Plans

Community Health Options

2022 Individual/Family
Healthcare Plans

Community Health Options offers a variety of affordable health insurance options, so you can choose the benefit plan that is the right fit for you or your family.

For more information about each metal level, check out our blog.

Community Health Options
Showing plans for
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  • Vision
  • Pediatric Vision
  • Pediatric Dental
  • Chiropractic/Osteopathic Care
  • CISP
  • Acupuncture
  • Wellness Benefits
  • Health Coaching
  • Reduced Copays
  • Amwell® Telehealth
  • Preferred Providers and Services
  • National Coverage
  • Out-of-Country

Catastrophic Level

Catastrophic plans are for people under 30 or others with certain exemptions.

These plans have the lowest monthly premiums and highest deductibles. This level is an affordable way to protect from worst-case scenarios. Eligibility for catastrophic plans is limited to individuals under 30 or those with a hardship exemption from the Marketplace. These plans do not qualify for Advance Premium Tax Credits.

Health Options Clear Choice Catastrophic HMO NE
$8,700 $17,400
Deductible
$8,700 $17,400
Out-of-pocket Maximum
0% 0%
Coinsurance
  • No out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(3) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then visit 2-3 $50 co-pay, no deductible required; then, 0% co-insurance after deductible
Specialty Care Office Visit
0% co-insurance after deductible
Urgent Care Center
0% co-insurance after deductible
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 cost first 3 visits, then 0% co-insurance after deductible
Emergency Room Visit
0% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
0% co-insurance after deductible
Tier 2 – Generics
0% co-insurance after deductible
Tier 3 – Preferred Brands
0% co-insurance after deductible
Tier 4 – Non-Preferred Brands
0% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
0% co-insurance after deductible

Bronze Level

In Bronze plans, the insurance company pays about 60%, and the Member pays 40% of the cost for health services.

Bronze plans have low premiums but require Members to pay more for services used. These plans keep monthly costs low, while providing the same quality coverage when you receive care.

Health Options Clear Choice Bronze $8700 HMO NE
$8,700 $17,400
Deductible
$8,700 $17,400
Out-of-pocket Maximum
0% 0%
Coinsurance
  • No out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(4) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • CISP The Chronic Illness Support Program makes it easier for Members to manage and pay for the treatment of select chronic conditions including asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes and hypertension.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $50 co-pay; no deductible required
Specialty Care Office Visit
$100 co-pay; no deductible required
Urgent Care Center
0% co-insurance after deductible
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $50 co-pay; no deductible required
Emergency Room Visit
0% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$25 co-pay; no deductible required
Tier 3 – Preferred Brands
0% co-insurance after deductible
Tier 4 – Non-Preferred Brands
0% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
0% co-insurance after deductible

Health Options Clear Choice Bronze $8700 PPO NE
$8,700 $17,400
Deductible
$8,700 $17,400
Out-of-pocket Maximum
0% 0%
Coinsurance
  • Includes out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(4) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • CISP The Chronic Illness Support Program makes it easier for Members to manage and pay for the treatment of select chronic conditions including asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes and hypertension.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $50 co-pay; no deductible required
Specialty Care Office Visit
$100 co-pay; no deductible required
Urgent Care Center
0% co-insurance after deductible
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $50 co-pay; no deductible required
Emergency Room Visit
0% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$25 co-pay; no deductible required
Tier 3 – Preferred Brands
$0 co-insurance after deductible
Tier 4 – Non-Preferred Brands
0% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
0% co-insurance after deductible

