Forms & Documents
Summary of Benefits & Coverage
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Last Updated: Sep 25, 2023
Last Updated: Sep 25, 2023
Preferred Provider Organization (PPO) Plan 256: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$35/$50 Rx
Last Updated: Sep 25, 2023
Preferred Provider Organization (PPO) Plan 335: 100% In-Network Coinsurance, 80% Out-of-Network Coinsurance; w/ BlueCard - Prescription Drug: Co-Insurance Co-Pay 70%/30% Rx
Last Updated: Oct 31, 2022
Preferred Provider Organization (PPO) Plan 37: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; w/ BlueCard - Prescription Drug: MMRx
Last Updated: Sep 25, 2023
Preferred Provider Organization (PPO) Plan 401: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$25 Rx
Last Updated: Sep 25, 2023
Preferred Provider Organization (PPO) Plan 406: 80% In-Network Coinsurance, 60% Out-of-Network Coinsurance; w/ BlueCard - Prescription Drug: Fixed Co-Pay $15/$35/$50 Rx
Last Updated: Sep 25, 2023
Last Updated: Sep 25, 2023
Last Updated: Oct 31, 2022
Last Updated: Sep 25, 2023
Last Updated: Oct 31, 2022
Last Updated: Sep 25, 2023
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
Last Updated: Sep 25, 2023
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
Last Updated: Sep 25, 2023
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
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Last Updated: Oct 31, 2022
Last Updated: Sep 25, 2023
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
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Last Updated: Oct 31, 2022
Last Updated: Sep 25, 2023
Last Updated: Oct 31, 2022
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Last Updated: Oct 31, 2022
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Last Updated: Oct 31, 2022
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Last Updated: Oct 31, 2022
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Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
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Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
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Last Updated: Oct 31, 2022
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Last Updated: Oct 31, 2022
Last Updated: Sep 25, 2023
Last Updated: Oct 31, 2022
Last Updated: Oct 31, 2022
Last Updated: Sep 25, 2023
Last Updated: Sep 25, 2023
Last Updated: Oct 31, 2022
MyWay HSA Direct Access 80/60 - $15/$35/$50 Rx (CDHRx) Plan 608
Last Updated: Sep 25, 2023
MyWay HSA Direct Access 80/60 - $15/$35/$50 Rx (CDHRx) Plan 608L
Last Updated: Oct 31, 2022
MyWay HSA Direct Access 80/60 - $15/$35/$50 Rx (CDHRx) Plan 609
Last Updated: Sep 25, 2023
MyWay HSA Direct Access 80/60 - $15/$35/$50 Rx (CDHRx) Plan 609L
Last Updated: Oct 31, 2022
MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) Plan 618
Last Updated: Nov 15, 2023
MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) Plan 618L
Last Updated: Oct 31, 2022
MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) Plan 619
Last Updated: Sep 25, 2023
MyWay HSA Direct Access 100/70 - $15/$35/$50 Rx (CDHRx) Plan 619L
Last Updated: Oct 31, 2022
MyWay HSA Direct Access 100% - $15/$35/$50 Rx (CDHRx) Plan 620
Last Updated: Nov 15, 2023
MyWay HSA Direct Access 100% - $15/$35/$50 Rx (CDHRx) Plan 621
Last Updated: Sep 25, 2023
Last Updated: Sep 25, 2023
Last Updated: Sep 25, 2023
Last Updated: Oct 31, 2022
Last Updated: Sep 25, 2023
Last Updated: Oct 31, 2022
