Plan Popup
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
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 lower premiums but require Members to pay a higher deductible and often higher out-of-pocket costs compared to other metal levels. These plans keep monthly premium costs low, while providing the same quality coverage when you receive care.
Health Options Clear Choice Bronze $9450 HMO NE
$9,450 $18,900
Deductible
$9,450 $18,900
Out-of-pocket Maximum
0% 0%
Coinsurance
- No out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions not available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(4) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $50 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay; no deductible required
Urgent Care Center
0% coinsurance after deductible
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $50 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
0% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$30 copay; no deductible required
Tier 3 – Preferred Brands
0% coinsurance after deductible
Tier 4 – Non-Preferred Brands
0% coinsurance after deductible
Tier 5 – Specialty (30 day supply only)
0% coinsurance after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Bronze $9450 HMO NE
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Bronze $9450 PPO NE
$9,450 $18,900
Deductible
$9,450 $18,900
Out-of-pocket Maximum
0% 0%
Coinsurance
- Includes out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions not available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(4) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $50 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay; no deductible required
Urgent Care Center
0% coinsurance after deductible
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $50 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
0% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$30 copay; no deductible required
Tier 3 – Preferred Brands
0% coinsurance after deductible
Tier 4 – Non-Preferred Brands
0% coinsurance after deductible
Tier 5 – Specialty (30 day supply only)
0% coinsurance after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Bronze $9450 PPO NE
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Bronze $8000 Healthy Maine HMO NE
$8,000 $16,000
Deductible
$9,450 $18,900
Out-of-pocket Maximum
50% 50%
Coinsurance
- No out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions not available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(7) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” [4]=> string(11) “acupuncture” [5]=> string(8) “coaching” [6]=> string(8) “wellness” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
Acupuncture Reimbursement up to $50 per treatment session; maximum 12 visits per calendar year.
Health Coaching This Healthy Maine plan includes unlimited personal health coaching to help you stay motivated and engaged in your health goals, all at $0 cost-share.
Wellness Benefits This plan includes WellRight, our online digital wellbeing platform and mobile app. Benefits include gamified wellness challenges that enable users to choose a wellness journey that’s personalized, integration with wearable devices, and a comprehensive health assessment for all family members at no cost.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay after deductible
Urgent Care Center
$60 copay; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
50% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$25 copay; no deductible required
Tier 3 – Preferred Brands
30% coinsurance after deductible
Tier 4 – Non-Preferred Brands
50% coinsurance after deductible
Tier 5 – Specialty (30 day supply only)
50% coinsurance after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Bronze $8000 Healthy Maine HMO NE
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Bronze $8000 Healthy Maine PPO NE
$8,000 $16,000
Deductible
$9,450 $18,900
Out-of-pocket Maximum
50% 50%
Coinsurance
- Includes out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions not available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(7) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” [4]=> string(11) “acupuncture” [5]=> string(8) “coaching” [6]=> string(8) “wellness” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
- Acupuncture Reimbursement up to $50 per treatment session; maximum 12 visits per calendar year.
- Health Coaching This Healthy Maine plan includes unlimited personal health coaching to help you stay motivated and engaged in your health goals, all at $0 cost-share.
- Wellness Benefits This plan includes WellRight, our online digital wellbeing platform and mobile app. Benefits include gamified wellness challenges that enable users to choose a wellness journey that’s personalized, integration with wearable devices, and a comprehensive health assessment for all family members at no cost.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay after deductible
Urgent Care Center
$60 copay; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
50% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$25 copay; no deductible required
Tier 3 – Preferred Brands
30% coinsurance after deductible
Tier 4 – Non-Preferred Brands
50% coinsurance after deductible
Tier 5 – Specialty (30 day supply only)
50% coinsurance after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Bronze $8000 Healthy Maine PPO NE
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Bronze $7500 HMO Tiered NE
Preferred Tier The tiered plan offers a preferred cost-share, deductible and out-of-pocket maximum expense. Services received from a preferred provider have a lower cost-share than a standard provider. Expenses from these services will be applied to the preferred deductible, and both the preferred and standard out-of-pocket maximums. Preferred providers are high quality, cost-effective, in-network providers.
