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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
1 - Plan 1: - MMRx View File | Download File Last Updated: Oct 3, 2019 2 - Plan 2: - MMRx View File | Download File Last Updated: Oct 3, 2019 11 - Plan 11: - MMRx View File | Download File Last Updated: Oct 3, 2019 12 - Plan 12: - MMRx View File | Download File Last Updated: Oct 3, 2019 13 - Plan 13: - MMRx View File | Download File Last Updated: Oct 3, 2019 14 - Plan 14: - MMRx View File | Download File Last Updated: Oct 3, 2019 19 - Plan 19: - MMRx View File | Download File Last Updated: Oct 3, 2019 32 - PPO - 100/80 - MMRx View File | Download File Last Updated: Oct 3, 2019 33 - PPO - 100/80 - MMRx View File | Download File Last Updated: Oct 3, 2019 34 - PPO - 90/70 - MMRx View File | Download File Last Updated: Oct 3, 2019 35 - PPO - 90/70 - MMRx View File | Download File Last Updated: Oct 3, 2019 36 - PPO - 80/60 - MMRx View File | Download File Last Updated: Oct 3, 2019 37 - PPO - 80/60 - MMRx View File | Download File Last Updated: Oct 3, 2019 38 - PPO - 100/80 - MMRx View File | Download File Last Updated: Oct 3, 2019 39 - PPO - 90/70 - MMRx View File | Download File Last Updated: Oct 3, 2019 40 - PPO - 80/60 - MMRx View File | Download File Last Updated: Oct 3, 2019 100 - Plan 1: - MMRx View File | Download File Last Updated: Oct 3, 2019 191 - Plan 19: - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 255 - PPO - 80/60 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 256 - PPO - 80/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 257 - PPO - 80/60 - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 3, 2019 321 - PPO - 100/80 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 325 - PPO - 100/80 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 326 - PPO - 100/80 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 331 - PPO - 100/80 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 335 - PPO - 100/80 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 336 - PPO - 100/80 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 341 - PPO - 90/70 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 345 - PPO - 90/70 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 346 - PPO - 90/70 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 351 - PPO - 90/70 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 355 - PPO - 90/70 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 356 - PPO - 90/70 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 361 - PPO - 80/60 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 366 - PPO - 80/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 371 - PPO - 80/60 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 375 - PPO - 80/60 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 376 - PPO - 80/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 381 - PPO - 100/80 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 386 - PPO - 100/80 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 391 - PPO - 90/70 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 395 - PPO - 90/70 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 396 - PPO - 90/70 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 401 - PPO - 80/60 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 405 - PPO - 80/60 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 406 - PPO - 80/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 411 - DA - 100/60 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 415 - DA - 100/60 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 416 - DA - 100/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 417 - DA - 100/60 - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 4, 2019 421 - DA - 90/60 - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 425 - DA - 90/60 - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 426 - DA - 90/60 - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 427 - DA - 90/60 - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 3, 2019 431 - DA - 90/60 - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 435 - DA - 90/60 - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 436 - DA - 90/60 - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 437 - DA - 90/60 - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 3, 2019 441 - DA - 80/60 - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 445 - DA - 80/60 - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 446 - DA - 80/60 - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 447 - DA - 80/60 - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 3, 2019 451 - DA - 100/60 R - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 455 - DA - 100/60 R - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 456 - DA - 100/60 R - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 457 - DA - 100/60 R - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 3, 2019 461 - DA - 80/60 R - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 465 - DA - 80/60 R - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 466 - DA - 80/60 R - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 467 - DA - 80/60 R - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 3, 2019 471 - DA - $1500 Deductible - 80/60 - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 475 - DA - $1500 Deductible - 80/60 - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 476 - DA - $1500 Deductible - 80/60 - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 477 - DA - $1500 Deductible - 80/60 - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 3, 2019 481 - DA - $2500 Deductible - 80/60 - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 485 - DA - $2500 Deductible - 80/60 - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 486 - DA - $2500 Deductible - 80/60 - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 487 - DA - $2500 Deductible - 80/60 - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 3, 2019 491 - DA - $1500 Deductible - 100/60 - HSCP - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 495 - DA - $1500 Deductible - 100/60 - HSCP - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 496 - DA - $1500 Deductible - 100/60 - HSCP - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 497 - DA - $1500 Deductible - 100/60 - HSCP - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 3, 2019 508 - MyWay HSA Preferred Provider Organization 80/60 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 3, 2019 509 - MyWay HSA Preferred Provider Organization 80/60 - CDHRx View File | Download File Last Updated: Oct 3, 2019 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 3, 2019 609 - MyWay HSA Direct Access 80/60 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 3, 2019 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 3, 2019 619 - MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 3, 2019 620 - MyWay HSA Direct Access 100% - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 3, 2019 621 - MyWay HSA Direct Access 100% - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 3, 2019 623 - MyWay HSA Direct Access 70% - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 3, 2019 628 - MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 3, 2019 629 - MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 3, 2019 630 - MyWay HSA Direct Access 100% - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 3, 2019 631 - MyWay HSA Direct Access 100% - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 3, 2019 633 - MyWay HSA Direct Access 70% - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Apr 24, 2020 638 - MyWay HSA Direct Access 80/60 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 3, 2019 639 - MyWay HSA Direct Access 80/60 - $15/$35/$50 Rx (CDHRx) View File | Download File Last Updated: Oct 3, 2019 811 - Direct Access EPO - 100% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 815 - Direct Access EPO - 100% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 816 - Direct Access EPO - 100% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 817 - Direct Access EPO - 100% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 3, 2019 821 - Direct Access EPO - 80% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 825 - Direct Access EPO - 80% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 826 - Direct Access EPO - 80% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 827 - Direct Access EPO - 80% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 3, 2019 831 - Direct Access EPO - $1500 Deductible - 80% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 835 - Direct Access EPO - $1500 Deductible - 80% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 836 - Direct Access EPO - $1500 Deductible - 80% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 837 - Direct Access EPO - $1500 Deductible - 80% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 3, 2019 841 - Direct Access EPO - $2500 Deductible - 80% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 845 - Direct Access EPO - $2500 Deductible - 80% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 846 - Direct Access EPO - $2500 Deductible - 80% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 847 - Direct Access EPO - $2500 Deductible - 80% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 3, 2019 851 - Direct Access EPO - $2500 Deductible - 100% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 855 - Direct Access EPO - $2500 Deductible - 100% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 856 - Direct Access EPO - $2500 Deductible - 100% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 857 - Direct Access EPO - $2500 Deductible - 100% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 3, 2019 861 - Direct Access EPO - $2500 Deductible - 50% Network Only - Fixed Co-Pay $15/$25 Rx View File | Download File Last Updated: Oct 3, 2019 865 - Direct Access EPO - $2500 Deductible - 50% Network Only - Co-Insurance Co-pay 70%/30% Rx View File | Download File Last Updated: Oct 3, 2019 866 - Direct Access EPO - $2500 Deductible - 50% Network Only - Fixed Co-Pay $15/$35/$50 Rx View File | Download File Last Updated: Oct 3, 2019 867 - Direct Access EPO - $2500 Deductible - 50% Network Only - Co-Insurance Co-pay 50%/50% Rx View File | Download File Last Updated: Oct 3, 2019 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 3, 2019 929 - OMNIA HSA 80/50 - 60% Rx (after Deductible) View File | Download File Last Updated: Oct 3, 2019 934 - OMNIA 100/50 - $15/60%/50% Rx View File | Download File Last Updated: Oct 3, 2019 949 - OMNIA HSA 90/70 - 60% Rx (after Deductible) View File | Download File Last Updated: Oct 3, 2019 958 - OMNIA 50/50 - 50% Rx (after Deductible) View File | Download File Last Updated: Oct 3, 2019

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