Health Options Clear Choice Bronze $7500 HMO Tiered NE
$7,500 $15,000
Deductible
$8,700 $17,400
Out-of-pocket Maximum
50% 50%
Coinsurance
  • No out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(4) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” [3]=> string(9) “preferred” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
  • Preferred Providers and Services Preferred providers and services are designated by a in the provider directory. Provider types include primary care, pediatrics, ob-gyn, specialties, P/T, O/T, S/T, urgent care facilities, imaging centers, labs, and out-patient hospital services. Preferred providers offer lower cost-sharing.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $40 co-pay Preferred/$70 co-pay Standard; no deductible required
Specialty Care Office Visit
50% co-insurance after deductible
Urgent Care Center
$60 co-pay Preferred/$90 co-pay Standard; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $40 co-pay Preferred/$70 co-pay Standard; no deductible required
Emergency Room Visit
50% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$25 co-pay; no deductible required
Tier 3 – Preferred Brands
$50 co-pay after deductible
Tier 4 – Non-Preferred Brands
$100 co-pay after deductible
Tier 5 – Specialty (30 day supply only)
$250 co-pay after deductible

Health Options Clear Choice Bronze $7500 HMO NE
$7,500 $15,000
Deductible
$8,700 $17,400
Out-of-pocket Maximum
50% 50%
Coinsurance
  • No out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(3) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $40 co-pay; no deductible required
Specialty Care Office Visit
50% co-insurance after deductible
Urgent Care Center
$60 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $40 co-pay; no deductible required
Emergency Room Visit
50% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$25 co-pay; no deductible required
Tier 3 – Preferred Brands
$50 co-pay after deductible
Tier 4 – Non-Preferred Brands
$100 co-pay after deductible
Tier 5 – Specialty (30 day supply only)
$250 co-pay after deductible

Health Options Clear Choice Bronze $7500 PPO NE
$7,500 $15,000
Deductible
$8,700 $17,400
Out-of-pocket Maximum
50% 50%
Coinsurance
  • Includes out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(3) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $40 co-pay; no deductible required
Specialty Care Office Visit
50% co-insurance after deductible
Urgent Care Center
$60 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $40 co-pay; no deductible required
Emergency Room Visit
50% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$25 co-pay; no deductible required
Tier 3 – Preferred Brands
$50 co-pay after deductible
Tier 4 – Non-Preferred Brands
$100 co-pay after deductible
Tier 5 – Specialty (30 day supply only)
$250 co-pay after deductible

Health Options Clear Choice Bronze $7000 HSA PPO NE
$7,000 $14,000
Deductible
$7,000 $14,000
Out-of-pocket Maximum
0% 0%
Coinsurance
  • Includes out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(3) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
0% co-insurance after deductible
Specialty Care Office Visit
0% co-insurance after deductible
Urgent Care Center
0% co-insurance after deductible
Amwell® Urgent Telehealth
$0 co-pay after deductible
Mental Health/Substance Use Disorder (Outpatient)
0% co-insurance after deductible
Emergency Room Visit
0% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
0% co-insurance after deductible
Tier 2 – Generics
0% co-insurance after deductible
Tier 3 – Preferred Brands
0% co-insurance after deductible
Tier 4 – Non-Preferred Brands
0% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
0% co-insurance after deductible

Health Options Clear Choice Bronze $5900 HSA PPO NE
$5,900 $11,800
Deductible
$7,050 $14,100
Out-of-pocket Maximum
50% 50%
Coinsurance
  • Includes out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(3) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
50% co-insurance after deductible
Specialty Care Office Visit
50% co-insurance after deductible
Urgent Care Center
50% co-insurance after deductible
Amwell® Urgent Telehealth
$0 co-pay after deductible
Mental Health/Substance Use Disorder (Outpatient)
50% co-insurance after deductible
Emergency Room Visit
50% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
50% co-insurance after deductible
Tier 2 – Generics
50% co-insurance after deductible
Tier 3 – Preferred Brands
50% co-insurance after deductible
Tier 4 – Non-Preferred Brands
50% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
50% co-insurance after deductible