$7,500 $15,000
Deductible
$9,450 $18,900
Out-of-pocket Maximum
50% 50%
Coinsurance
Standard Tier The tiered plan offers a standard cost share, deductible and out-of-pocket maximum expense. Services received from a standard provider have a higher cost share than a preferred provider. Expenses from these services will be applied to the standard deductible and standard out-of-pocket maximum. Standard providers are high quality, in-network providers.
$9,000 $18,000
Deductible
$9,450 $18,900
Out-of-pocket Maximum
60% 60%
Coinsurance
- No out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions not available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(5) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” [4]=> string(9) “preferred” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
- 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 $45 copay Preferred / $65 copay Standard; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay Preferred / $100 copay Standard; no deductible required
Urgent Care Center
$60 copay Preferred / $80 copay Standard; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $45 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
50% Coinsurance after Deductible
Prescriptions
Tier 1 – Preferred Generics
Tier 2 – Generics
Tier 3 – Preferred Brands
$50 copay after deductible
Tier 4 – Non-Preferred Brands
$100 copay after deductible
Tier 5 – Specialty (30 day supply only)
$250 copay after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Bronze $7500 HMO Tiered NE
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Bronze $7500 HMO NE
$7,500 $15,000
Deductible
$9,450 $18,900
Out-of-pocket Maximum
50% 50%
Coinsurance
- No out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions not available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(4) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $45 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay; no deductible required
Urgent Care Center
$60 copay; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $45 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
50% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$30 copay; no deductible required
Tier 3 – Preferred Brands
$50 copay after deductible
Tier 4 – Non-Preferred Brands
$100 copay after deductible
Tier 5 – Specialty (30 day supply only)
$250 copay after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Bronze $7500 HMO NE
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Bronze $7500 PPO NE
$7,500 $15,000
Deductible
$9,450 $18,900
Out-of-pocket Maximum
50% 50%
Coinsurance
- Includes out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions not available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(4) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $45 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay; no deductible required
Urgent Care Center
$60 copay; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $45 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
50% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$30 copay; no deductible required
Tier 3 – Preferred Brands
$50 copay after deductible
Tier 4 – Non-Preferred Brands
$100 copay after deductible
Tier 5 – Specialty (30 day supply only)
$250 copay after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Bronze $7500 PPO NE
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Bronze $7500 PPO NE Dental
$7,500 $15,000
Deductible
$9,450 $18,900
Out-of-pocket Maximum
50% 50%
Coinsurance
- Includes out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions not available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(5) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” [4]=> string(4) “cisp” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Pediatric Dental Plan includes pediatric dental coverage for children aged 18 or younger, exclusive of orthodontia.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $45 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay; no deductible required
Urgent Care Center
$60 copay; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $45 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
50% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$30 copay; no deductible required
Tier 3 – Preferred Brands
$50 copay after deductible
Tier 4 – Non-Preferred Brands
$100 copay after deductible
Tier 5 – Specialty (30 day supply only)
$250 copay after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Bronze $7500 PPO NE Dental
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Bronze $7200 HSA Plus PPO NE
$7,200 $14,400
Deductible
$7,200 $14,400
Out-of-pocket Maximum
0% 0%
Coinsurance
- Includes out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions not available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(3) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
0% coinsurance after deductible
Specialty Care Office Visit
0% coinsurance after deductible
Urgent Care Center
0% coinsurance after deductible
Amwell® Urgent Telehealth
0 copay after deductible
Mental Health/Substance Use Disorder (Outpatient)
0% coinsurance after deductible
Emergency Room Visit
0% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
0% coinsurance after deductible
Tier 2 – Generics
0% coinsurance after deductible
Tier 3 – Preferred Brands
0% coinsurance after deductible
Tier 4 – Non-Preferred Brands
0% coinsurance after deductible
