AMT - Summary of Benefits & Coverage

1 - Plan 1: - MMRx

Last Updated: Nov 1, 2022

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100 - Plan 1: - MMRx

Last Updated: Nov 1, 2022

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11 - Plan 11: - MMRx

Last Updated: Nov 1, 2022

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12 - Plan 12: - MMRx

Last Updated: Nov 1, 2022

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2 - Plan 2: - MMRx

Last Updated: Nov 1, 2022

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255 - PPO - 80/60 HSCP - $1000 DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Preferred Provider Organization (PPO) Plan 255: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; $1000 Deductible; w/ BlueCard - Prescription Drug: Co-Insurance Co-Pay 70%/30% Rx

Last Updated: Oct 31, 2022

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256 - PPO - 80/60 HSCP - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Preferred Provider Organization (PPO) Plan 256: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; $1000 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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257 - PPO - 80/60 HSCP - $1000 DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Preferred Provider Organization (PPO) Plan 257: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; $1000 Deductible; w/ BlueCard - Prescription Drug: Co-Insurance Co-Pay 50%/50% Rx

Last Updated: Oct 31, 2022

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32 - PPO - 100/80 - $250 DEDUCTIBLE - MMRx

Preferred Provider Organization (PPO) Plan 32: 100% In-Network Coinsurance, 80% Out-of-Network Coinsurance; $250 Deductible; w/ BlueCard - Prescription Drug: MMRx

Last Updated: Oct 31, 2022

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321 - PPO - 100/80 - $250 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Preferred Provider Organization (PPO) Plan 321: 100% In-Network Coinsurance, 80% Out-of-Network Coinsurance; $250 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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325 - PPO - 100/80 - $250 DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Preferred Provider Organization (PPO) Plan 325: 100% In-Network Coinsurance, 80% Out-of-Network Coinsurance; $250 Deductible; w/ BlueCard - Prescription Drug: Co-Insurance Co-Pay 70%/30% Rx

Last Updated: Oct 31, 2022

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326 - PPO - 100/80 - $250 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Preferred Provider Organization (PPO) Plan 326: 100% In-Network Coinsurance, 80% Out-of-Network Coinsurance; $250 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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33 - PPO - 100/80 - $500 DEDUCTIBLE - MMRx

Preferred Provider Organization (PPO) Plan 33: 100% In-Network Coinsurance, 80% Out-of-Network Coinsurance; $500 Deductible; w/ BlueCard - Prescription Drug: MMRx

Last Updated: Oct 31, 2022

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331 - PPO - 100/80 - $500 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Preferred Provider Organization (PPO) Plan 331: 100% In-Network Coinsurance, 80% Out-of-Network Coinsurance; $500 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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335 - PPO - 100/80 - $500 DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Preferred Provider Organization (PPO) Plan 335: 100% In-Network Coinsurance, 80% Out-of-Network Coinsurance; $500 Deductible; w/ BlueCard - Prescription Drug: Co-Insurance Co-Pay 70%/30% Rx

Last Updated: Oct 31, 2022

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336 - PPO - 100/80 - $500 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Preferred Provider Organization (PPO) Plan 336: 100% In-Network Coinsurance, 80% Out-of-Network Coinsurance; $500 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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34 - PPO - 90/70 - $250 DEDUCTIBLE - MMRx

Preferred Provider Organization (PPO) Plan 34: 90% In-Network Coinsurance, 70% Out-of-Network Coinsurance; $250 Deductible; w/ BlueCard - Prescription Drug: MMRx

Last Updated: Oct 31, 2022

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341 - PPO - 90/70 - $250 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Preferred Provider Organization (PPO) Plan 341: 90% In-Network Coinsurance, 70% Out-of-Network Coinsurance; $250 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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345 - PPO - 90/70 - $250 DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Preferred Provider Organization (PPO) Plan 345: 90% In-Network Coinsurance, 70% Out-of-Network Coinsurance; $250 Deductible; w/ BlueCard - Prescription Drug: Co-Insurance Co-Pay 70%/30% Rx

