Archived small group plans

2020 Wisconsin QHP HMO

• HMO full-pay $0 Ded 10255050 Rx – SBC
• HMO CO 90 $250 Ded 10255050 Rx- SBC
• HMO Co-80 $500 Ded 10255050 Rx- SBC
• HMO Co-80 $1,000 Ded 10255050 Rx- SBC
• HMO Co-80 $1,250 Ded 20407550 Rx- SBC
• HMO Co-80 $2,500 Ded 20407550 Rx- SBC
• HMO Co-80 $3,500 Ded 20407550 Rx- SBC
• HMO Co-50 $5,000 Ded 205010050 Rx- SBC
• HMO Co-100 $6,950 Ded. SBC
• HMO Co-100 $7,500 Ded. SBC
• HMO Co-100 $8,150 Ded. SBC
• HMO $2700 Ded- SBC
• HMO HSA $5,000 Ded- SBC

2020 Wisconsin QHP EPO

• EPO full-pay $0 Ded 10255050 Rx – SBC
• EPO CO 90 $250 Ded 10255050 Rx- SBC
• EPO Co-80 $500 Ded 10255050 Rx- SBC
• EPO Co-80 $1,000 Ded 10255050 Rx- SBC
• EPO Co-80 $1,250 Ded 20407550 Rx- SBC
• EPO Co-80 $2,500 Ded 20407550 Rx- SBC
• EPO Co-80 $3,500 Ded 20407550 Rx- SBC
• EPO Co-50 $5,000 Ded 205010050 Rx- SBC
• EPO Co-100 $6,950 Ded. SBC
• EPO Co-100 $7,500 Ded. SBC
• EPO Co-100 $8,150 Ded. SBC
• EPO $2700 Ded- SBC
• EPO HSA $5,000 Ded. SBC

QHP Formulary
4-tier QHP full Formulary

2020 Illinois QHP HMO

• HMO full-fay $0 Ded 10255050 Rx – SBC
• HMO CO 90 $250 Ded 10255050 Rx- SBC
• HMO Co-80 $500 Ded 10255050 Rx- SBC
• HMO Co-80 $1,000 Ded 10255050 Rx- SBC
• HMO Co-80 $1,250 Ded 20407550 Rx- SBC
• HMO Co-80 $2,500 Ded 20407550 Rx- SBC
• HMO Co-80 $3,500 Ded 20407550 Rx- SBC
• HMO Co-50 $5,000 Ded 205010050 Rx- SBC
• HMO Co-100 $6,950 Ded. SBC
• HMO Co-100 $7,500 Ded. SBC
• HMO Co-100 $8,150 Ded. SBC
• HMO $2700 Ded- SBC
• HMO HSA $5,000 Ded- SBC
  • Certificate of Coverage
  • Small group booklet: Wisconsin and Illinois PDF
  • QHP Formulary 4-tier

2019 Wisconsin QHP HMO

• HMO full-pay $0 Ded 10255050 Rx – SBC
• HMO Co-90 $250 Ded 10255050 Rx- SBC
• HMO Co-80 $500 Ded 10255050 Rx- SBC
• HMO Co-80 $1,000 Ded 10255050 Rx- SBC
• HMO Co-80 $1,250 Ded 20407550 Rx- SBC
• HMO Co-80 $2,500 Ded 20407550 Rx- SBC
• HMO Co-80 $3,500 Ded 20407550 Rx- SBC
• HMO Co-70 $4,250 Ded 205010050 Rx- SBC
• HMO Co-50 $5,000 Ded 205010050 Rx- SBC
• HMO HSA $2,700 Ded- SBC
• HMO HSA $4,000 Ded- SBC
• HMO HSA $5,000 Ded- SBC
• HMO HSA $6,550 Ded- SBC

2019 Wisconsin QHP EPO

• EPO full-pay $0 Ded 10255050 Rx – SBC
• EPO Co-90 $250 Ded 10255050 Rx- SBC
• EPO Co-80 $500 Ded 10255050 Rx- SBC
• EPO Co-80 $1,000 Ded 10255050 Rx- SBC
• EPO Co-80 $1,250 Ded 20407550 Rx- SBC
• EPO Co-80 $2,500 Ded 20407550 Rx- SBC
• EPO Co-80 $3,500 Ded 20407550 Rx- SBC
• EPO Co-70 $4,250 Ded 205010050 Rx- SBC
• EPO Co-50 $5,000 Ded 205010050 Rx- SBC
• EPO HSA $2,700 Ded- SBC
• EPO HSA $4,000 Ded- SBC
• EPO HSA $5,000 Ded- SBC
• EPO HSA $6,550 Ded- SBC

Uniform glossary

2019 Wisconsin QHP PPO

• PPO Co 80/60 $250 Ded- SBC
• PPO Co 80/ 60 $500 Ded- SBC
• PPO Co 80/60 $1,250 Ded- SBC
• PPO Co 80/60 $2,500 Ded – SBC

2019 Illinois QHP HMO

• HMO Full Pay $0 Ded 10255050 Rx – SBC
• HMO CO 90 $250 Ded 10255050 Rx- SBC
• HMO Co-80 $500 Ded 10255050 Rx- SBC
• HMO Co-80 $1,000 Ded 10255050 Rx- SBC
• HMO Co-80 $1,250 Ded 20407550 Rx- SBC
• HMO Co-80 $2,500 Ded 20407550 Rx- SBC
• HMO Co-80 $3,500 Ded 20407550 Rx- SBC
• HMO Co-70 $4,250 Ded 205010050 Rx- SBC
• HMO Co-50 $5,000 Ded 205010050 Rx- SBC
• HMO HSA $2,700 Ded- SBC
• HMO HSA $4,000 Ded- SBC
• HMO HSA $5,000 Ded- SBC
• HMO HSA $6,550 Ded- SBC
  • 2019 small group booklet: Wisconsin and Illinois
  • QHP Formulary 4-tier
  • Uniform glossary