Health Options Evergreen Bronze HMO Tiered NE
$5,700 $11,400
Deductible
$8,700 $17,400
Out-of-pocket Maximum
35% 35%
Coinsurance
  • No out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(5) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” [4]=> string(9) “preferred” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • CISP The Chronic Illness Support Program makes it easier for Members to manage and pay for the treatment of select chronic conditions including asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes and hypertension.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
  • Preferred Providers and Services Preferred providers and services are designated by a in the provider directory. Provider types include primary care, pediatrics, ob-gyn, specialties, P/T, O/T, S/T, urgent care facilities, imaging centers, labs, and out-patient hospital services. Preferred providers offer lower cost-sharing.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
Preferred: $0 first visit, then 2-3 visit $50 co-pay (no deductible required), then 35% co-insurance after deductible; Standard: $0 first visit, then 2-3 visit $80 co-pay (no deductible required), then 55% co-insurance after deductible
Specialty Care Office Visit
35% coinsurance after deductible
Urgent Care Center
$95 co-pay Preferred/$125 co-pay Standard; no deductible required
Amwell® Urgent Telehealth
0% co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
Preferred: $0 cost first 3 visits, then 35% co-insurance after deductible/Standard: $0 cost first visit, then 55% co-insurance after deductible
Emergency Room Visit
35% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
35% co-insurance after deductible
Tier 2 – Generics
35% co-insurance after deductible
Tier 3 – Preferred Brands
35% co-insurance after deductible
Tier 4 – Non-Preferred Brands
35% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
35% co-insurance after deductible

Health Options Evergreen Bronze HMO NE
$5,700 $11,400
Deductible
$8,700 $17,400
Out-of-pocket Maximum
35% 35%
Coinsurance
  • No out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(4) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • CISP The Chronic Illness Support Program makes it easier for Members to manage and pay for the treatment of select chronic conditions including asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes and hypertension.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then visit 2-3 $50 co-pay, no deductible required; then, 35% co-insurance after deductible
Specialty Care Office Visit
35% co-insurance after deductible
Urgent Care Center
$95 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 cost first 3 visit, then 35% co-insurance after deductible
Emergency Room Visit
35% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
35% co-insurance after deductible
Tier 2 – Generics
35% co-insurance after deductible
Tier 3 – Preferred Brands
35% co-insurance after deductible
Tier 4 – Non-Preferred Brands
35% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
35% co-insurance after deductible

Health Options Evergreen Bronze PPO NE
$5,700 $11,400
Deductible
$8,700 $17,400
Out-of-pocket Maximum
35% 35%
Coinsurance
  • Includes out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(4) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • CISP The Chronic Illness Support Program makes it easier for Members to manage and pay for the treatment of select chronic conditions including asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes and hypertension.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then visit 2-3 $50 co-pay, no deductible required; then, 35% co-insurance after deductible
Specialty Care Office Visit
35% co-insurance after deductible
Urgent Care Center
$95 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 cost first 3 visit, then 35% co-insurance after deductible
Emergency Room Visit
35% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
35% co-insurance after deductible
Tier 2 – Generics
35% co-insurance after deductible
Tier 3 – Preferred Brands
35% co-insurance after deductible
Tier 4 – Non-Preferred Brands
35% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
35% co-insurance after deductible

Health Options Evergreen Bronze PPO NE Dental
$5,700 $11,400
Deductible
$8,700 $17,400
Out-of-pocket Maximum
35% 35%
Coinsurance
  • Includes out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(5) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” [4]=> string(4) “cisp” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Pediatric Dental Plan includes pediatric dental coverage through Northeast Delta Dental® with a separate, low deductible.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • CISP The Chronic Illness Support Program makes it easier for Members to manage and pay for the treatment of select chronic conditions including asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes and hypertension.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then visit 2-3 $50 co-pay, no deductible required; then, 35% co-insurance after deductible
Specialty Care Office Visit
35% co-insurance after deductible
Urgent Care Center
$95 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 cost first 3 visit, then 35% co-insurance after deductible
Emergency Room Visit
35% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
35% co-insurance after deductible
Tier 2 – Generics
35% co-insurance after deductible
Tier 3 – Preferred Brands
35% co-insurance after deductible
Tier 4 – Non-Preferred Brands
35% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
35% co-insurance after deductible

Silver Level

In Silver plans, the insurance company pays about 70%, and the Member pays 30% of the cost for health services.