Tier 5 – Specialty (30 day supply only)
0% coinsurance after deductible
Includes expanded, pre-deductible drug list
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Bronze $7200 HSA Plus PPO NE
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Bronze $5900 HSA PPO NE
$5,900 $11,800
Deductible
$7,500 $15,000
Out-of-pocket Maximum
50% 50%
Coinsurance
- Includes out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions not available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(4) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” [3]=> string(8) “wellness” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- Wellness Benefits This plan includes WellRight, our online digital wellbeing platform and mobile app. Benefits include gamified wellness challenges that enable users to choose a wellness journey that’s personalized, integration with wearable devices, and a comprehensive health assessment for all family members at no cost.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
50% coinsurance after deductible
Specialty Care Office Visit
50% coinsurance after deductible
Urgent Care Center
50% coinsurance after deductible
Amwell® Urgent Telehealth
$0 copay after deductible
Mental Health/Substance Use Disorder (Outpatient)
50% coinsurance after deductible
Emergency Room Visit
50% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
50% coinsurance after deductible
Tier 2 – Generics
50% coinsurance after deductible
Tier 3 – Preferred Brands
50% coinsurance after deductible
Tier 4 – Non-Preferred Brands
50% coinsurance after deductible
Tier 5 – Specialty (30 day supply only)
50% coinsurance after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Bronze $5900 HSA PPO NE
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Bronze Level – Off-Exchange Only
The following plans are offered directly through Health Options and are exempt from purchase with Advance Premium Tax Credits. In Bronze plans, the insurance company pays about 60%, and the Member pays 40% of the cost for health services.
You may purchase them directly through our storefront.
Health Options Clear Choice Bronze $9450 PPO NE Dental Off MP
$9,450 $18,900
Deductible
$9,450 $18,900
Out-of-pocket Maximum
0% 0%
Coinsurance
- Includes out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- 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(12) “adult_vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” [4]=> string(4) “cisp” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Pediatric Dental Plan includes pediatric dental coverage for children aged 18 or younger, exclusive of orthodontia.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $50 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay; no deductible required
Urgent Care Center
0% coinsurance after deductible
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $50 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
0% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$30 copay; no deductible required
Tier 3 – Preferred Brands
0% coinsurance after deductible
Tier 4 – Non-Preferred Brands
0% coinsurance after deductible
Tier 5 – Specialty (30 day supply only)
0% coinsurance after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Bronze $9450 PPO NE Dental Off MP
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Bronze $9450 PPO National Dental Off MP
$9,450 $18,900
Deductible
$9,450 $18,900
Out-of-pocket Maximum
0% 0%
Coinsurance
- Includes out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions not available on this plan
- Not available at CoverME.gov marketplace; purchase directly from Community Health Options
INCLUDES
array(6) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” [4]=> string(4) “cisp” [5]=> string(8) “national” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Pediatric Dental Plan includes pediatric dental coverage for children aged 18 or younger, exclusive of orthodontia.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
- National Coverage Plan includes in-network access to providers throughout the U.S.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $50 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay; no deductible required
Urgent Care Center
0% coinsurance after deductible
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $50 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
0% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$30 copay; no deductible required
Tier 3 – Preferred Brands
0% coinsurance after deductible
Tier 4 – Non-Preferred Brands
0% coinsurance after deductible
Tier 5 – Specialty (30 day supply only)
0% coinsurance after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Bronze $9450 PPO National Dental Off MP
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Bronze $8000 Healthy Maine HMO NE Off MP
$8,000 $16,000
Deductible
$9,450 $18,900
Out-of-pocket Maximum
50% 50%
Coinsurance
- No out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions not available on this plan
- Not available at CoverME.gov marketplace; purchase directly from Community Health Options
INCLUDES
array(7) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” [4]=> string(11) “acupuncture” [5]=> string(8) “coaching” [6]=> string(8) “wellness” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
- Acupuncture Reimbursement up to $50 per treatment session; maximum 12 visits per calendar year.
