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Medical Plans

(PPO) Preferred Provider Organization

Plan 256 - PPO - 80/60 HSCP

Plan 256 - PPO - 80/60 HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 370 - PPO - 80/60

Plan 370 - PPO - 80/60

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 401 - PPO - 80/60

Plan 401 - PPO - 80/60

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 406 - PPO - 80/60

Plan 406 - PPO - 80/60

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

(DA) Direct Access Plans

Plan 411 - DA - 100/60

Plan 411 - DA - 100/60

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 415 - DA - 100/60

Plan 415 - DA - 100/60

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 416 - DA - 100/60

Plan 416 - DA - 100/60

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 461 - DA - 80/60-R HSCP

Plan 461 - DA - 80/60-R HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 466 - DA - 80/60-R HSCP

Plan 466 - DA - 80/60-R HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 467 - DA - 80/60-R HSCP

Plan 467 - DA - 80/60-R HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 421 - DA - 90/60

Plan 421 - DA - 90/60

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 436 - DA - 90/60 HSCP

Plan 436 - DA - 90/60 HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 446 - DA - 80/60 HSCP

Plan 446 - DA - 80/60 HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 447 - DA - 80/60 HSCP

Plan 447 - DA - 80/60 HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 455 - DA - 100/60-R HSCP

Plan 455 - DA - 100/60-R HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 456 - DA - 100/60-R HSCP

Plan 456 - DA - 100/60-R HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 457 - DA - 100/60-R HSCP

Plan 457 - DA - 100/60-R HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 476 - DA - 80/60

Plan 476 - DA - 80/60

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 486 - DA - 80/60

Plan 486 - DA - 80/60

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 487 - DA - 80/60

Plan 487 - DA - 80/60

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 491 - DA - 100/60-R HSCP

Plan 491 - DA - 100/60-R HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 496 - DA - 100/60-R HSCP

Plan 496 - DA - 100/60-R HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 596 - DA - 50/50-R HSCP

Plan 596 - DA - 50/50-R HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 41L - DA - 100/60

Plan 41L - DA - 100/60

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 41L - DA - 100/60

Plan 41L - DA - 100/60

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 41L - DA - 100/60

Plan 41L - DA - 100/60

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 42L - DA - 90/60

Plan 42L - DA - 90/60

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 43L - DA - 90/60 HSCP

Plan 43L - DA - 90/60 HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 44L - DA - 80/60 HSCP

Plan 44L - DA - 80/60 HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 44L - DA - 80/60 HSCP

Plan 44L - DA - 80/60 HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 45L - DA - 100/60-R HSCP

Plan 45L - DA - 100/60-R HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 45L - DA - 100/60-R HSCP

Plan 45L - DA - 100/60-R HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 46L - DA - 80/60-R HSCP

Plan 46L - DA - 80/60-R HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 46L - DA - 80/60-R HSCP

Plan 46L - DA - 80/60-R HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 46L - DA - 80/60-R HSCP

Plan 46L - DA - 80/60-R HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 48L - DA - 80/60

Plan 48L - DA - 80/60

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 49L - DA - 100/60-R HSCP

Plan 49L - DA - 100/60-R HSCP

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

(EPO) Exclusive Provider Organization

Plan 811 - EPO - DA 100% NETWORK ONLY

Plan 811 - EPO - DA 100% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 815 - EPO - DA 100% NETWORK ONLY

Plan 815 - EPO - DA 100% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 816 - EPO - DA 100% NETWORK ONLY

Plan 816 - EPO - DA 100% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 821 - EPO - DA 80% NETWORK ONLY

Plan 821 - EPO - DA 80% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 825 - EPO - DA 80% NETWORK ONLY

Plan 825 - EPO - DA 80% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 826 - EPO - DA 80% NETWORK ONLY

Plan 826 - EPO - DA 80% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 836 - EPO - DA 80% NETWORK ONLY

Plan 836 - EPO - DA 80% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 837 - EPO - DA 80% NETWORK ONLY