Last Updated: Oct 31, 2022

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346 - PPO - 90/70 - $250 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Preferred Provider Organization (PPO) Plan 346: 90% In-Network Coinsurance, 70% Out-of-Network Coinsurance; $250 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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35 - PPO - 90/70 - $500 DEDUCTIBLE - MMRx

Preferred Provider Organization (PPO) Plan 35: 90% In-Network Coinsurance, 70% Out-of-Network Coinsurance; $500 Deductible; w/ BlueCard - Prescription Drug: MMRx

Last Updated: Oct 31, 2022

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351 - PPO - 90/70 - $500 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Preferred Provider Organization (PPO) Plan 351: 90% In-Network Coinsurance, 70% Out-of-Network Coinsurance; $500 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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355 - PPO - 90/70 - $500 DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Preferred Provider Organization (PPO) Plan 355: 90% In-Network Coinsurance, 70% Out-of-Network Coinsurance; $500 Deductible; w/ BlueCard - Prescription Drug: Co-Insurance Co-Pay 70%/30% Rx

Last Updated: Oct 31, 2022

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356 - PPO - 90/70 - $500 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Preferred Provider Organization (PPO) Plan 356: 90% In-Network Coinsurance, 70% Out-of-Network Coinsurance; $500 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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36 - PPO - 80/60 - $250 DEDUCTIBLE - MMRx

Preferred Provider Organization (PPO) Plan 36: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; $250 Deductible; w/ BlueCard - Prescription Drug: MMRx

Last Updated: Oct 31, 2022

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361 - PPO - 80/60 - $250 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Preferred Provider Organization (PPO) Plan 361: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; $250 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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366 - PPO - 80/60 - $250 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Preferred Provider Organization (PPO) Plan 366: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; $250 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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37 - PPO - 80/60 - $500 DEDUCTIBLE - MMRx

Preferred Provider Organization (PPO) Plan 37: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; $500 Deductible; w/ BlueCard - Prescription Drug: MMRx

Last Updated: Oct 31, 2022

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371 - PPO - 80/60 - $500 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Preferred Provider Organization (PPO) Plan 371: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; $500 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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375 - PPO - 80/60 - $500 DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Preferred Provider Organization (PPO) Plan 375: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; $500 Deductible; w/ BlueCard - Prescription Drug: Co-Insurance Co-Pay 70%/30% Rx

Last Updated: Oct 31, 2022

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376 - PPO - 80/60 - $500 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Preferred Provider Organization (PPO) Plan 376: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; $500 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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38 - PPO - 100/80 - $1000 DEDUCTIBLE - MMRx

Preferred Provider Organization (PPO) Plan 38: 100% In-Network Coinsurance, 80% Out-of-Network Coinsurance; $1000 Deductible; w/ BlueCard - Prescription Drug: MMRx

Last Updated: Oct 31, 2022

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381 - PPO - 100/80 - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Preferred Provider Organization (PPO) Plan 381: 100% In-Network Coinsurance, 80% Out-of-Network Coinsurance; $1000 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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386 - PPO - 100/80 - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Preferred Provider Organization (PPO) Plan 386: 100% In-Network Coinsurance, 80% Out-of-Network Coinsurance; $1000 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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39 - PPO - 90/70 - $1000 DEDUCTIBLE - MMRx

Preferred Provider Organization (PPO) Plan 39: 90% In-Network Coinsurance, 70% Out-of-Network Coinsurance; $1000 Deductible; w/ BlueCard - Prescription Drug: MMRx

Last Updated: Oct 31, 2022

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391 - PPO - 90/70 - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Preferred Provider Organization (PPO) Plan 391: 90% In-Network Coinsurance, 70% Out-of-Network Coinsurance; $1000 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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395 - PPO - 90/70 - $1000 DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Preferred Provider Organization (PPO) Plan 395: 90% In-Network Coinsurance, 70% Out-of-Network Coinsurance; $1000 Deductible; w/ BlueCard - Prescription Drug: Co-Insurance Co-Pay 70%/30% Rx

