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Summary of Benefits & Coverage

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Last Updated: Nov 1, 2022

Last Updated: Nov 1, 2022

Last Updated: Nov 1, 2022

Last Updated: Nov 1, 2022

Last Updated: Nov 1, 2022

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

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

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

873, EPO, High Deductible, In Network Only

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022

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

Last Updated: Oct 31, 2022