- Health Coaching This Healthy Maine plan includes unlimited personal health coaching to help you stay motivated and engaged in your health goals, all at $0 cost-share.
- Wellness Benefits This plan includes WellRight, our online digital wellbeing platform and mobile app. Benefits include gamified wellness challenges that enable users to choose a wellness journey that’s personalized, integration with wearable devices, and a comprehensive health assessment for all family members at no cost.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay after deductible
Urgent Care Center
$60 copay; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
50% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$25 copay; no deductible required
Tier 3 – Preferred Brands
30% coinsurance after deductible
Tier 4 – Non-Preferred Brands
50% coinsurance after deductible
Tier 5 – Specialty (30 day supply only)
50% coinsurance after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Bronze $8000 Healthy Maine HMO NE Off MP
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Bronze $8000 Healthy Maine PPO NE Off MP
$8,000 $16,000
Deductible
$9,450 $18,900
Out-of-pocket Maximum
50% 50%
Coinsurance
- Includes out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions not available on this plan
- Not available at CoverME.gov marketplace; purchase directly from Community Health Options
INCLUDES
array(7) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” [4]=> string(11) “acupuncture” [5]=> string(8) “coaching” [6]=> string(8) “wellness” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
- Acupuncture Reimbursement up to $50 per treatment session; maximum 12 visits per calendar year.
- Health Coaching This Healthy Maine plan includes unlimited personal health coaching to help you stay motivated and engaged in your health goals, all at $0 cost-share.
- Wellness Benefits This plan includes WellRight, our online digital wellbeing platform and mobile app. Benefits include gamified wellness challenges that enable users to choose a wellness journey that’s personalized, integration with wearable devices, and a comprehensive health assessment for all family members at no cost.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay after deductible
Urgent Care Center
$60 copay; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
50% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$25 copay; no deductible required
Tier 3 – Preferred Brands
30% coinsurance after deductible
Tier 4 – Non-Preferred Brands
50% coinsurance after deductible
Tier 5 – Specialty (30 day supply only)
50% coinsurance after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Bronze $8000 Healthy Maine PPO NE Off MP
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Bronze $7500 HMO Tiered NE Dental Off MP
Preferred Tier The tiered plan offers a preferred cost-share, deductible and out-of-pocket maximum expense. Services received from a preferred provider have a lower cost-share than a standard provider. Expenses from these services will be applied to the preferred deductible, and both the preferred and standard out-of-pocket maximums. Preferred providers are high quality, cost-effective, in-network providers.
$7,500 $15,000
Deductible
$9,450 $18,900
Out-of-pocket Maximum
50% 50%
Coinsurance
Standard Tier The tiered plan offers a standard cost share, deductible and out-of-pocket maximum expense. Services received from a standard provider have a higher cost share than a preferred provider. Expenses from these services will be applied to the standard deductible and standard out-of-pocket maximum. Standard providers are high quality, in-network providers.