Last Updated: Oct 31, 2022

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396 - PPO - 90/70 - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Preferred Provider Organization (PPO) Plan 396: 90% In-Network Coinsurance, 70% Out-of-Network Coinsurance; $1000 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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40 - PPO - 80/60 - $1000 DEDUCTIBLE - MMRx

Preferred Provider Organization (PPO) Plan 40: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; $1000 Deductible; w/ BlueCard - Prescription Drug: MMRx

Last Updated: Oct 31, 2022

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401 - PPO - 80/60 - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Preferred Provider Organization (PPO) Plan 401: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; $1000 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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405 - PPO - 80/60 - $1000 DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Preferred Provider Organization (PPO) Plan 405: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; $1000 Deductible; w/ BlueCard - Prescription Drug: Co-Insurance Co-Pay 70%/30% Rx

Last Updated: Oct 31, 2022

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406 - PPO - 80/60 - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Preferred Provider Organization (PPO) Plan 406: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; $1000 Deductible; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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411 - DA - 100/60 - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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411L - DA - 100/60 - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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415 - DA - 100/60 - $1000 DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Last Updated: Oct 31, 2022

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415L - DA - 100/60 - $1000 DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Last Updated: Oct 31, 2022

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416 - DA - 100/60 - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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416L - DA - 100/60 - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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417 - DA - 100/60 - $1000 DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Oct 31, 2022

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417L - DA - 100/60 - $1000 DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Oct 31, 2022

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421 - DA - 90/60 - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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421L - DA - 90/60 - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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425 - DA - 90/60 - $1000 DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Last Updated: Oct 31, 2022

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425L - DA - 90/60 - $1000 DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Last Updated: Oct 31, 2022

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426 - DA - 90/60 - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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426L - DA - 90/60 - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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427 - DA - 90/60 - $1000 DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Oct 31, 2022

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427L - DA - 90/60 - $1000 DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Oct 31, 2022

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431 - DA - 90/60 HSCP - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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431L - DA - 90/60 HSCP - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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435L - DA - 90/60 HSCP - $1000 DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Last Updated: Oct 31, 2022

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436 - DA - 90/60 HSCP - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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436L - DA - 90/60 HSCP - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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437L - DA - 90/60 HSCP - $1000 DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Oct 31, 2022

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441L - DA - 80/60 HSCP - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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445L - DA - 80/60 HSCP - $1000 DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Last Updated: Oct 31, 2022

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446 - DA - 80/60 HSCP - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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446L - DA - 80/60 HSCP - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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447 - DA - 80/60 HSCP - $1000 DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Oct 31, 2022

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447L - DA - 80/60 HSCP - $1000 DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Oct 31, 2022

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451L - DA - 100/60-R HSCP - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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455 - DA - 100/60-R HSCP - $1000 DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Last Updated: Oct 31, 2022

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455L - DA - 100/60-R HSCP - $1000 DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Last Updated: Oct 31, 2022

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456 - DA - 100/60-R HSCP - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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456L - DA - 100/60-R HSCP - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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457 - DA - 100/60-R HSCP - $1000 DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Oct 31, 2022

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457L - DA - 100/60-R HSCP - $1000 DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Oct 31, 2022

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461 - DA - 80/60-R HSCP - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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461L - DA - 80/60-R HSCP - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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465L - DA - 80/60-R HSCP - $1000 DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Last Updated: Oct 31, 2022

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466 - DA - 80/60-R HSCP - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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466L - DA - 80/60-R HSCP - $1000 DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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467 - DA - 80/60-R HSCP - $1000 DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Oct 31, 2022

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467L - DA - 80/60-R HSCP - $1000 DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Oct 31, 2022

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471 - DA - 80/60 - $1500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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471L - DA - 80/60 - $1500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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475L - DA - 80/60 - $1500 HIGH DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Last Updated: Oct 31, 2022