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Last Updated: Sep 25, 2023
Last Updated: Sep 25, 2023
Last Updated: Sep 25, 2023
Last Updated: Oct 31, 2022
Last Updated: Sep 25, 2023
Last Updated: Oct 31, 2022
Direct Access EPO - 100% Network Only - Fixed Co-Pay $15/$25 Rx Plan 811
Last Updated: Sep 25, 2023
Direct Access EPO - 100% Network Only - Co-Insurance Co-pay 70%/30% Rx Plan 815
Last Updated: Sep 25, 2023
Direct Access EPO - 100% Network Only - Fixed Co-Pay $15/$35/$50 Rx Plan 816
Last Updated: Sep 25, 2023
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: Sep 25, 2023
Direct Access EPO - 80% Network Only - Co-Insurance Co-pay 70%/30% Rx Plan 825
Last Updated: Sep 25, 2023
Direct Access EPO - 80% Network Only - Fixed Co-Pay $15/$35/$50 Rx Plan 826
Last Updated: Sep 25, 2023
Direct Access EPO - 80% Network Only - Co-Insurance Co-pay 50%/50% Rx Plan 827
Last Updated: Oct 31, 2022
Direct Access EPO - 80% Network Only - Fixed Co-Pay $15/$25 Rx Plan 831
Last Updated: Oct 31, 2022
Direct Access EPO - 80% Network Only - Co-Insurance Co-pay 70%/30% Rx Plan 835
Last Updated: Oct 31, 2022
Direct Access EPO - 80% Network Only - Fixed Co-Pay $15/$35/$50 Rx Plan 836
Last Updated: Sep 25, 2023
Direct Access EPO - 80% Network Only - Co-Insurance Co-pay 50%/50% Rx Plan 837
Last Updated: Sep 25, 2023
Direct Access EPO - 80% Network Only - Fixed Co-Pay $15/$25 Rx Plan 841
Last Updated: Sep 25, 2023
Direct Access EPO - 80% Network Only - Co-Insurance Co-pay 70%/30% Rx Plan 845
Last Updated: Oct 31, 2022
Direct Access EPO - 80% Network Only - Fixed Co-Pay $15/$35/$50 Rx Plan 846
Last Updated: Sep 25, 2023
Direct Access EPO - 80% Network Only - Co-Insurance Co-pay 50%/50% Rx Plan 847
Last Updated: Sep 25, 2023
Direct Access EPO - 100% Network Only - Fixed Co-Pay $15/$25 Rx Plan 851
Last Updated: Sep 25, 2023
Direct Access EPO - 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 - 100% Network Only - Fixed Co-Pay $15/$35/$50 Rx Plan 856
Last Updated: Sep 25, 2023
Summary of Benefits and Coverage - Direct Access EPO - 100% Network Only - Co-Insurance Co-pay 50%/50% Rx Plan 857
Last Updated: Sep 25, 2023
Summary of Benefits and Coverage - DA EPO - 50% Network Only Plan 861 2Teir $15/$25 Rx
Last Updated: Oct 31, 2022
Summary of Benefits and Coverage - DA EPO - 50% Plan 865 70%/30% Rx, Network Only
Last Updated: Oct 31, 2022
Summary of Benefits and Coverage - DA EPO - 50% Network Only Plan 866 3Tier $15/$35/$50 Rx
Last Updated: Nov 15, 2023
Summary of Benefits and Coverage - DA EPO - 50% Plan 867 50% Rx, Network Only
Last Updated: Sep 25, 2023
Summary of Benefits and Coverage - DA EPO - 50% Network Only Plan 886 3Tier $15/$35/$50 Rx
Last Updated: Jan 10, 2024
Summary of Benefits and Coverage - Omnia EPO - 100/60 Plan 913 $10/$50/$75 Rx
Last Updated: Sep 25, 2023
Summary of Benefits and Coverage - Omnia HSA EPO - 80/50 Plan 929
Last Updated: Nov 15, 2023
Summary of Benefits and Coverage - Omnia EPO - 100/50 Plan 934
Last Updated: Sep 25, 2023
Summary of Benefits and Coverage - Omnia HSA EPO - 90/70 Plan 949
Last Updated: Oct 9, 2023
Last Updated: Nov 15, 2023
Summary of Benefits and Coverage - Omnia - EPO - 55/45 Plan 952 50% Rx
Last Updated: Jan 10, 2024
Summary of Benefits and Coverage - Omnia - EPO - 50% Plan 958 50% Rx
Last Updated: Jan 10, 2024
Summary of Benefits and Coverage - Omnia HSA EPO - 90/70 Plan 959
Last Updated: Oct 9, 2023
Summary of Benefits and Coverage - Omnia - EPO - 50% Plan 968 50% Rx
Last Updated: Jan 10, 2024
