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Forms & Documents: Summary of Benefits & Coverage

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Claim Forms	Enrollment/Waiver Forms	Financial Information	Summary of Benefits & Coverage	Summary Plan Descriptions
11 - Plan 11: - MMRx View File | Download File Last Updated: Oct 17, 2017 19 - Plan 19: - MMRx View File | Download File Last Updated: Oct 17, 2017 32 - PPO - 100/80 - MMRx View File | Download File Last Updated: Oct 17, 2017 33 - PPO - 100/80 - MMRx View File | Download File Last Updated: Oct 17, 2017 34 - PPO - 90/70 - MMRx View File | Download File Last Updated: Oct 17, 2017 35 - PPO - 90/70 - MMRx View File | Download File Last Updated: Oct 17, 2017 36 - PPO - 80/60 - MMRx View File | Download File Last Updated: Oct 17, 2017 37 - PPO - 80/60 - MMRx View File | Download File Last Updated: Oct 17, 2017 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 17, 2017 40 - PPO - 80/60 - MMRx View File | Download File Last Updated: Oct 17, 2017 100 - Plan 1: - MMRx View File | Download File Last Updated: Oct 17, 2017 255 - PPO - 80/60 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 256 - PPO - 80/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 257 - PPO - 80/60 - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 17, 2017 321 - PPO - 100/80 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 325 - PPO - 100/80 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 326 - PPO - 100/80 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 331 - PPO - 100/80 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 335 - PPO - 100/80 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 336 - PPO - 100/80 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 341 - PPO - 90/70 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 345 - PPO - 90/70 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 346 - PPO - 90/70 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 351 - PPO - 90/70 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 355 - PPO - 90/70 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 356 - PPO - 90/70 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 361 - PPO - 80/60 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 366 - PPO - 80/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 371 - PPO - 80/60 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 375 - PPO - 80/60 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 376 - PPO - 80/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 381 - PPO - 100/80 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 385 - PPO - 100/80 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Jun 20, 2017 386 - PPO - 100/80 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 391 - PPO - 90/70 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 395 - PPO - 90/70 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 396 - PPO - 90/70 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 401 - PPO - 80/60 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 405 - PPO - 80/60 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 406 - PPO - 80/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 411 - DA - 100/60 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 415 - DA - 100/60 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 416 - DA - 100/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 417 - DA - 100/60 - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 17, 2017 421 - DA - 90/60 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 425 - DA - 90/60 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 426 - DA - 90/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 427 - DA - 90/60 - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 17, 2017 431 - DA - 90/60 - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 435 - DA - 90/60 - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 436 - DA - 90/60 - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 437 - DA - 90/60 - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 17, 2017 441 - DA - 80/60 - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 445 - DA - 80/60 - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 446 - DA - 80/60 - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 447 - DA - 80/60 - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 17, 2017 451 - DA - 100/60 R - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 455 - DA - 100/60 R - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 456 - DA - 100/60 R - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 457 - DA - 100/60 R - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 17, 2017 461 - DA - 80/60 R - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 465 - DA - 80/60 R - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 466 - DA - 80/60 R - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 467 - DA - 80/60 R - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 17, 2017 471 - DA - $1500 Deductible - 80/60 - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 475 - DA - $1500 Deductible - 80/60 - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 476 - DA - $1500 Deductible - 80/60 - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 477 - DA - $1500 Deductible - 80/60 - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 17, 2017 481 - DA - $2500 Deductible - 80/60 - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 485 - DA - $2500 Deductible - 80/60 - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 486 - DA - $2500 Deductible - 80/60 - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 487 - DA - $2500 Deductible - 80/60 - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 17, 2017 491 - DA - $1500 Deductible - 100/60 - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 495 - DA - $1500 Deductible - 100/60 - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 496 - DA - $1500 Deductible - 100/60 - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 497 - DA - $1500 Deductible - 100/60 - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 17, 2017 508 - MyWay HSA Preferred Provider Organization 80/60 - CDHRx View File | Download File Last Updated: Oct 17, 2017 509 - MyWay HSA Preferred Provider Organization 80/60 - CDHRx View File | Download File Last Updated: Oct 17, 2017 608 - MyWay HSA Direct Access 80/60 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 17, 2017 609 - MyWay HSA Direct Access 80/60 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 17, 2017 618 - MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 17, 2017 619 - MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 17, 2017 620 - MyWay HSA Direct Access 100% - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 17, 2017 621 - MyWay HSA Direct Access 100% - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 17, 2017 628 - MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Jun 20, 2017 629 - MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 18, 2017 630 - MyWay HSA Direct Access 100% - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 18, 2017 631 - MyWay HSA Direct Access 100% - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 18, 2017 811 - Direct Access EPO - 100% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 815 - Direct Access EPO - 100% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 816 - Direct Access EPO - 100% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 817 - Direct Access EPO - 100% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 18, 2017 821 - Direct Access EPO - 80% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 825 - Direct Access EPO - 80% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 826 - Direct Access EPO - 80% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 827 - Direct Access EPO - 80% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 17, 2017 831 - Direct Access EPO - $1500 Deductible - 80% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 835 - Direct Access EPO - $1500 Deductible - 80% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 836 - Direct Access EPO - $1500 Deductible - 80% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 837 - Direct Access EPO - $1500 Deductible - 80% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 17, 2017 841 - Direct Access EPO - $2500 Deductible - 80% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 845 - Direct Access EPO - $2500 Deductible - 80% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 846 - Direct Access EPO - $2500 Deductible - 80% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 847 - Direct Access EPO - $2500 Deductible - 80% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 17, 2017 851 - Direct Access EPO - $2500 Deductible - 100% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Jan 15, 2018 855 - Direct Access EPO - $2500 Deductible - 100% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Jan 15, 2018 856 - Direct Access EPO - $2500 Deductible - 100% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Jan 15, 2018 857 - Direct Access EPO - $2500 Deductible - 100% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Jan 15, 2018 861 - Direct Access EPO - $2500 Deductible - 50% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 17, 2017 865 - Direct Access EPO - $2500 Deductible - 50% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 17, 2017 866 - Direct Access EPO - $2500 Deductible - 50% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 17, 2017 867 - Direct Access EPO - $2500 Deductible - 50% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 17, 2017 913 - OMNIA 100/60 - Fixed Co-Pay $10/$50/$75 Rx View File | Download File Last Updated: Oct 17, 2017 929 - OMNIA HSA 80/50 - 60% Rx (after Deductible) View File | Download File Last Updated: Oct 17, 2017 934 - OMNIA 100/50 - $15/60%/50% Rx View File | Download File Last Updated: Oct 17, 2017 949 - OMNIA HSA 90/70 - 60% Rx (after Deductible) View File | Download File Last Updated: Oct 17, 2017 958 - OMNIA 50/50 - 50% Rx (after Deductible) View File | Download File Last Updated: Oct 17, 2017

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