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476 - DA - 80/60 - $1500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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476L - DA - 80/60 - $1500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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477L - DA - 80/60 - $1500 HIGH DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Oct 31, 2022

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481L - DA - 80/60 - $2500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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485L - DA - 80/60 - $2500 HIGH DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Last Updated: Oct 31, 2022

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486 - DA - 80/60 - $2500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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486L - DA - 80/60 - $2500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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487 - DA - 80/60 - $2500 HIGH DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Oct 31, 2022

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487L - DA - 80/60 - $2500 HIGH DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Oct 31, 2022

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491 - DA - 100/60-R HSCP - $1500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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491L - DA - 100/60-R HSCP - $1500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Last Updated: Oct 31, 2022

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495L - DA - 100/60-R HSCP - $1500 HIGH DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Last Updated: Oct 31, 2022

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496 - DA - 100/60-R HSCP - $1500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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496L - DA - 100/60-R HSCP - $1500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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497L - DA - 100/60-R HSCP - $1500 HIGH DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Oct 31, 2022

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508 - PPO - 100/80/60 HSA - $1500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 31, 2022

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509 - PPO - 100/80/60 HSA - $2500 HIGH DEDUCTIBLE - CDHRx

Last Updated: Oct 31, 2022

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596 - DA - 50/50-R HSCP - $2500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Oct 31, 2022

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608 - DA - 100/80/60 HSA - $1500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

MyWay HSA Direct Access 80/60 - $15/$35/$50 Rx (CDHRx) Plan 608

Last Updated: Oct 31, 2022

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608L - DA - 100/80/60 HSA - $1500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

MyWay HSA Direct Access 80/60 - $15/$35/$50 Rx (CDHRx) Plan 608L

Last Updated: Oct 31, 2022

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609 - DA - 100/80/60 HSA - $2500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

MyWay HSA Direct Access 80/60 - $15/$35/$50 Rx (CDHRx) Plan 609

Last Updated: Oct 31, 2022

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609L - DA - 100/80/60 HSA - $2500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

MyWay HSA Direct Access 80/60 - $15/$35/$50 Rx (CDHRx) Plan 609L

Last Updated: Oct 31, 2022

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611 - DA - 50/50 HSA - $2500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

611, HSA, Direct Access

Last Updated: Oct 31, 2022

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611L - DA - 50/50 HSA - $2500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

611L, HSA, Direct Access

Last Updated: Oct 31, 2022

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618 - DA - 100/70 HSA - $1500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) Plan 618

Last Updated: Oct 31, 2022

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618L - DA - 100/70 HSA - $1500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) Plan 618L

Last Updated: Oct 31, 2022

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619 - DA - 100/70 HSA - $2500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) Plan 619

Last Updated: Oct 31, 2022

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619L - DA - 100/70 HSA - $2500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) Plan 619L

Last Updated: Oct 31, 2022

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620 - DA - 100% HSA - $1500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

MyWay HSA Direct Access 100% - $15/$35/$50 Rx (CDHRx) Plan 620

Last Updated: Oct 31, 2022

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621 - DA - 100% HSA - $2500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

MyWay HSA Direct Access 100% - $15/$35/$50 Rx (CDHRx) Plan 621

Last Updated: Oct 31, 2022

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623 - DA - 70% HSA - $2500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 31, 2022

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628 - DA - 100/70 HSA - $1500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 31, 2022

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628L - DA - 100/70 HSA - $1500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 31, 2022

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629 - DA - 100/70 HSA - $2500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 31, 2022

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629L - DA - 100/70 HSA - $2500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 31, 2022

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630 - DA - 100% HSA - $1500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 31, 2022

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631 - DA - 100% HSA - $2500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 31, 2022

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633 - DA - 70% HSA - $2500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 31, 2022

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638 - DA - 100/80/60 HSA - $1500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 31, 2022

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638L - DA - 100/80/60 HSA - $1500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 31, 2022

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639 - DA - 100/80/60 HSA - $2500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 31, 2022

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639L - DA - 100/80/60 HSA - $2500 HIGH DEDUCTIBLE - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 31, 2022

