40 Square

Welcome to the 40 Square rate estimate tool

This tool can be used to give you and your family members an estimated cost of coverage for all six 40 Square health plan offerings based on zip code and age only.

Click "Get Started" below to begin.

Step 1 - Enter Employer's Zip Code


Step 2 - Members to Estimate

Please enter the date of birth for each member you wish to estimate. Press the "Add New Member" to add additional members.

Dates must be in the form of m/d/yyyy (e.g. 9/9/1968)



NameDate of Birth 



Open enrollment will take place November 1, 2017 to December 15, 2017. You can return to 40square.coop at that time to receive a full quote.



$1,500 Deductible Plan $2,500 Deductible Plan $3,500 Deductible Plan
HSA Compatible
$4,500 Deductible Plan
HSA Compatible
$5,500 Deductible Plan
HSA Compatible
$6,550 Deductible Plan
HSA Compatible
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Total Monthly Rate Estimate: ${{ total.gp1 }} ${{ total.sp1 }} ${{ total.sp2 }} ${{ total.bp1 }} ${{ total.bp2 }} ${{ total.bp3 }}
 
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$1,500 Deductible Plan $2,500 Deductible Plan $3,500 Deductible Plan
HSA Compatible
$4,500 Deductible Plan
HSA Compatible
$5,500 Deductible Plan
HSA Compatible
$6,550 Deductible Plan
HSA Compatible
Benefit In-Network In-Network In-Network In-Network In-Network In-Network
Annual Deductible
  Single $1,500 $2,500 $3,500 $4,500 $5,500 $6,500
  Family $3,000 $5,000 $7,000 $9,000 $11,000 $13,100

Benefit Percentage & Out-of-Pocket Maximum

(Includes deductible, coinsurance, and co-pays)
Deductible and 20% except where noted below. Out-of-Pocket Maximum

  $3,000 / person
  $6,000 / family
Deductible and 25% except where noted below. Out-of-Pocket Maximum

  $7,150 / person
  $14,300 / family
Deductible and 20% except where noted below. Out-of-Pocket Maximum

  $4,500 / person
  $9,000 / family
Deductible and 20% except where noted below. Out-of-Pocket Maximum

  $6,500 / person
  $13,100 / family
Deductible and 25% except where noted below. Out-of-Pocket Maximum

  $6,850 / person
  $13,700 / family
Deductible and 30% except where noted below. Out-of-Pocket Maximum

  $7,150 / person
  $14,300 / family
Office Visits (Illness and Injury) Deductible & 20% Deductible & 20% Deductible & 25% Deductible & 30%
  Primary Care $40 $40
  Specialist $75 $75
  Retail Health Clinic $20 $20
  Urgent Care $50 $50
  E-visits $15 $15

Routine Preventative Care

  Physicals, Pre-Cancer Screening, Immunizations, Routine Labs

100%
(Deductible Waived)

100%
(Deductible Waived)

100%
(Deductible Waived)

100%
(Deductible Waived)

100%
(Deductible Waived)

100%
(Deductible Waived)
Hospital and Professional Services
  Inpatient Deductible & 20% Deductible & 25% Deductible & 20% Deductible & 20% Deductible & 25% Deductible & 30%
  Outpatient Deductible & 20% Deductible & 25% Deductible & 20% Deductible & 20% Deductible & 25% Deductible & 30%
  Emergency Room Deductible & 20% Deductible & 25% Deductible & 20% Deductible & 20% Deductible & 25% Deductible & 30%
Prescription Drugs
Retail 31-Day Supply 31-Day Supply Deductible & 20% Deductible & 20% Deductible & 25% Deductible & 30%
  Generic $10 $10
  Formulary $40 $40
  Non-formulary $100 $100
Mail-Order 90-Day Supply 90-Day Supply
  Generic $25 $25
  Formulary $100 $100
  Non-formulary $250 $250
Specialty (per script) 20% to $350 25% to $350
Benefit Out-of-Network Out-of-Network Out-of-Network Out-of-Network Out-of-Network Out-of-Network
Deductible
  Single $10,000 / person $10,000 / person $10,000 / person $10,000 / person $10,000 / person $10,000 / person
  Family $20,000 / family $20,000 / family $20,000 / family $20,000 / family $20,000 / family $20,000 / family

Benefit Percentage & Out-of-Pocket Maximum

(Includes deductible, coinsurance)
Deductible and 50%. Out-of-Pocket Maximum

  $30,000 / person
  $60,000 / family
Deductible and 50%. Out-of-Pocket Maximum

  $30,000 / person
  $60,000 / family
Deductible and 50%. Out-of-Pocket Maximum

  $30,000 / person
  $60,000 / family
Deductible and 50%. Out-of-Pocket Maximum

  $30,000 / person
  $60,000 / family
Deductible and 50%. Out-of-Pocket Maximum

  $30,000 / person
  $60,000 / family
Deductible and 50%. Out-of-Pocket Maximum

  $30,000 / person
  $60,000 / family