Forms

2011 HC2 Enrollment/Change Form

 

Family Health Statement

In-Area Plan Summaries

• HMO $30/$45
• HMO $30/$45-$2,500
• HMO $20
• POS $30/$45
• POS $30/$45-$2,500-20%
• POS $30/$45-$5,000
• POS $30/$45-$3,000
• POS $20/$40-$1,500
• POS $20/$40-$2,500
• POS $20 and $20 OA
• POS $2,000
  

Benefit Comparison by Insurance Company

HSA Compatible Plan Summaries

• ConnectiCare POS $2500 B
• Oxford $2000 D
• $2500E

Out of Area Plan Summaries

• Oxford USA $20
• Oxford USA $30
• Oxford USA POS $20/$40-$1,500
• Oxford USA POS $30/$45-$3,000
• Oxford USA POS $2,000
• Oxford USA PPO $2,000D (HSA compatible)