2017

Navitus EHB Formulary (updated 4-1-17)

2017 4th Qtr SimpleCare Rates – ON (5000)

2017 4th Qtr SimpleCare Rates – OFF

2017 3rd Qtr SimpleCare Rates – ON (5000)

2017 3rd Qtr SimpleCare Rates – OFF

2017 2nd Qtr SimpleCare Rates – ON (5000) 

2017 2nd Qtr SimpleCare Rates – OFF

2017 1st Qtr SimpleCare Rates – ON (5000) 

2017 1st Qtr SimpleCare Rates – OFF

Platinum

0050040
OFF Marketplace
ON Marketplace

0050042
OFF Marketplace
ON Marketplace

0050044
OFF Marketplace
ON Marketplace

Gold

0050046
OFF Marketplace
ON Marketplace

0050048
OFF Marketplace
ON Marketplace

0050050
OFF Marketplace
ON Marketplace

0050052
OFF Marketplace
ON Marketplace

0050054
OFF Marketplace
ON Marketplace

Silver

0050056
OFF Marketplace
ON Marketplace

0050058
OFF Marketplace
ON Marketplace

0050060
OFF Marketplace
ON Marketplace

0050062
OFF Marketplace
ON Marketplace

0050064
OFF Marketplace
ON Marketplace

0050066
OFF Marketplace
ON Marketplace

0050068
OFF Marketplace
ON Marketplace

0050070
OFF Marketplace
ON Marketplace

Bronze

0050074
OFF Marketplace
ON Marketplace

OFF Marketplace – 80000 Series

Alliant Health Plans Network & PHCS Wrap Network

Platinum

0080040
OFF Marketplace
–

0080042
OFF Marketplace
–

0080044
OFF Marketplace

Gold

0080046
OFF Marketplace
–

0080048
OFF Marketplace
–

0080050
OFF Marketplace
–

0080052
OFF Marketplace
–

0080054
OFF Marketplace
–

Silver

0080056
OFF Marketplace
–

0080058
OFF Marketplace
–

0080060
OFF Marketplace
–

0080062
OFF Marketplace
–

0080064
OFF Marketplace
–

0080066
OFF Marketplace
–

0080068
OFF Marketplace
–

0080070
OFF Marketplace
–

Bronze

0080074
OFF Marketplace
–

OFF Marketplace – 900 Series

Alliant Health Plans Network & PHCS Wrap Network

Gold

0090076
OFF Marketplace
–

0090077
OFF Marketplace

Silver

0090078
OFF Marketplace
–

0090079
OFF Marketplace

Bronze

0090080
OFF Marketplace
–

0090081
OFF Marketplace

2016

2016 4th Qtr SimpleCare Rates

2016 3rd Qtr SimpleCare Rates

2016 2nd Qtr SimpleCare Rates

ON & OFF Marketplace – 50000 Series

Alliant Health Plans Network

Gold

0050001
OFF Marketplace
ON Marketplace

0050002
OFF Marketplace
ON Marketplace

0050003
OFF Marketplace
ON Marketplace

0050004
OFF Marketplace
ON Marketplace

0050005
OFF Marketplace
ON Marketplace

0050006
OFF Marketplace
ON Marketplace

Silver

0050007
OFF Marketplace
ON Marketplace

0050008
OFF Marketplace
ON Marketplace

0050009
OFF Marketplace
ON Marketplace

0050010
OFF Marketplace
ON Marketplace

0050011
OFF Marketplace
ON Marketplace

0050012
OFF Marketplace
ON Marketplace

0050013
OFF Marketplace
ON Marketplace

0050014
OFF Marketplace
ON Marketplace

0050015
OFF Marketplace
ON Marketplace

0050016
OFF Marketplace
ON Marketplace

0050019
OFF Marketplace
ON Marketplace

0050020
OFF Marketplace
ON Marketplace

0050021
OFF Marketplace
ON Marketplace

Bronze

0050017
OFF Marketplace
ON Marketplace

0050018
OFF Marketplace
ON Marketplace

0050022
OFF Marketplace
ON Marketplace

OFF Marketplace – 80000 & 90000 Series

Alliant Health Plans & PHCS Wrap Network

Gold

0080023
OFF Marketplace
–

0080024
OFF Marketplace
–

0080025
OFF Marketplace
–

0080026
OFF Marketplace
–

0080027
OFF Marketplace
–

0080028
OFF Marketplace

Silver

0080029
OFF Marketplace
–

0080030
OFF Marketplace
–

0080031
OFF Marketplace
–

0080032
OFF Marketplace
–

0080033
OFF Marketplace
–

0080034
OFF Marketplace
–

0080035
OFF Marketplace
–

0080036
OFF Marketplace
–

0080037
OFF Marketplace
–

0080038
OFF Marketplace
–

0080041
OFF Marketplace
–

0080042
OFF Marketplace
–

0080043
OFF Marketplace

Bronze

0080039
OFF Marketplace
–

0080040
OFF Marketplace
–

0090044
OFF Marketplace

Legacy Plans

10CYPP

Alliant Health Plans Network & PHCS Wrap Network

501
02 – 07 – 09
18 – 19 – 32

1002
02 – 07 – 09
18 – 19 – 32

2002
02 – 07 – 09
18 – 19 – 32

2505
02 – 07 – 09
18 – 19 – 32

5001
02 – 07 – 09
18 – 19 – 32

7501
02 – 07 – 09
18 – 19 – 32

502
02 – 07 – 09
19 – Rx19

1500
02 – 07 – 09
18 – 19 – 32

2501
02 – 07 – 09
18 – 19 – 32

3001
02 – 07 – 09
18 – 19 – 32

5003
02 – 07 – 09
18 – 19 – 32

7502
02 – 07 – 09
18 – 19 – 32

1000
02 – 07 – 09
18 – 19 – 32

1501
02 – 07 – 09
18 – 19 – 32

2502
02 – 07 – 09
18 – 19 – 32

3002
02 – 07 – 09
18 – 19 – 32

5004
02 – 07 – 09
18 – 19 – 32

1001
02 – 07 – 09
18 – 19 – 32

2001
02 – 07 – 09
18 – 19 – 32

2504
02 – 07 – 09
18 – 19 – 32

3003
02 – 07 – 09
18 – 19 – 32

5005
02 – 07 – 09
18 – 19 – 32

10HDHP

Alliant Health Plans Network & PHCS Wrap Network

1500
14
–

5000
14

2501
14
–

2502
14
–

3000
14
–