Silver plans offer moderate monthly premiums and moderate costs when you need care. If your income qualifies you for cost-sharing reductions, you must choose a Silver level plan for the associated savings.

Health Options Clear Choice Silver $5500 Off Marketplace HMO Tiered NE Dental
$5,500 $11,000
Deductible
$7,500 $15,000
Out-of-pocket Maximum
30% 30%
Coinsurance
  • No out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Not available at CoverME.gov marketplace; purchase directly from Community Health Options
INCLUDES
array(5) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” [4]=> string(9) “preferred” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Pediatric Dental Plan includes pediatric dental coverage through Northeast Delta Dental® with a separate, low deductible.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
  • Preferred Providers and Services Preferred providers and services are designated by a in the provider directory. Provider types include primary care, pediatrics, ob-gyn, specialties, P/T, O/T, S/T, urgent care facilities, imaging centers, labs, and out-patient hospital services. Preferred providers offer lower cost-sharing.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $30 co-pay Preferred/$60 co-pay Standard; no deductible required
Specialty Care Office Visit
$60 co-pay; no deductible required
Urgent Care Center
$40 co-pay Preferred/$70 co-pay Standard; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $30 co-pay Preferred/$60 co-pay Standard; no deductible required
Emergency Room Visit
30% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$25 co-pay; no deductible required
Tier 3 – Preferred Brands
$50 co-pay; no deductible required
Tier 4 – Non-Preferred Brands
30% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
50% co-insurance after deductible

Health Options Clear Choice Silver $5500 Off Marketplace HMO NE Dental
$5,500 $11,000
Deductible
$7,500 $15,000
Out-of-pocket Maximum
30% 30%
Coinsurance
  • No out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Not available at CoverME.gov marketplace; purchase directly from Community Health Options
INCLUDES
array(4) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Pediatric Dental Plan includes pediatric dental coverage through Northeast Delta Dental® with a separate, low deductible.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $30 co-pay; no deductible required
Specialty Care Office Visit
$60 co-pay; no deductible required
Urgent Care Center
$40 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $30 co-pay; no deductible required
Emergency Room Visit
30% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$25 co-pay; no deductible required
Tier 3 – Preferred Brands
$50 co-pay; no deductible required
Tier 4 – Non-Preferred Brands
30% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
50% co-insurance after deductible

Health Options Clear Choice Silver $4500 HSA Off Marketplace HMO NE Dental
$4,500 $9,000
Deductible
$7,000 $14,000
Out-of-pocket Maximum
20% 20%
Coinsurance
  • No out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Not available at CoverME.gov marketplace; purchase directly from Community Health Options
INCLUDES
array(4) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Pediatric Dental Plan includes pediatric dental coverage through Northeast Delta Dental® with a separate, low deductible.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
20% co-insurance after deductible
Specialty Care Office Visit
20% co-insurance after deductible
Urgent Care Center
20% co-insurance after deductible
Amwell® Urgent Telehealth
$0 co-pay after deductible
Mental Health/Substance Use Disorder (Outpatient)
20% co-insurance after deductible
Emergency Room Visit
20% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
20% co-insurance after deductible
Tier 2 – Generics
20% co-insurance after deductible
Tier 3 – Preferred Brands
20% co-insurance after deductible
Tier 4 – Non-Preferred Brands
20% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
20% co-insurance after deductible