$9,000 $18,000
Deductible
$9,450 $18,900
Out-of-pocket Maximum
60% 60%
Coinsurance
- No out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions not available on this plan
- Not available at CoverME.gov marketplace; purchase directly from Community Health Options
INCLUDES
array(6) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” [4]=> string(4) “cisp” [5]=> string(9) “preferred” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Pediatric Dental Plan includes pediatric dental coverage for children aged 18 or younger, exclusive of orthodontia.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
- 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 $45 copay Preferred / $65 copay Standard; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay Preferred / $100 copay Standard; no deductible required
Urgent Care Center
$60 copay Preferred / $80 copay Standard; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $45 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
50% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$30 copay; no deductible required
Tier 3 – Preferred Brands
$50 copay after deductible
Tier 4 – Non-Preferred Brands
$100 copay after deductible
Tier 5 – Specialty (30 day supply only)
$250 copay after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Bronze $7500 HMO Tiered NE Dental Off MP
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Bronze $7500 PPO NE Dental Off MP
$7,500 $15,000
Deductible
$9,450 $18,900
Out-of-pocket Maximum
50% 50%
Coinsurance
- Includes out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- 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(12) “adult_vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” [4]=> string(4) “cisp” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Pediatric Dental Plan includes pediatric dental coverage for children aged 18 or younger, exclusive of orthodontia.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $45 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay; no deductible required
Urgent Care Center
$60 copay; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $45 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
50% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$30 copay; no deductible required
Tier 3 – Preferred Brands
$50 copay after deductible
Tier 4 – Non-Preferred Brands
$100 copay after deductible
Tier 5 – Specialty (30 day supply only)
$250 copay after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Bronze $7500 PPO NE Dental Off MP
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Bronze $7500 PPO National Dental Off MP
$7,500 $15,000
Deductible
$9,450 $18,900
Out-of-pocket Maximum
50% 50%
Coinsurance
- Includes out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions not available on this plan
- Not available at CoverME.gov marketplace; purchase directly from Community Health Options
INCLUDES
array(6) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” [4]=> string(4) “cisp” [5]=> string(8) “national” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Pediatric Dental Plan includes pediatric dental coverage for children aged 18 or younger, exclusive of orthodontia.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
- National Coverage Plan includes in-network access to providers throughout the U.S.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $45 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay; no deductible required
Urgent Care Center
$60 copay; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $45 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
50% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$30 copay; no deductible required
Tier 3 – Preferred Brands
$50 copay after deductible
Tier 4 – Non-Preferred Brands
$100 copay after deductible
Tier 5 – Specialty (30 day supply only)
$250 copay after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Bronze $7500 PPO National Dental Off MP
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Bronze $7200 HSA Plus PPO National Dental Off MP
$7,200 $14,400
Deductible
$7,200 $14,400
Out-of-pocket Maximum
0% 0%
Coinsurance
- Includes out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- 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(12) “adult_vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” [4]=> string(8) “national” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Pediatric Dental Plan includes pediatric dental coverage for children aged 18 or younger, exclusive of orthodontia.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- National Coverage Plan includes in-network access to providers throughout the U.S.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
0% coinsurance after deductible
Specialty Care Office Visit
0% coinsurance after deductible
Urgent Care Center
0% coinsurance after deductible
Amwell® Urgent Telehealth
$0 copay after deductible
Mental Health/Substance Use Disorder (Outpatient)
0% coinsurance after deductible
Emergency Room Visit
0% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
0% coinsurance after deductible
Tier 2 – Generics
0% coinsurance after deductible
Tier 3 – Preferred Brands
0% coinsurance after deductible
Tier 4 – Non-Preferred Brands
0% coinsurance after deductible
Tier 5 – Specialty (30 day supply only)
0% coinsurance after deductible
Includes expanded, pre-deductible drug list
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Bronze $7200 HSA Plus PPO National Dental Off MP
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Bronze $6300 HSA Plus PPO National Dental Off MP
$6,300 $12,600
Deductible
$7,500 $15,000
Out-of-pocket Maximum
50% 50%
Coinsurance
- Includes out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- 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(12) “adult_vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” [4]=> string(8) “national” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Pediatric Dental Plan includes pediatric dental coverage for children aged 18 or younger, exclusive of orthodontia.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- National Coverage Plan includes in-network access to providers throughout the U.S.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
50% coinsurance after deductible
Specialty Care Office Visit
50% coinsurance after deductible
Urgent Care Center
50% coinsurance after deductible
Amwell® Urgent Telehealth
$0 copay after deductible
Mental Health/Substance Use Disorder (Outpatient)
50% coinsurance after deductible
Emergency Room Visit
50% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
50% coinsurance after deductible
Tier 2 – Generics
50% coinsurance after deductible
Tier 3 – Preferred Brands
50% coinsurance after deductible
Tier 4 – Non-Preferred Brands
50% coinsurance after deductible
Tier 5 – Specialty (30 day supply only)
50% coinsurance after deductible
Includes expanded, pre-deductible drug list
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Bronze $6300 HSA Plus PPO National Dental Off MP
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
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, a moderate deductible, and often moderate out-of-pocket costs compared with other metal levels. 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 $4200 HMO Tiered NE
Preferred Tier The tiered plan offers a preferred cost-share, deductible and out-of-pocket maximum expense. Services received from a preferred provider have a lower cost-share than a standard provider. Expenses from these services will be applied to the preferred deductible, and both the preferred and standard out-of-pocket maximums. Preferred providers are high quality, cost-effective, in-network providers.