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811 - EPO - DA 100% NETWORK ONLY - Fixed Co-Pay $15/$25 Rx

Direct Access EPO - 100% Network Only - Fixed Co-Pay $15/$25 Rx Plan 811

Last Updated: Oct 31, 2022

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815 - EPO - DA 100% NETWORK ONLY - Co-Insurance Co-pay 70%/30% Rx

Direct Access EPO - 100% Network Only - Co-Insurance Co-pay 70%/30% Rx Plan 815

Last Updated: Oct 31, 2022

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816 - EPO - DA 100% NETWORK ONLY - Fixed Co-Pay $15/$35/$50 Rx

Direct Access EPO - 100% Network Only - Fixed Co-Pay $15/$35/$50 Rx Plan 816

Last Updated: Oct 31, 2022

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817 - EPO - DA 100% NETWORK ONLY - Co-Insurance Co-pay 50%/50% Rx

Direct Access EPO - 100% Network Only - Co-Insurance Co-pay 50%/50% Rx Plan 817

Last Updated: Oct 31, 2022

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821 - EPO - DA 80% NETWORK ONLY - Fixed Co-Pay $15/$25 Rx

Direct Access EPO - 80% Network Only - Fixed Co-Pay $15/$25 Rx Plan 821

Last Updated: Oct 31, 2022

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825 - EPO - DA 80% NETWORK ONLY - Co-Insurance Co-pay 70%/30% Rx

Direct Access EPO - 80% Network Only - Co-Insurance Co-pay 70%/30% Rx Plan 825

Last Updated: Oct 31, 2022

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826 - EPO - DA 80% NETWORK ONLY - Fixed Co-Pay $15/$35/$50 Rx

Direct Access EPO - 80% Network Only - Fixed Co-Pay $15/$35/$50 Rx Plan 826

Last Updated: Oct 31, 2022

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827 - EPO - DA 80% NETWORK ONLY - Co-Insurance Co-pay 50%/50% Rx

Direct Access EPO - 80% Network Only - Co-Insurance Co-pay 50%/50% Rx Plan 827

Last Updated: Oct 31, 2022

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831 - EPO - DA 80% NETWORK ONLY - $1500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Direct Access EPO - $1500 Deductible - 80% Network Only - Fixed Co-Pay $15/$25 Rx Plan 831

Last Updated: Oct 31, 2022

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835 - EPO - DA 80% NETWORK ONLY - $1500 HIGH DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Direct Access EPO - $1500 Deductible - 80% Network Only - Co-Insurance Co-pay 70%/30% Rx Plan 835

Last Updated: Oct 31, 2022

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836 - EPO - DA 80% NETWORK ONLY - $1500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Direct Access EPO - $1500 Deductible - 80% Network Only - Fixed Co-Pay $15/$35/$50 Rx Plan 836

Last Updated: Oct 31, 2022

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837 - EPO - DA 80% NETWORK ONLY - $1500 HIGH DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Direct Access EPO - $1500 Deductible - 80% Network Only - Co-Insurance Co-pay 50%/50% Rx Plan 837

Last Updated: Oct 31, 2022

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841 - EPO - DA 80% NETWORK ONLY - $2500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Direct Access EPO - $2500 Deductible - 80% Network Only - Fixed Co-Pay $15/$25 Rx Plan 841

Last Updated: Oct 31, 2022

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845 - EPO - DA 80% NETWORK ONLY - $2500 HIGH DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Direct Access EPO - $2500 Deductible - 80% Network Only - Co-Insurance Co-pay 70%/30% Rx Plan 845

Last Updated: Oct 31, 2022

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846 - EPO - DA 80% NETWORK ONLY - $2500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Direct Access EPO - $2500 Deductible - 80% Network Only - Fixed Co-Pay $15/$35/$50 Rx Plan 846

Last Updated: Oct 31, 2022

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847 - EPO - DA 80% NETWORK ONLY - $2500 HIGH DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Direct Access EPO - $2500 Deductible - 80% Network Only - Co-Insurance Co-pay 50%/50% Rx Plan 847