Health Options Clear Choice Silver $3500 HSA Off Marketplace HMO NE Dental
$3,500 $7,000
Deductible
$7,000 $14,000
Out-of-pocket Maximum
10% 10%
Coinsurance
  • No out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Not available at CoverME.gov marketplace; purchase directly from Community Health Options
INCLUDES
array(4) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Pediatric Dental Plan includes pediatric dental coverage through Northeast Delta Dental® with a separate, low deductible.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
10% co-insurance after deductible
Specialty Care Office Visit
10% co-insurance after deductible
Urgent Care Center
10% co-insurance after deductible
Amwell® Urgent Telehealth
$0 co-pay after deductible
Mental Health/Substance Use Disorder (Outpatient)
10% co-insurance after deductible
Emergency Room Visit
10% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
10% co-insurance after deductible
Tier 2 – Generics
10% co-insurance after deductible
Tier 3 – Preferred Brands
10% co-insurance after deductible
Tier 4 – Non-Preferred Brands
10% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
10% co-insurance after deductible

Health Options Clear Choice Silver $3500 HMO Tiered NE
$3,500 $7,000
Deductible
$8,700 $17,400
Out-of-pocket Maximum
40% 40%
Coinsurance
  • No out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(4) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” [3]=> string(9) “preferred” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
  • Preferred Providers and Services Preferred providers and services are designated by a in the provider directory. Provider types include primary care, pediatrics, ob-gyn, specialties, P/T, O/T, S/T, urgent care facilities, imaging centers, labs, and out-patient hospital services. Preferred providers offer lower cost-sharing.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $30 co-pay Preferred/$60 co-pay Standard; no deductible required
Specialty Care Office Visit
$60 co-pay; no deductible required
Urgent Care Center
$40 co-pay Preferred/$70 co-pay Standard; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $30 co-pay Preferred/$60 co-pay Standard; no deductible required
Emergency Room Visit
40% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$25 co-pay; no deductible required
Tier 3 – Preferred Brands
$50 co-pay; no deductible required
Tier 4 – Non-Preferred Brands
$100 co-pay after deductible
Tier 5 – Specialty (30 day supply only)
$250 co-pay after deductible

Health Options Clear Choice Silver $3500 HMO NE
$3,500 $7,000
Deductible
$8,700 $17,400
Out-of-pocket Maximum
40% 40%
Coinsurance
  • No out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(3) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $30 co-pay; no deductible required
Specialty Care Office Visit
$60 co-pay; no deductible required
Urgent Care Center
$40 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $30 co-pay; no deductible required
Emergency Room Visit
40% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$25 co-pay; no deductible required
Tier 3 – Preferred Brands
$50 co-pay; no deductible required
Tier 4 – Non-Preferred Brands
$100 co-pay after deductible
Tier 5 – Specialty (30 day supply only)
$250 co-pay after deductible

Health Options Clear Choice Silver $3500 PPO National
$3,500 $7,000
Deductible
$8,700 $17,400
Out-of-pocket Maximum
40% 40%
Coinsurance
  • Includes out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(4) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” [3]=> string(8) “national” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
  • National Coverage Plan includes in-network access to providers throughout the U.S. via the First Health Network.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $30 co-pay; no deductible required
Specialty Care Office Visit
$60 co-pay; no deductible required
Urgent Care Center
$40 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $30 co-pay; no deductible required
Emergency Room Visit
40% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$25 co-pay; no deductible required
Tier 3 – Preferred Brands
$40 co-pay; no deductible required
Tier 4 – Non-Preferred Brands
$100 co-pay after deductible
Tier 5 – Specialty (30 day supply only)
$250 co-pay after deductible

Health Options Katahdin Silver HMO Tiered NE
$3,000 $6,000
Deductible
$7,500 $15,000
Out-of-pocket Maximum
40% 40%
Coinsurance
  • No out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(5) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” [4]=> string(9) “preferred” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • CISP The Chronic Illness Support Program makes it easier for Members to manage and pay for the treatment of select chronic conditions including asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes and hypertension.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
  • Preferred Providers and Services Preferred providers and services are designated by a in the provider directory. Provider types include primary care, pediatrics, ob-gyn, specialties, P/T, O/T, S/T, urgent care facilities, imaging centers, labs, and out-patient hospital services. Preferred providers offer lower cost-sharing.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $30 co-pay Preferred/$60 co-pay Standard; no deductible required
Specialty Care Office Visit
$50 co-pay with no deductible
Urgent Care Center
$95 co-pay Preferred/$125 co-pay Standard; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first 3 visits, then $30 co-pay Preferred/$60 co-pay Standard; no deductible required
Emergency Room Visit
50% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$30 co-pay; no deductible required
Tier 3 – Preferred Brands
40% co-insurance after deductible
Tier 4 – Non-Preferred Brands
50% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
50% co-insurance after deductible

