HOME > Forms & Documents: Summary of Benefits & Coverage

Forms & Documents: Summary of Benefits & Coverage

To download a file right click on the "Download File" link and select either "Save Link As..." or "Save Target As...".

Claim Forms	Enrollment/Waiver Forms	Financial Information	Summary of Benefits & Coverage	Summary Plan Descriptions
1 - Plan 1: - MMRx View File | Download File Last Updated: Oct 19, 2018 2 - Plan 2: - MMRx View File | Download File Last Updated: Oct 19, 2018 11 - Plan 11: - MMRx View File | Download File Last Updated: Oct 19, 2018 12 - Plan 12: - MMRx View File | Download File Last Updated: Oct 19, 2018 13 - Plan 13: - MMRx View File | Download File Last Updated: Oct 19, 2018 14 - Plan 14: - MMRx View File | Download File Last Updated: Oct 19, 2018 19 - Plan 19: - MMRx View File | Download File Last Updated: Oct 19, 2018 32 - PPO - 100/80 - MMRx View File | Download File Last Updated: Oct 19, 2018 33 - PPO - 100/80 - MMRx View File | Download File Last Updated: Oct 19, 2018 34 - PPO - 90/70 - MMRx View File | Download File Last Updated: Oct 19, 2018 35 - PPO - 90/70 - MMRx View File | Download File Last Updated: Oct 19, 2018 36 - PPO - 80/60 - MMRx View File | Download File Last Updated: Oct 19, 2018 37 - PPO - 80/60 - MMRx View File | Download File Last Updated: Oct 19, 2018 38 - PPO - 100/80 - MMRx View File | Download File Last Updated: Oct 17, 2017 39 - PPO - 90/70 - MMRx View File | Download File Last Updated: Oct 19, 2018 40 - PPO - 80/60 - MMRx View File | Download File Last Updated: Oct 19, 2018 100 - Plan 1: - MMRx View File | Download File Last Updated: Oct 19, 2018 191 - Plan 19: - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 19, 2018 255 - PPO - 80/60 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 19, 2018 256 - PPO - 80/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 19, 2018 257 - PPO - 80/60 - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 19, 2018 321 - PPO - 100/80 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 19, 2018 325 - PPO - 100/80 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 19, 2018 326 - PPO - 100/80 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 19, 2018 331 - PPO - 100/80 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 19, 2018 335 - PPO - 100/80 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 19, 2018 336 - PPO - 100/80 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 19, 2018 341 - PPO - 90/70 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 19, 2018 345 - PPO - 90/70 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 19, 2018 346 - PPO - 90/70 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 19, 2018 351 - PPO - 90/70 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 19, 2018 355 - PPO - 90/70 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 19, 2018 356 - PPO - 90/70 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 19, 2018 361 - PPO - 80/60 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 19, 2018 366 - PPO - 80/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 19, 2018 371 - PPO - 80/60 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 19, 2018 375 - PPO - 80/60 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 19, 2018 376 - PPO - 80/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 19, 2018 381 - PPO - 100/80 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 19, 2018 385 - PPO - 100/80 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 19, 2018 386 - PPO - 100/80 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 19, 2018 391 - PPO - 90/70 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 19, 2018 395 - PPO - 90/70 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 19, 2018 396 - PPO - 90/70 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 19, 2018 401 - PPO - 80/60 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 19, 2018 405 - PPO - 80/60 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 19, 2018 406 - PPO - 80/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 19, 2018 411 - DA - 100/60 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 12, 2018 415 - DA - 100/60 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 12, 2018 416 - DA - 100/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 12, 2018 417 - DA - 100/60 - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 12, 2018 421 - DA - 90/60 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 12, 2018 425 - DA - 90/60 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 12, 2018 426 - DA - 90/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 12, 2018 427 - DA - 90/60 - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 12, 2018 431 - DA - 90/60 - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 12, 2018 435 - DA - 90/60 - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 12, 2018 436 - DA - 90/60 - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 12, 2018 437 - DA - 90/60 - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 12, 2018 441 - DA - 80/60 - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 12, 2018 445 - DA - 80/60 - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 12, 2018 446 - DA - 80/60 - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 12, 2018 447 - DA - 80/60 - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 12, 2018 451 - DA - 100/60 R - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 12, 2018 455 - DA - 100/60 R - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 12, 2018 456 - DA - 100/60 R - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 12, 2018 457 - DA - 100/60 R - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 12, 2018 461 - DA - 80/60 R - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 12, 2018 465 - DA - 80/60 R - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 12, 2018 466 - DA - 80/60 R - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 12, 2018 467 - DA - 80/60 R - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 12, 2018 471 - DA - $1500 Deductible - 80/60 - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 