Last Updated: Oct 31, 2022

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851 - EPO - DA 100% NETWORK ONLY - $2500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Direct Access EPO - $2500 Deductible - 100% Network Only - Fixed Co-Pay $15/$25 Rx Plan 851

Last Updated: Oct 31, 2022

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855 - EPO - DA 100% NETWORK ONLY - $2500 HIGH DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Direct Access EPO - $2500 Deductible - 100% Network Only - Co-Insurance Co-pay 70%/30% Rx Plan 855

Last Updated: Oct 31, 2022

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856 - EPO - DA 100% NETWORK ONLY - $2500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Summary of Benefits and Coverage - Direct Access EPO - $2500 Deductible - 100% Network Only - Fixed Co-Pay $15/$35/$50 Rx Plan 856

Last Updated: Oct 31, 2022

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857 - EPO - DA 100% NETWORK ONLY - $2500 HIGH DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Summary of Benefits and Coverage - Direct Access EPO - $2500 Deductible - 100% Network Only - Co-Insurance Co-pay 50%/50% Rx Plan 857

Last Updated: Oct 31, 2022

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861 - EPO - DA 50% NETWORK ONLY - $2500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$25 Rx

Summary of Benefits and Coverage - DA EPO - 50% Network Only Plan 861 2Teir $15/$25 Rx, $2500 Deductible

Last Updated: Oct 31, 2022

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865 - EPO - DA 50% NETWORK ONLY - $2500 HIGH DEDUCTIBLE - Co-Insurance Co-pay 70%/30% Rx

Summary of Benefits and Coverage - DA EPO - 50% Plan 865 70%/30% Rx, $2500 Deductible, Network Only

Last Updated: Oct 31, 2022

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866 - EPO - DA 50% NETWORK ONLY - $2500 HIGH DEDUCTIBLE - Fixed Co-Pay $15/$35/$50 Rx

Summary of Benefits and Coverage - DA EPO - 50% Network Only Plan 866 3Tier $15/$35/$50 Rx, $2500 Deductible

Last Updated: Oct 31, 2022

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867 - EPO - DA 50% NETWORK ONLY - $2500 HIGH DEDUCTIBLE - Co-Insurance Co-pay 50%/50% Rx

Summary of Benefits and Coverage - DA EPO - 50% Plan 867 50% Rx, $2500 Deductible, Network Only

Last Updated: Oct 31, 2022

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873 - EPO - DA 50% NETWORK ONLY - $3500 HIGH DEDUCTIBLE - Fixed Co-Pay $10/$50/$75 Rx

873, EPO, High Deductible, In Network Only

Last Updated: Oct 31, 2022

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913 - OMNIA - 100/60 - Fixed Co-Pay $10/$50/$75 Rx

Summary of Benefits and Coverage - Omnia EPO - 100/60 Plan 913 $10/$50/$75 Rx

Last Updated: Oct 31, 2022

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929 - OMNIA - 80/50 HSA - 60% Rx (after Deductible)

Summary of Benefits and Coverage - Omnia HSA EPO - 80/50 Plan 929

Last Updated: Oct 31, 2022

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934 - OMNIA - 100/50 - $15/60%/50% Rx

Summary of Benefits and Coverage - Omnia EPO - 100/50 Plan 934

Last Updated: Oct 31, 2022

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949 - OMNIA - 90/70 HSA - 60% Rx (after Deductible)

Summary of Benefits and Coverage - Omnia HSA EPO - 90/70 Plan 949

Last Updated: Oct 31, 2022

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950 - OMNIA - 65/55 - $25/50%/50% Rx

Last Updated: Oct 31, 2022

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958 - OMNIA - 50/50 - 50% Rx (after Deductible)

Summary of Benefits and Coverage - Omnia - EPO - 50% Plan 958 50% Rx

Last Updated: Oct 31, 2022

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Forms & Documents

Summary of Benefits & Coverage