Health Options Katahdin Silver HMO NE
$3,000 $6,000
Deductible
$7,500 $15,000
Out-of-pocket Maximum
40% 40%
Coinsurance
  • No out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(4) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • CISP The Chronic Illness Support Program makes it easier for Members to manage and pay for the treatment of select chronic conditions including asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes and hypertension.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $30 co-pay; no deductible required
Specialty Care Office Visit
$50 co-pay; no deductible required
Urgent Care Center
$95 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first 3 visit, then $30 co-pay; no deductible required
Emergency Room Visit
50% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$30 co-pay; no deductible required
Tier 3 – Preferred Brands
40% co-insurance after deductible
Tier 4 – Non-Preferred Brands
50% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
50% co-insurance after deductible

Health Options Acadia Silver HMO NE
$2,500 $5,000
Deductible
$7,500 $15,000
Out-of-pocket Maximum
40% 40%
Coinsurance
  • No out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(3) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $20 co-pay; no deductible required
Specialty Care Office Visit
40% co-insurance after deductible
Urgent Care Center
$95 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first 3 visits, then $20 co-pay; no deductible required
Emergency Room Visit
40% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$30 co-pay; no deductible required
Tier 3 – Preferred Brands
40% co-insurance after deductible
Tier 4 – Non-Preferred Brands
50% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
50% co-insurance after deductible

Health Options Acadia Silver HMO NE Dental
$2,500 $5,000
Deductible
$7,500 $15,000
Out-of-pocket Maximum
40% 40%
Coinsurance
  • No out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(4) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Pediatric Dental Plan includes pediatric dental coverage through Northeast Delta Dental® with a separate, low deductible.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $20 co-pay; no deductible required
Specialty Care Office Visit
40% co-insurance after deductible
Urgent Care Center
$95 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first 3 visits, then $20 co-pay; no deductible required
Emergency Room Visit
40% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$30 co-pay; no deductible required
Tier 3 – Preferred Brands
40% co-insurance after deductible
Tier 4 – Non-Preferred Brands
50% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
50% co-insurance after deductible

Health Options Acadia Silver PPO NE
$2,500 $5,000
Deductible
$7,500 $15,000
Out-of-pocket Maximum
40% 40%
Coinsurance
  • Includes out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(3) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $20 co-pay; no deductible required
Specialty Care Office Visit
40% co-insurance after deductible
Urgent Care Center
$95 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first 3 visits, then $20 co-pay; no deductible required
Emergency Room Visit
40% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$30 co-pay; no deductible required
Tier 3 – Preferred Brands
40% co-insurance after deductible
Tier 4 – Non-Preferred Brands
50% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
50% co-insurance after deductible

Health Options Acadia Silver PPO NE Dental
$2,500 $5,000
Deductible
$7,500 $15,000
Out-of-pocket Maximum
40% 40%
Coinsurance
  • Includes out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(4) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Pediatric Dental Plan includes pediatric dental coverage through Northeast Delta Dental® with a separate, low deductible.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $20 co-pay; no deductible required
Specialty Care Office Visit
40% co-insurance after deductible
Urgent Care Center
$95 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first 3 visits, then $20 co-pay; no deductible required
Emergency Room Visit
40% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$30 co-pay; no deductible required
Tier 3 – Preferred Brands
40% co-insurance after deductible
Tier 4 – Non-Preferred Brands
50% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
50% co-insurance after deductible