Plan 837 - EPO - DA 80% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 841 - EPO - DA 80% NETWORK ONLY

Plan 841 - EPO - DA 80% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 846 - EPO - DA 80% NETWORK ONLY

Plan 846 - EPO - DA 80% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 847 - EPO - DA 80% NETWORK ONLY

Plan 847 - EPO - DA 80% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 851 - EPO - DA 100% NETWORK ONLY

Plan 851 - EPO - DA 100% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 856 - EPO - DA 100% NETWORK ONLY

Plan 856 - EPO - DA 100% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 857 - EPO - DA 100% NETWORK ONLY

Plan 857 - EPO - DA 100% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 866 - EPO - DA 50% NETWORK ONLY

Plan 866 - EPO - DA 50% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 867 - EPO - DA 50% NETWORK ONLY

Plan 867 - EPO - DA 50% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 873 - EPO - DA 50% NETWORK ONLY

Plan 873 - EPO - DA 50% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 886 - EPO - DA 50% NETWORK ONLY

Plan 886 - EPO - DA 50% NETWORK ONLY

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

(HSA) Health Savings Account

Plan 508 - PPO - 100/80/60 HSA

Plan 508 - PPO - 100/80/60 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 608 - DA - 100/80/60 HSA

Plan 608 - DA - 100/80/60 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 608 - DA - 100/80/60 HSA

Plan 608 - DA - 100/80/60 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 618 - DA - 100/70 HSA

Plan 618 - DA - 100/70 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 618 - DA - 100/70 HSA

Plan 618 - DA - 100/70 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 619 - DA - 100/70 HSA

Plan 619 - DA - 100/70 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 619 - DA - 100/70 HSA

Plan 619 - DA - 100/70 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 620 - DA - 100% HSA

Plan 620 - DA - 100% HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 620 - DA - 100% HSA

Plan 620 - DA - 100% HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 621 - DA - 100% HSA

Plan 621 - DA - 100% HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 621 - DA - 100% HSA

Plan 621 - DA - 100% HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 509 - PPO - 100/80/60 HSA

Plan 509 - PPO - 100/80/60 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 609 - DA - 100/80/60 HSA

Plan 609 - DA - 100/80/60 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 609 - DA - 100/80/60 HSA

Plan 609 - DA - 100/80/60 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 611 - DA - 50/50 HSA

Plan 611 - DA - 50/50 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 611 - DA - 50/50 HSA

Plan 611 - DA - 50/50 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 623 - DA - 70% HSA

Plan 623 - DA - 70% HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 623 - DA - 70% HSA

Plan 623 - DA - 70% HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 608L - DA - 100/80/60 HSA

Plan 608L - DA - 100/80/60 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 608L - DA - 100/80/60 HSA

Plan 608L - DA - 100/80/60 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 611L - DA - 50/50 HSA

Plan 611L - DA - 50/50 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

OMNIA

Plan 913 - OMNIA - 100/60

Plan 913 - OMNIA - 100/60

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Benefit Description Summary of Benefits and Coverage Summary Plan Description (Med) Summary Plan Description (Rx)

Plan 929 - OMNIA - 80/50 HSA

Plan 929 - OMNIA - 80/50 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 934 - OMNIA - 100/50

Plan 934 - OMNIA - 100/50

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 949 - OMNIA - 90/70 HSA

Plan 949 - OMNIA - 90/70 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 949 - OMNIA - 90/70 HSA

Plan 949 - OMNIA - 90/70 HSA

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 958 - OMNIA - 50/50

Plan 958 - OMNIA - 50/50

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 950 - OMNIA - 65/55

Plan 950 - OMNIA - 65/55

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Benefit Description Summary of Benefits and Coverage

Plan 952 - OMNIA - 55/45

Plan 952 - OMNIA - 55/45

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

Plan 968 - OMNIA - 50/50

Plan 968 - OMNIA - 50/50

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Benefit Description Summary of Benefits and Coverage Summary Plan Description

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