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Claim Forms Enrollment/Waiver Forms Summary of Benefits & Coverage

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80/60 PPO HSCP

Last Updated: Apr 23, 2021

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PPO - 100/80

Last Updated: Feb 13, 2023

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PPO - 100/80

Last Updated: Feb 13, 2023

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PPO – 90/70

Last Updated: Feb 13, 2023

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PPO – 90/70

Last Updated: Feb 13, 2023

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PPO – 80/60

Last Updated: Feb 13, 2023

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PPO – 80/60

Last Updated: Feb 13, 2023

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PPO - 100/80

Last Updated: Feb 13, 2023

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PPO – 90/70

Last Updated: Feb 13, 2023

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PPO – 80/60

Last Updated: Feb 13, 2023

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Plan 41X Direct Access-100/60

Last Updated: Feb 13, 2023

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Plan 41XL Direct Access-100/60

Last Updated: Feb 13, 2023

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Plan 42X Direct Access-90/60

Last Updated: Feb 13, 2023

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Plan 42XL Direct Access-90/60

Last Updated: Feb 13, 2023

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Plan 43X Direct Access-90/60- HSCP

Last Updated: Feb 13, 2023

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Plan 43XL Direct Access-90/60- HSCP

Last Updated: Feb 13, 2023

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Plan 44X Direct Access-80/60- HSCP

Last Updated: Feb 13, 2023

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Plan 44XL Direct Access-80/60- HSCP

Last Updated: Feb 13, 2023

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Plan 45X: Direct Access-100/60-R HSCP

Last Updated: Feb 13, 2023

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Plan 45XL Direct Access-100/60-R HSCP

Last Updated: Feb 13, 2023

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Plan 46X Direct Access-80/60- R HSCP

Last Updated: Feb 13, 2023

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Plan 46XL Direct Access-80/60- R HSCP

Last Updated: Feb 13, 2023

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Plan 47X Direct Access-80/60

Last Updated: Feb 13, 2023

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Plan 47XL Direct Access-80/60

Last Updated: Feb 13, 2023

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Plan 48X Direct Access-80/60

Last Updated: Feb 13, 2023

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Plan 48XL Direct Access-80/60

Last Updated: Feb 13, 2023

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Plan 49X Direct Access-100/60-R HSCP

Last Updated: Feb 13, 2023

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Plan 49XL Direct Access-100/60-R HSCP

Last Updated: Feb 13, 2023

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100/80/60 Health Savings Account

Last Updated: Feb 13, 2023

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Plan 59X: Direct Access-50/50-R HSCP

Last Updated: Feb 13, 2023

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Direct Access-100/80/60 Health Savings Account

Last Updated: Feb 13, 2023

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Direct Access-100/80/60 Health Savings Account

Last Updated: Feb 13, 2023

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Direct Access-100/80/60 Health Savings Account

Last Updated: Feb 13, 2023

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Direct Access-100/80/60 Health Savings Account

Last Updated: Feb 13, 2023

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Direct Access-50/50 Health Savings Account

Last Updated: Feb 13, 2023

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Direct Access-50/50 Health Savings Account

Last Updated: Feb 13, 2023

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Direct Access-100/70 Health Savings Account

Last Updated: Feb 13, 2023

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Direct Access-100/70 Health Savings Account

Last Updated: Feb 13, 2023

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Direct Access-100/70 Health Savings Account

Last Updated: Feb 13, 2023

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Direct Access-100/70 Health Savings Account

Last Updated: Feb 13, 2023

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Direct Access-100% Health Savings Account

Last Updated: Feb 13, 2023

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Direct Access-100% Health Savings Account

Last Updated: Feb 13, 2023

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Direct Access-70% Health Savings Account

Last Updated: Feb 13, 2023

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Advantage EPO DIRECT ACCESS 100%

Last Updated: Feb 13, 2023

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Advantage EPO DIRECT ACCESS 80%

Last Updated: Feb 13, 2023

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Advantage EPO DIRECT ACCESS 80%

Last Updated: Feb 13, 2023

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Advantage EPO DIRECT ACCESS 80%

Last Updated: Feb 13, 2023

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Advantage EPO DIRECT ACCESS 100%

Last Updated: Feb 13, 2023

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Advantage EPO DIRECT ACCESS 50%

Last Updated: Feb 13, 2023

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Advantage EPO DIRECT ACCESS 50%

Last Updated: Feb 13, 2023

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Summary Plan Description - OMNIA - 100/60 - Plan 913

Last Updated: Feb 13, 2023

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Summary Plan Description - OMNIA HSA Compatible 80/50 - Plan 929

Last Updated: Feb 13, 2023

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Summary Plan Description - OMNIA 100/50 - Plan 934

Last Updated: Feb 13, 2023

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Summary Plan Description - OMNIA HSA Compatible 90/70 - Plan 949/959

Last Updated: Feb 13, 2023

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Summary Plan Description - OMNIA 65/55 - Plan 950

Last Updated: Feb 13, 2023

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Summary Plan Description - OMNIA 50/50 - Plan 958

Last Updated: Feb 13, 2023

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Hospital,Medical Surgical, Major Medical

Last Updated: Apr 23, 2021

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COMPREHENSIVE HEALTH PLAN 80%

Last Updated: Feb 13, 2023

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COMPREHENSIVE HEALTH PLAN 80%

Last Updated: Apr 23, 2021

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COMPREHENSIVE HEALTH PLAN 50%

Last Updated: Apr 23, 2021

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Prescription Drug $15/$25

Last Updated: Apr 27, 2021

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Prescription Drug - $10/$50/$75

Last Updated: Apr 27, 2021

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Prescription Drug 70/30

Last Updated: Apr 27, 2021

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Prescription Drug $15/$35/$50

Last Updated: Apr 27, 2021

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Prescription Drug 50/50

Last Updated: Apr 27, 2021

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