$4,200 $8,400
Deductible
$9,100 $18,200
Out-of-pocket Maximum
40% 40%
Coinsurance
Standard Tier The tiered plan offers a standard cost share, deductible and out-of-pocket maximum expense. Services received from a standard provider have a higher cost share than a preferred provider. Expenses from these services will be applied to the standard deductible and standard out-of-pocket maximum. Standard providers are high quality, in-network providers.
$5,040 $10,080
Deductible
$9,450 $18,900
Out-of-pocket Maximum
60% 60%
Coinsurance
- No out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(5) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” [4]=> string(9) “preferred” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
- 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 $35 copay Preferred / $55 copay Standard; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay Preferred/$95 copay Standard; no deductible required
Urgent Care Center
$40 copay Preferred/$60 copay Standard; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $35 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
40% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$20 copay; no deductible required
Tier 3 – Preferred Brands
$50 copay; no deductible required
Tier 4 – Non-Preferred Brands
$100 copay after deductible
Tier 5 – Specialty (30 day supply only)
$250 copay after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Silver $4200 HMO Tiered NE
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Silver $4200 HMO NE
$4,200 $8,400
Deductible
$9,100 $18,200
Out-of-pocket Maximum
40% 40%
Coinsurance
- No out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(4) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $35 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay; no deductible required
Urgent Care Center
$40 copay; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $35 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
40% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$20 copay; no deductible required
Tier 3 – Preferred Brands
$50 copay; no deductible required
Tier 4 – Non-Preferred Brands
$100 copay after deductible
Tier 5 – Specialty (30 day supply only)
$250 copay after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Silver $4200 HMO NE
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Silver $4200 PPO NE
$4,200 $8,400
Deductible
$9,100 $18,200
Out-of-pocket Maximum
40% 40%
Coinsurance
- Includes out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(4) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $35 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay; no deductible required
Urgent Care Center
$40 copay; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $35 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
40% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$20 copay; no deductible required
Tier 3 – Preferred Brands
$50 copay; no deductible required
Tier 4 – Non-Preferred Brands
$100 copay after deductible
Tier 5 – Specialty (30 day supply only)
$250 copay after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Silver $4200 PPO NE
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Silver $3500 HMO Tiered NE
Preferred Tier The tiered plan offers a preferred cost-share, deductible and out-of-pocket maximum expense. Services received from a preferred provider have a lower cost-share than a standard provider. Expenses from these services will be applied to the preferred deductible, and both the preferred and standard out-of-pocket maximums. Preferred providers are high quality, cost-effective, in-network providers.
$3,500 $7,000
Deductible
$9,100 $18,200
Out-of-pocket Maximum
40% 40%
Coinsurance
Standard Tier The tiered plan offers a standard cost share, deductible and out-of-pocket maximum expense. Services received from a standard provider have a higher cost share than a preferred provider. Expenses from these services will be applied to the standard deductible and standard out-of-pocket maximum. Standard providers are high quality, in-network providers.