12, 2018 475 - DA - $1500 Deductible - 80/60 - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 12, 2018 476 - DA - $1500 Deductible - 80/60 - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 12, 2018 477 - DA - $1500 Deductible - 80/60 - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 12, 2018 481 - DA - $2500 Deductible - 80/60 - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 12, 2018 485 - DA - $2500 Deductible - 80/60 - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 12, 2018 486 - DA - $2500 Deductible - 80/60 - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 12, 2018 487 - DA - $2500 Deductible - 80/60 - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 12, 2018 491 - DA - $1500 Deductible - 100/60 - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 12, 2018 495 - DA - $1500 Deductible - 100/60 - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 12, 2018 496 - DA - $1500 Deductible - 100/60 - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 12, 2018 497 - DA - $1500 Deductible - 100/60 - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 12, 2018 508 - MyWay HSA Preferred Provider Organization 80/60 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 12, 2018 509 - MyWay HSA Preferred Provider Organization 80/60 - CDHRx View File | Download File Last Updated: Oct 12, 2018 596 - DA - $2500 Deductible - 50/50 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Sep 10, 2019 608 - MyWay HSA Direct Access 80/60 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 12, 2018 609 - MyWay HSA Direct Access 80/60 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 12, 2018 611 - MyWay HSA Direct Access 50/50 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Sep 10, 2019 618 - MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 12, 2018 619 - MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 12, 2018 620 - MyWay HSA Direct Access 100% - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 12, 2018 621 - MyWay HSA Direct Access 100% - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 12, 2018 623 - MyWay HSA Direct Access 70% - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Sep 10, 2019 628 - MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 12, 2018 629 - MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 12, 2018 630 - MyWay HSA Direct Access 100% - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 12, 2018 631 - MyWay HSA Direct Access 100% - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 12, 2018 638 - MyWay HSA Direct Access 80/60 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 12, 2018 639 - MyWay HSA Direct Access 80/60 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 12, 2018 811 - Direct Access EPO - 100% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 12, 2018 815 - Direct Access EPO - 100% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 12, 2018 816 - Direct Access EPO - 100% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 12, 2018 817 - Direct Access EPO - 100% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 12, 2018 821 - Direct Access EPO - 80% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 12, 2018 825 - Direct Access EPO - 80% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 12, 2018 826 - Direct Access EPO - 80% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 12, 2018 827 - Direct Access EPO - 80% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 12, 2018 831 - Direct Access EPO - $1500 Deductible - 80% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 12, 2018 835 - Direct Access EPO - $1500 Deductible - 80% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 12, 2018 836 - Direct Access EPO - $1500 Deductible - 80% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 12, 2018 837 - Direct Access EPO - $1500 Deductible - 80% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 12, 2018 841 - Direct Access EPO - $2500 Deductible - 80% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 12, 2018 845 - Direct Access EPO - $2500 Deductible - 80% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 12, 2018 846 - Direct Access EPO - $2500 Deductible - 80% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 12, 2018 847 - Direct Access EPO - $2500 Deductible - 80% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 12, 2018 851 - Direct Access EPO - $2500 Deductible - 100% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 19, 2018 855 - Direct Access EPO - $2500 Deductible - 100% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 19, 2018 856 - Direct Access EPO - $2500 Deductible - 100% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 19, 2018 857 - Direct Access EPO - $2500 Deductible - 100% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 19, 2018 861 - Direct Access EPO - $2500 Deductible - 50% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 12, 2018 865 - Direct Access EPO - $2500 Deductible - 50% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 12, 2018 866 - Direct Access EPO - $2500 Deductible - 50% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 12, 2018 867 - Direct Access EPO - $2500 Deductible - 50% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 12, 2018 873 - Direct Access EPO - $3500 Deductible - 50% Network Only - Fixed Co-Pay $10/$50/$75 Rx View File | Download File Last Updated: Sep 10, 2019 913 - OMNIA 100/60 - Fixed Co-Pay $10/$50/$75 Rx View File | Download File Last Updated: Oct 30, 2018 929 - OMNIA HSA 80/50 - 60% Rx (after Deductible) View File | Download File Last Updated: Oct 30, 2018 934 - OMNIA 100/50 - $15/60%/50% Rx View File | Download File Last Updated: Oct 30, 2018 949 - OMNIA HSA 90/70 - 60% Rx (after Deductible) View File | Download File Last Updated: Oct 30, 2018 958 - OMNIA 50/50 - 50% Rx (after Deductible) View File | Download File Last Updated: Oct 30, 2018

- Get Adobe Reader to view the files with this icon.
- Get Microsoft Word Viewer to view the files with this icon, if you don't already have Microsoft Word installed.