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Forms & Documents

Summary of Benefits & Coverage

Other Forms & Documents

Claim Forms Enrollment/Waiver Forms Summary Plan Descriptions

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1 - Plan 1: - MMRx

Last Updated: Oct 30, 2024

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11 - Plan 11: - MMRx

Last Updated: Oct 30, 2024

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12 - Plan 12: - MMRx

Last Updated: Oct 30, 2024

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19 - Plan 19: - MMRx

Last Updated: Oct 30, 2024

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2 - Plan 2: - MMRx

Last Updated: Oct 30, 2024

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256 - PPO - 80/60 HSCP - Fixed Co-Pay $15/$35/$50 Rx

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

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37 - PPO - 80/60 - MMRx

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

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401 - PPO - 80/60 - Fixed Co-Pay $15/$25 Rx

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

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406 - PPO - 80/60 - Fixed Co-Pay $15/$35/$50 Rx

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

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411 - DA - 100/60 - Fixed Co-Pay $15/$25 Rx

Last Updated: Sep 29, 2024

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411L - DA - 100/60 - Fixed Co-Pay $15/$25 Rx

Last Updated: Sep 29, 2024

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415 - DA - 100/60 - Co-Insurance Co-pay 70%/30% Rx

Last Updated: Sep 29, 2024

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415L - DA - 100/60 - Co-Insurance Co-pay 70%/30% Rx

Last Updated: Sep 29, 2024

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416 - DA - 100/60 - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Sep 29, 2024

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416L - DA - 100/60 - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Sep 29, 2024

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421 - DA - 90/60 - Fixed Co-Pay $15/$25 Rx

Last Updated: Sep 29, 2024

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421L - DA - 90/60 - Fixed Co-Pay $15/$25 Rx

Last Updated: Sep 29, 2024

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436 - DA - 90/60 HSCP - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Sep 29, 2024

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436L - DA - 90/60 HSCP - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Sep 29, 2024

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446 - DA - 80/60 HSCP - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Sep 29, 2024

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446L - DA - 80/60 HSCP - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Sep 29, 2024

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447 - DA - 80/60 HSCP - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Sep 29, 2024

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447L - DA - 80/60 HSCP - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Sep 29, 2024

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455 - DA - 100/60-R HSCP - Co-Insurance Co-pay 70%/30% Rx

Last Updated: Sep 29, 2024

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455L - DA - 100/60-R HSCP - Co-Insurance Co-pay 70%/30% Rx

Last Updated: Sep 29, 2024

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456 - DA - 100/60-R HSCP - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Sep 29, 2024

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457 - DA - 100/60-R HSCP - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Sep 29, 2024

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457L - DA - 100/60-R HSCP - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Sep 29, 2024

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461 - DA - 80/60-R HSCP - Fixed Co-Pay $15/$25 Rx

Last Updated: Sep 29, 2024

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461L - DA - 80/60-R HSCP - Fixed Co-Pay $15/$25 Rx

Last Updated: Sep 29, 2024

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466 - DA - 80/60-R HSCP - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Sep 29, 2024

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466L - DA - 80/60-R HSCP - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Sep 29, 2024

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467 - DA - 80/60-R HSCP - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Sep 29, 2024

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467L - DA - 80/60-R HSCP - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Sep 29, 2024

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476 - DA - 80/60 - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Sep 29, 2024

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486 - DA - 80/60 - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Sep 29, 2024

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487 - DA - 80/60 - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Sep 29, 2024

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487L - DA - 80/60 - Co-Insurance Co-pay 50%/50% Rx

Last Updated: Sep 29, 2024

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491 - DA - 100/60-R HSCP - Fixed Co-Pay $15/$25 Rx

Last Updated: Sep 29, 2024

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491L - DA - 100/60-R HSCP - Fixed Co-Pay $15/$25 Rx

Last Updated: Sep 29, 2024

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496 - DA - 100/60-R HSCP - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Sep 29, 2024

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508 - PPO - 100/80/60 HSA - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 30, 2025

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509 - PPO - 100/80/60 HSA - CDHRx

Last Updated: Oct 30, 2025

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596 - DA - 50/50-R HSCP - Fixed Co-Pay $15/$35/$50 Rx

Last Updated: Sep 29, 2024

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608 - DA - 100/80/60 HSA - $15/$35/$50 Rx (CDHRx)

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

Last Updated: Oct 30, 2025

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608L - DA - 100/80/60 HSA - $15/$35/$50 Rx (CDHRx)

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

Last Updated: Oct 30, 2025

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609 - DA - 100/80/60 HSA - $15/$35/$50 Rx (CDHRx)

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

Last Updated: Oct 30, 2025

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611 - DA - 50/50 HSA - $15/$35/$50 Rx (CDHRx)

611, HSA, Direct Access

Last Updated: Oct 30, 2025

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611L - DA - 50/50 HSA - $15/$35/$50 Rx (CDHRx)

611L, HSA, Direct Access

Last Updated: Oct 30, 2025

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613 - DA - 50/50 HSA - $15/$35/$50 Rx (CDHRx)

613, HSA, Direct Access

Last Updated: Oct 30, 2025

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618 - DA - 100/70 HSA - $15/$35/$50 Rx (CDHRx)

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

Last Updated: Oct 30, 2025

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619 - DA - 100/70 HSA - $15/$35/$50 Rx (CDHRx)

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

Last Updated: Oct 30, 2025

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620 - DA - 100% HSA - $15/$35/$50 Rx (CDHRx)