$4,200 $8,400
Deductible
$9,100 $18,200
Out-of-pocket Maximum
60% 60%
Coinsurance
- No out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(5) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” [4]=> string(9) “preferred” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
- 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 copay Preferred / $60 copay Standard; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay Preferred/$95 copay Standard; no deductible required
Urgent Care Center
$40 copay Preferred/$60 copay Standard; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
40% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$25 copay; no deductible required
Tier 3 – Preferred Brands
$50 copay; no deductible required
Tier 4 – Non-Preferred Brands
$100 copay after deductible
Tier 5 – Specialty (30 day supply only)
$250 copay after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Silver $3500 HMO Tiered NE
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Silver $3500 HMO NE
$3,500 $7,000
Deductible
$9,100 $18,200
Out-of-pocket Maximum
40% 40%
Coinsurance
- No out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(4) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay; no deductible required
Urgent Care Center
$40 copay; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
40% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$25 copay; no deductible required
Tier 3 – Preferred Brands
$50 copay; no deductible required
Tier 4 – Non-Preferred Brands
$100 copay after deductible
Tier 5 – Specialty (30 day supply only)
$250 copay after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Silver $3500 HMO NE
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Silver $3500 HMO NE Dental
$3,500 $7,000
Deductible
$9,100 $18,200
Out-of-pocket Maximum
40% 40%
Coinsurance
- No out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(5) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” [4]=> string(4) “cisp” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Pediatric Dental Plan includes pediatric dental coverage for children aged 18 or younger, exclusive of orthodontia.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay; no deductible required
Urgent Care Center
$40 copay; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
40% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$25 copay; no deductible required
Tier 3 – Preferred Brands
$50 copay; no deductible required
Tier 4 – Non-Preferred Brands
$100 copay after deductible
Tier 5 – Specialty (30 day supply only)
$250 copay after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Silver $3500 HMO NE Dental
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Silver $3500 PPO National
$3,500 $7,000
Deductible
$9,100 $18,200
Out-of-pocket Maximum
40% 40%
Coinsurance
- Includes out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(5) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” [4]=> string(8) “national” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
- National Coverage Plan includes in-network access to providers throughout the U.S.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay; no deductible required
Urgent Care Center
$40 copay; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
40% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$25 copay; no deductible required
Tier 3 – Preferred Brands
$50 copay; no deductible required
Tier 4 – Non-Preferred Brands
$100 copay after deductible
Tier 5 – Specialty (30 day supply only)
$250 copay after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Silver $3500 PPO National
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Silver $3000 PPO NE
$3,000 $6,000
Deductible
$9,100 $18,200
Out-of-pocket Maximum
40% 40%
Coinsurance
- Includes out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(4) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(12) “chiropractic” [3]=> string(4) “cisp” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay; no deductible required
Urgent Care Center
$40 copay; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
40% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$25 copay; no deductible required
Tier 3 – Preferred Brands
$50 copay; no deductible required
Tier 4 – Non-Preferred Brands
30% coinsurance up to max of $300/script after deductible
Tier 5 – Specialty (30 day supply only)
50% coinsurance up to max of $600/script after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Silver $3000 PPO NE
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Health Options Clear Choice Silver $3000 PPO NE Dental
$3,000 $6,000
Deductible
$9,100 $18,200
Out-of-pocket Maximum
40% 40%
Coinsurance
- Includes out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions available on this plan
- Available on the CoverME.gov marketplace
INCLUDES
array(5) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” [4]=> string(4) “cisp” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Pediatric Dental Plan includes pediatric dental coverage for children aged 18 or younger, exclusive of orthodontia.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
COST-SHARING BREAKDOWN
Common Services
Primary Care Office Visit
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Specialty Care Office Visit
$80 copay; no deductible required
Urgent Care Center
$40 copay; no deductible required
Amwell® Urgent Telehealth
$0 copay; no deductible required
Mental Health/Substance Use Disorder (Outpatient)
$0 first visit, then $40 copay; no deductible required; copays accumulate to the deductible
Emergency Room Visit
40% coinsurance after deductible
Prescriptions
Tier 1 – Preferred Generics
$5 copay; no deductible required
Tier 2 – Generics
$25 copay; no deductible required
Tier 3 – Preferred Brands
$50 copay; no deductible required
Tier 4 – Non-Preferred Brands
30% coinsurance up to max of $300/script after deductible
Tier 5 – Specialty (30 day supply only)
50% coinsurance up to max of $600/script after deductible
Plan Popup
Summary of Benefits and Coverage
Health Options Clear Choice Silver $3000 PPO NE Dental
The Summary of Benefits and Coverage (SBC) is a standard format that the U.S. government has designed to make it easier to do an apples-to-apples comparison of individual plans.
