HOME > Forms & Documents: Summary of Benefits & Coverage

Forms & Documents: Summary of Benefits & Coverage

To download a file right click on the "Download File" link and select either "Save Link As..." or "Save Target As...".

Summary of Benefits & Coverage
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
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

- Get Adobe Reader to view the files with this icon.
- Get Microsoft Word Viewer to view the files with this icon, if you don't already have Microsoft Word installed.

Copyright © 2015 Association Master Trust. All Rights Reserved.

Home | Site Map | News | Notices | Privacy Policy | How to use our site (FAQ)
Terms of Service | Best Viewed Information