	TO 20/5000 + 500D
Other
Out-of-Area	NA	Out-of-Area

Large Group Riders
Product Type	Benefit
Vision	Vision 200
Vision	Vision 300
RXtra plans (2-copay per 90 day mail order)	RXtra 10/20
	RXtra 10/30
	RXtra 10/40
	RXtra 15/30
	RXtra 15/45
	RXtra 15/50
	RXtra 10/50/1000
	RXtra 10/50/2000
Rx Plans	Rx 10/20
	RX 10/30
	Rx 10/40
	Rx 15/30
	Rx 15/45
	Rx 15/50
	Rx 10/50/1000
	Rx 10/50/2000

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