Health Options Acadia Silver PPO National
$2,500 $5,000
Deductible
$7,500 $15,000
Out-of-pocket Maximum
40% 40%
Coinsurance
  • Includes out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(4) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” [3]=> string(8) “national” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
  • National Coverage Plan includes in-network access to providers throughout the U.S. via the First Health Network.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $20 co-pay; no deductible required
Specialty Care Office Visit
40% co-insurance after deductible
Urgent Care Center
$95 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first 3 visits, then $20 co-pay; no deductible required
Emergency Room Visit
40% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$30 co-pay; no deductible required
Tier 3 – Preferred Brands
40% co-insurance after deductible
Tier 4 – Non-Preferred Brands
50% co-insurance after deductible
Tier 5 – Specialty (30 day supply only)
50% co-insurance after deductible

Gold Level

In Gold plans, the insurance company pays about 80% and the Member pays 20% of the cost for health services.

Gold plans have higher monthly premiums but lower costs when you need care. These plans are a good option if you prefer lower out-of-pocket expenses, anticipate the need for frequent or high-cost medical treatment, and are comfortable with a larger monthly premium expense.

Health Options Clear Choice Gold $2500 PPO NE
$2,500 $5,000
Deductible
$6,000 $12,000
Out-of-pocket Maximum
30% 30%
Coinsurance
  • Includes out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(4) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • CISP The Chronic Illness Support Program makes it easier for Members to manage and pay for the treatment of select chronic conditions including asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes and hypertension.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $25 co-pay; no deductible required
Specialty Care Office Visit
$50 co-pay; no deductible required
Urgent Care Center
$40 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $25 co-pay; no deductible required
Emergency Room Visit
30% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$25 co-pay; no deductible required
Tier 3 – Preferred Brands
$50 co-pay; no deductible required
Tier 4 – Non-Preferred Brands
30% co-insurance, up to max of $300/Rx; no deductible required
Tier 5 – Specialty (30 day supply only)
50% co-insurance. up to max of $600/Rx; no deductible required

Health Options Clear Choice Gold $2500 PPO NE Dental
$2,500 $5,000
Deductible
$6,000 $12,000
Out-of-pocket Maximum
30% 30%
Coinsurance
  • Includes out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(5) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” [4]=> string(4) “cisp” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Pediatric Dental Plan includes pediatric dental coverage through Northeast Delta Dental® with a separate, low deductible.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • CISP The Chronic Illness Support Program makes it easier for Members to manage and pay for the treatment of select chronic conditions including asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes and hypertension.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $25 co-pay; no deductible required
Specialty Care Office Visit
$50 co-pay; no deductible required
Urgent Care Center
$40 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $25 co-pay; no deductible required
Emergency Room Visit
30% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$25 co-pay; no deductible required
Tier 3 – Preferred Brands
$50 co-pay; no deductible required
Tier 4 – Non-Preferred Brands
30% co-insurance, up to max of $300/Rx; no deductible required
Tier 5 – Specialty (30 day supply only)
50% co-insurance. up to max of $600/Rx; no deductible required

Health Options Clear Choice Gold $2500 PPO National Dental
$2,500 $5,000
Deductible
$6,000 $12,000
Out-of-pocket Maximum
30% 30%
Coinsurance
  • Includes out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(6) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” [4]=> string(4) “cisp” [5]=> string(8) “national” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Pediatric Dental Plan includes pediatric dental coverage through Northeast Delta Dental® with a separate, low deductible.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • CISP The Chronic Illness Support Program makes it easier for Members to manage and pay for the treatment of select chronic conditions including asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes and hypertension.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
  • National Coverage Plan includes in-network access to providers throughout the U.S. via the First Health Network.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $25 co-pay; no deductible required
Specialty Care Office Visit
$50 co-pay; no deductible required
Urgent Care Center
$40 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $25 co-pay; no deductible required
Emergency Room Visit
30% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$25 co-pay; no deductible required
Tier 3 – Preferred Brands
$50 co-pay; no deductible required
Tier 4 – Non-Preferred Brands
30% co-insurance, up to max of $300/Rx; no deductible required
Tier 5 – Specialty (30 day supply only)
50% co-insurance. up to max of $600/Rx; no deductible required

