Presbyterian Group Summary of Benefits

The following are Presbyterian's Summaries of Benefits for High Deductible Health Plan (HDHP), HMO, POS, PPO, and Indemnity programs as well as Prescription Drug, Substance Abuse, Dental and Vision Riders.

Check out our Forms and Documents page for side-by-side comparisons of these products.

All documents on this page are Adobe Acrobat files.

PHP Health Care Reform Endorsement 
PIC Health Care Reform Endorsement

HDHP (qualified High Deductible Health Plans)

Small Group Size 2-50

• HDHP PPO Plans without Rx
  • Advantage Care 1200/80 (10022)
  • Advantage Care 2500/100 (10023)
  • Advantage Care 2500/80 (10024)
  • Advantage Care 5000/100 (10025)

• HDHP PPO Plans with Rx
  • Advantage Care 1200/80 (10022)
  • Advantage Care 2500/100 (10023)
  • Advantage Care 2500/80 (10024)
  • Advantage Care 5000/100 (10025)

Large Group (size 51+)

HDHP PPO Plans without Rx

• Advantage Care 1200/80 (10022)
• Advantage Care 2500/100 (10023)
• Advantage Care 2500/80 (10024)
• Advantage Care 5000/100 (10025)

HDHP Indemnity Plans

• Advantage Care 1200/80 LG (10002)
• Advantage Care 2500/80 LG (10003)
• Advantage Care 5000/100 LG (10004)

HDHP Large Group Riders

• Prescription Drug Rider
• PPO SA Rider
• Indemnity SA Rider

The above large group HDHP medical plans include a discount prescription drug benefit only. For a more comprehensive prescription benefit, the Prescription Drug Rider must be purchased.

HMO

Small Group Size 2-50

• Value Care 10/250 (10021)
• Value Care 15/250 (10027)
• Value Care 15/500 without RX (10022)
• Value Care 20/500 (10029)
• Value Care 30/1000 (10031)
• Value Care 40/1500 (10053)

• Smart Care 500/30 (10039)
• Smart Care 750/30 (10040)
• Smart Care 1250/30 (10038)
• Smart Care 1250/30 without RX (10050)
• Smart Care 2000/30 (10041)
• Smart Care 2500/30 (10073)
• Smart Care 5000/30 (10074)

Large Group 51+

• Custom Care 5/100 (10024)
• Custom Care 10/0 (10026)
• Custom Care 10/250 (10025) 
• Custom Care 15/250 (10027)
• Custom Care 15/100 (10028)
• Custom Care 15/500 (10033)
• Custom Care 20/500 (10029)
• Custom Care 20/200 (10030)
• Custom Care 20/300 (10032)
• Custom Care 30/1000 (10031)
• Custom Care 30/500 (10047)
• Custom Care 40/1500 (10053)

• Smart Care 500/30 (10039) 
• Smart Care 750/30 (10040)
• Smart Care 1250/30 (10038)
• Smart Care 2000/30 (10041)
• Smart Care 2500/30 (10073)
• Smart Care 5000/30 (10074)

Group Size 4+

• My Care Active
• My Care Family
• My Care Independent

POS

Small Group Size 10-50

• Choice Care 10
• Choice Care 15
• Choice Care 30

Large Group 51+

• Flex Care 10
• Flex Care 15
• Flex Care 30

PPO

Small Group Size 2-50

• Preferred Care $250 dd 80-20 (10015)
• Preferred Care $500 dd 80-20 (10003)
• Preferred Care $750 dd 80-20 (10004)
• Preferred Care $1000 dd 80-20 (10005)
• Preferred Care $1500 dd 80-20 (10006)
• Preferred Care $2000 dd 80/20 (10007)
• Preferred Care $750 dd 70-30 (10009)
• Preferred Care $1000 dd 70-30 (10010)
• Preferred Care $1500 dd 70-30 (10011)
• Preferred Care $2000 dd 70-30 (10012)

Large Group Size 51+

• Preferred Care $250 dd 80-20 (10015)
• Preferred Care $500 dd 80-20 (10003)
• Preferred Care $750 dd 80-20 (10004)
• Preferred Care $1000 dd 80-20 (10005)
• Preferred Care $1500 dd 80-20 (10006)
• Preferred Care $2000 dd 80-20 (10007)
• Preferred Care $750 dd 70-30 (10009)
• Preferred Care $1000 dd 70-30 (10010)
• Preferred Care $1500 dd 70-30 (10011)
• Preferred Care $2000 dd 70-30 (10012)

INDEMNITY

• Indemnity Plan $250
• Indemnity Plan $500

RIDERS

Prescription and Substance Abuse Riders are available with all Large Group plans except HDHPs.

Prescription Drug Riders

HMO

• 7-25-45
• 10-20-40
• 10-30-50
• 10-35-55
• 15-35-55

POS

• 7-25-45
• 10-20-40
• 10-30-50
• 10-35-55
• 15-35-55

PPO

• 7-25-45
• 10-20-40
• 10-30-50
• 10-35-55
• 15-35-55

Substance Abuse Riders (no longer available after November 1, 2010)

HMO

• 20%
• 50%

POS

• 20%
• 50%

PPO

• 20%-40%
• 30%-50%

Vision

VSP Eyecare Plans
VSP 2-50 Rates
VSP 51 - 249 Rates
VSP 250 + Rates