This plan may have different SBC documents depending on whether your income and family size qualifies you for cost-sharing reductions. Choose the plan that applies to your family’s situation below. Not sure if your family qualifies for these savings? You can get free help understanding your options by calling our Member Services team at (855) 624-6463 or by visiting mainecahc.org.
Silver Level – Off Exchange Only
In Silver plans, the insurance company pays about 70%, and the Member pays 30% of the cost for health services.
While all our 2024 Individual and Family plans are available for purchase, the following plans are offered directly through Health Options and are exempt from purchase with Advance Premium Tax Credits. You may purchase them directly through our storefront.
Health Options Clear Choice Silver $5500 HMO Tiered NE Dental Off MP
Preferred Tier The tiered plan offers a preferred cost-share, deductible and out-of-pocket maximum expense. Services received from a preferred provider have a lower cost-share than a standard provider. Expenses from these services will be applied to the preferred deductible, and both the preferred and standard out-of-pocket maximums. Preferred providers are high quality, cost-effective, in-network providers.
$5,500 $11,000
Deductible
$8,500 $17,000
Out-of-pocket Maximum
30% 30%
Coinsurance
Standard Tier The tiered plan offers a standard cost share, deductible and out-of-pocket maximum expense. Services received from a standard provider have a higher cost share than a preferred provider. Expenses from these services will be applied to the standard deductible and standard out-of-pocket maximum. Standard providers are high quality, in-network providers.
$6,600 $13,200
Deductible
$9,100 $18,200
Out-of-pocket Maximum
50% 50%
Coinsurance
- No out-of-network benefits Out-of-network benefits have separate and higher deductibles and cost-sharing and Member responsibility for claims and pre-approval processes.
- Cost-share reductions not available on this plan
- Not available at CoverME.gov marketplace; purchase directly from Community Health Options
INCLUDES
array(7) < [0]=>string(10) “telehealth” [1]=> string(12) “adult_vision” [2]=> string(6) “dental” [3]=> string(12) “chiropractic” [4]=> string(4) “cisp” [5]=> string(9) “preferred” [6]=> string(8) “wellness” >
- Amwell® Telehealth Plan includes $0 access to telehealth for urgent care via Amwell®.
- Vision Plan includes pediatric/adult vision exams once every 12-month calendar year, as well as pediatric lenses, frames and contacts once every 24-month calendar year.
- Pediatric Dental Plan includes pediatric dental coverage for children aged 18 or younger, exclusive of orthodontia.
- Chiropractic/Osteopathic Care Plan includes in-network coverage for chiropractic and osteopathic manipulative therapy.
- CISP Plan includes our Chronic Illness Support Program, which reduces cost sharing for Members with asthma, diabetes, coronary artery disease, chronic pulmonary disease, and hypertension.
- Wellness Benefits This plan includes WellRight, our online digital wellbeing platform and mobile app. Benefits include gamified wellness challenges that enable users to choose a wellness journey that’s personalized, integration with wearable devices, and a comprehensive health assessment for all family members at no cost.
- 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 copay Preferred / $60 copay Standard; no deductible required; copays accumulate to the deductible
