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Forms & Documents: Summary of Benefits & Coverage

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