Health Options Clear Choice Gold $1500 PPO NE
$1,500 $3,000
Deductible
$5,000 $10,000
Out-of-pocket Maximum
30% 30%
Coinsurance
  • Includes out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(3) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $25 co-pay; no deductible required
Specialty Care Office Visit
$50 co-pay; no deductible required
Urgent Care Center
$40 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $25 co-pay; no deductible required
Emergency Room Visit
30% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$25 co-pay; no deductible required
Tier 3 – Preferred Brands
$50 co-pay; no deductible required
Tier 4 – Non-Preferred Brands
$100 co-pay after deductible
Tier 5 – Specialty (30 day supply only)
$250 co-pay after deductible

Health Options Clear Choice Gold $1500 PPO National
$1,500 $3,000
Deductible
$5,000 $10,000
Out-of-pocket Maximum
30% 30%
Coinsurance
  • Includes out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(4) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” [3]=> string(8) “national” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
  • National Coverage Plan includes in-network access to providers throughout the U.S. via the First Health Network.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $25 co-pay; no deductible required
Specialty Care Office Visit
$50 co-pay; no deductible required
Urgent Care Center
$40 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $25 co-pay; no deductible required
Emergency Room Visit
30% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 co-pay; no deductible required
Tier 2 – Generics
$25 co-pay; no deductible required
Tier 3 – Preferred Brands
$50 co-pay; no deductible required
Tier 4 – Non-Preferred Brands
$100 co-pay after deductible
Tier 5 – Specialty (30 day supply only)
$250 co-pay after deductible

Platinum Level

In Platinum plans, the insurance company pays about 90%, and the Member pays 10% of the cost for health services.

Our Platinum plan has the highest monthly premium but offers the most financial coverage when you need care. This plan is a good option for Members who are comfortable with the monthly premiums, prefer low out-of-pocket expenses, and expect to make frequent use of their health benefits.

Health Options Clear Choice Platinum PPO NE
$500 $1,000
Deductible
$3,000 $6,000
Out-of-pocket Maximum
20% 20%
Coinsurance
  • Includes out-of-network benefits Out-of-network provider visits and services have a separate, higher deductible and out-of-pocket maximum. Copays and coinsurance are also higher than in-network providers and services.
  • Does not include Site of Service reduced costs $25 copays for labs and $75 copays for X-rays at specified locations; no deductible required.
  • Cost-share reductions not available on this plan
  • Available on the CoverME.gov marketplace
INCLUDES
array(3) { [0]=> string(10) “telehealth” [1]=> string(6) “vision” [2]=> string(12) “chiropractic” }
  • Pediatric Vision Plan includes pediatric vision coverage, including exam and glasses or contacts for children aged 19 or younger.
  • Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy. Benefit is available with a copay on non-HSA plans.
  • Amwell® Telehealth Plan includes $0 copay for telehealth urgent care through Amwell® for non-HSA plans. HSA plans have a copay after deductible.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $20 co-pay; no deductible required
Specialty Care Office Visit
$40 co-pay; no deductible required
Urgent Care Center
$25 co-pay; no deductible required
Amwell® Urgent Telehealth
$0 co-pay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $20 co-pay; no deductible required
Emergency Room Visit
20% co-insurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$0 co-pay; no deductible required
Tier 2 – Generics
$0 co-pay; no deductible required
Tier 3 – Preferred Brands
$15 co-pay; no deductible required
Tier 4 – Non-Preferred Brands
$100 co-pay after deductible
Tier 5 – Specialty (30 day supply only)
$250 co-pay after deductible