Product Portfolio

Washington Small Group Plans

Small 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 10/20/1200
Personal Option w/ Deductible	$250	PE 10/10/1700 + 250D
	$250	PE 10/20/1700 + 250D
	$250	PE 15/20/2000 + 250D
	$250	PE 25/20/3000 + 250D
	$500	PE 15/20/2000 + 500D
	$500	PE 20/20/2000 + 500D
	$500	PE 25/20/3000 + 500D
	$750	PE 20/20/2500 + 750D
	$1500	PE 15/30/2500 + 1500D
	$1500	PE 25/30/2500 + 1500D
	$2000	PE 15/30/3000 + 2000D
	$2000	PE 25/30/3000 + 2000D
	$3000	PE 25/20/3000 + 3000D
	$5000	PE 20/20/4000 + 5000D
Providence Open Option
Open Option w/ Common Deductible	$250	OP 10/10/20/1700 + 250CD
	$250	OP 10/20/30/1200 + 250CD
	$500	OP 15/20/40/2000 + 500CD
	$500	OP 25/20/40/3000 + 500CD
	$750	OP 20/20/40/2500 + 750CD
	$1000	OP 15/30/50/2500 + 1000CD
	$1500	OP 15/30/50/2500 + 1500CD
	$1500	OP 25/20/30/2500 + 1500CD
	$2000	OP 20/20/30/3000 + 2000CD
	$3000	OP 25/20/40/3000 + 3000CD
	$5000	OP 20/20/40/4000 + 5000CD
Value Based Open Option w/ Common Deductible	$250	VBOP 10/20/30/40/3000 + 250CD
	$500	VBOP 10/20/30/40/3000 + 500CD
	$750	VBOP 10/20/30/40/3000 + 750CD
	$1000	VBOP 10/20/30/40/3000 + 1000CD
	$2000	VBOP 10/20/30/40/3000 + 2000CD
HSA Qualified	$1500	HSA OP 20/20/40/3000 + 1500CD
	$2000	HSA OP 20/20/40/4000 + 2000CD
	$2600	HSA OP 20/20/40/5000 + 2600CD

Small Group Riders
Product Type	Benefit
Vision	Vision 200
Vision	Vision 300
Open Option and Personal Option Rx	Rx 10/20
	Rx 15/50
	Rx 10/50/1000
	Rx 15/30
	Rx 20/40
	Rx 15/45
	Rx 5/10/30/50/2000
	Rx 5/10/50/50/2000
	Rx 5/15/30/50/2000
	Rx 5/15/40/50/2000
RXtra plans (2-copay per 90 day mail order)	RXtra 15/30
RXtra plans (2-copay per 90 day mail order)	RXtra 15/45
Domestic Partner	DOMPAR

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