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

Last Updated: Oct 30, 2025

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621 - DA - 100% HSA - $15/$35/$50 Rx (CDHRx)

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

Last Updated: Oct 30, 2025

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623 - DA - 70% HSA - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 30, 2025

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628 - DA - 100/70 HSA - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 30, 2025

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629 - DA - 100/70 HSA - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 30, 2025

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630 - DA - 100% HSA - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 30, 2025

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631 - DA - 100% HSA - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 30, 2025

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633 - DA - 70% HSA - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 30, 2025

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638 - DA - 100/80/60 HSA - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 30, 2025

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638L - DA - 100/80/60 HSA - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 30, 2025

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639 - DA - 100/80/60 HSA - $15/$35/$50 Rx (CDHRx)

Last Updated: Oct 30, 2025

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811 - EPO - DA 100% NETWORK ONLY - Fixed Co-Pay $15/$25 Rx

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

Last Updated: Oct 30, 2024

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815 - EPO - DA 100% NETWORK ONLY - Co-Insurance Co-pay 70%/30% Rx

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

Last Updated: Oct 30, 2024

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816 - EPO - DA 100% NETWORK ONLY - Fixed Co-Pay $15/$35/$50 Rx

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

Last Updated: Oct 30, 2024

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821 - EPO - DA 80% NETWORK ONLY - Fixed Co-Pay $15/$25 Rx

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

Last Updated: Oct 30, 2024

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825 - EPO - DA 80% NETWORK ONLY - Co-Insurance Co-pay 70%/30% Rx

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

Last Updated: Oct 30, 2024

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826 - EPO - DA 80% NETWORK ONLY - Fixed Co-Pay $15/$35/$50 Rx

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

Last Updated: Oct 30, 2024

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836 - EPO - DA 80% NETWORK ONLY - Fixed Co-Pay $15/$35/$50 Rx

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

Last Updated: Oct 30, 2024

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837 - EPO - DA 80% NETWORK ONLY - Co-Insurance Co-pay 50%/50% Rx

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

Last Updated: Oct 30, 2024

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841 - EPO - DA 80% NETWORK ONLY - Fixed Co-Pay $15/$25 Rx

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

Last Updated: Oct 30, 2024

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846 - EPO - DA 80% NETWORK ONLY - Fixed Co-Pay $15/$35/$50 Rx

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

Last Updated: Oct 30, 2024

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847 - EPO - DA 80% NETWORK ONLY - Co-Insurance Co-pay 50%/50% Rx

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

Last Updated: Oct 30, 2024

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851 - EPO - DA 100% NETWORK ONLY - Fixed Co-Pay $15/$25 Rx

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

Last Updated: Oct 30, 2024

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856 - EPO - DA 100% NETWORK ONLY - Fixed Co-Pay $15/$35/$50 Rx

Summary of Benefits and Coverage - Direct Access EPO - 100% Network Only - Fixed Co-Pay $15/$35/$50 Rx Plan 856

Last Updated: Oct 30, 2024

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857 - EPO - DA 100% NETWORK ONLY - Co-Insurance Co-pay 50%/50% Rx

Summary of Benefits and Coverage - Direct Access EPO - 100% Network Only - Co-Insurance Co-pay 50%/50% Rx Plan 857

Last Updated: Oct 30, 2024

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866 - EPO - DA 50% NETWORK ONLY - Fixed Co-Pay $15/$35/$50 Rx

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

Last Updated: Oct 30, 2024

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867 - EPO - DA 50% NETWORK ONLY - Co-Insurance Co-pay 50%/50% Rx

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

Last Updated: Oct 30, 2024

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873 - EPO - DA 50% NETWORK ONLY - Fixed Co-Pay $10/$50/$75 Rx

873, EPO, In Network Only

Last Updated: Oct 30, 2024

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886 - EPO - DA 50% NETWORK ONLY - Fixed Co-Pay $15/$35/$50 Rx

Summary of Benefits and Coverage - DA EPO - 50% Network Only Plan 886 3Tier $15/$35/$50 Rx

Last Updated: Oct 30, 2024

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913 - OMNIA - 100/60 - Fixed Co-Pay $10/$50/$75 Rx

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

Last Updated: Oct 30, 2024

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929 - OMNIA - 80/50 HSA - 60% Rx (after Deductible)

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

Last Updated: Oct 30, 2024

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934 - OMNIA - 100/50 - $15/60%/50% Rx

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

Last Updated: Oct 30, 2024

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949 - OMNIA - 90/70 HSA - 60% Rx (after Deductible)

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

Last Updated: Oct 30, 2024

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950 - OMNIA - 65/55 - $25/50%/50% Rx

Last Updated: Oct 30, 2024

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952 - OMNIA - 55/45 - $25/50%/50% Rx

Summary of Benefits and Coverage - Omnia - EPO - 55/45 Plan 952 50% Rx

Last Updated: Oct 30, 2024

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958 - OMNIA - 50/50 - 50% Rx (after Deductible)

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

Last Updated: Oct 30, 2024

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959 - OMNIA - 90/70 HSA - 60% Rx (after Deductible)

Summary of Benefits and Coverage - Omnia HSA EPO - 90/70 Plan 959

Last Updated: Oct 30, 2024

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968 - OMNIA - 50/50 - 50% Rx (after Deductible)

Summary of Benefits and Coverage - Omnia - EPO - 50% Plan 968 50% Rx

Last Updated: Oct 30, 2024

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