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Insurance documents

Read about the details of your insurance plan. This is all the “fine print” for the insurance plans we offer.

Information that's easy to read

If you’re looking for information that’s easy to read, the column labeled “Summary of Benefits and Coverage" is your best bet. These are also called SBCs. Use this document if you’re looking for detailed information about your plan. Plus, all SBCs are legally required to include the same information, so it’s easy to compare plans.

Questions about your plan? We’re here to help. Call Member Services at 952-883-5000.

2019 Large group plans

Empower Embedded HSA
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve
EZ Empower HSA Embedded 2700-100 MGC-900.37-EZ-HSA-19 BCH-900.37-EZ-ZC895C-19   EZ Empower HSA Embedded 2700-100 Open Access EZ Empower HSA Embedded 2700-100 Perform EZ Empower HSA Embedded 2700-100 Achieve
EZ Empower HSA Embedded 3000-100 MGC-900.37-EZ-HSA-19 BCH-900.37-EZ-ZC898C-19   EZ Empower HSA Embedded 3000-100 Open Access EZ Empower HSA Embedded 3000-100 Perform EZ Empower HSA Embedded 3000-100 Achieve
EZ Empower HSA Embedded 3500-100 MGC-900.37-EZ-HSA-19 BCH-900.37-EZ-ZC901C-19   EZ Empower HSA Embedded 3500-100 Open Access EZ Empower HSA Embedded 3500-100 Perform EZ Empower HSA Embedded 3500-100 Achieve
EZ Empower HSA Embedded 4000-100 MGC-900.37-EZ-HSA-19 BCH-900.37-EZ-ZC904C-19   EZ Empower HSA Embedded 4000-100 Open Access EZ Empower HSA Embedded 4000-100 Perform EZ Empower HSA Embedded 4000-100 Achieve
EZ Empower HSA Embedded 4500-100 MGC-900.37-EZ-HSA-19 BCH-900.37-EZ-ZC907C-19   EZ Empower HSA Embedded 4500-100 Open Access EZ Empower HSA Embedded 4500-100 Perform EZ Empower HSA Embedded 4500-100 Achieve
EZ Empower HSA Embedded 5000-100 MGC-900.37-EZ-HSA-19 BCH-900.37-EZ-ZC910C-19   EZ Empower HSA Embedded 5000-100 Open Access EZ Empower HSA Embedded 5000-100 Perform EZ Empower HSA Embedded 5000-100 Achieve
EZ Empower HSA Embedded 6350-100 MGC-900.37-EZ-HSA-19 BCH-900.37-EZ-ZC913C-19   EZ Empower HSA Embedded 6350-100 Open Access EZ Empower HSA Embedded 6350-100 Perform EZ Empower HSA Embedded 6350-100 Achieve
Copay and Deductible Copay
Plan name Contract Benefit charts Amendments Open Access (ND) Open Access (SD)
EZ 2000-45       EZ 2000-45 Open Access EZ 2000-45 Open Access
EZ 2500-45       EZ 2500-45 Open Access EZ 2500-45 Open Access
Three For Free
Plan name Contract Benefit charts Amendments Open Access (ND) Open Access (SD)
EZ Three for Free 2000-80       EZ Three for Free 2000-80 Open Access EZ Three for Free 2000-80 Open Access
EZ Three for Free 2500-80       EZ Three for Free 2500-80 Open Access EZ Three for Free 2500-80 Open Access
Empower HSA
Plan name Contract Benefit charts Amendments Open Access (ND) Open Access (SD)
EZ Empower HSA 2500-100       EZ Empower HSA 2500-100 Open Access EZ Empower HSA 2500-100 Open Access
EZ Empower HSA 3500-100       EZ Empower HSA 3500-100 Open Access EZ Empower HSA 3500-100 Open Access
Empower Embedded HAS
Plan name Contract Benefit charts Amendments Open Access (ND) Open Access (SD)
EZ Empower HSA Embedded 2700-100       EZ Empower HSA Embedded 2700-100 Open Access EZ Empower HSA Embedded 2700-100 Open Access
EZ Empower HSA Embedded 4000-100       EZ Empower HSA Embedded 4000-100 Open Access EZ Empower HSA Embedded 4000-100 Open Access
EZ Empower HSA Embedded 6350-100       EZ Empower HSA Embedded 6350-100 Open Access EZ Empower HSA Embedded 6350-100 Open Access
Empower HSA Rx Plus
Plan name Contract Benefit charts Amendments Open Access (ND) Open Access (SD)
EZ Empower HSA Rx Plus 3000-100       EZ Empower HSA Rx Plus 3000-100 Open Access EZ Empower HSA Rx Plus 3000-100 Open Access
EZ Empower HSA Rx Plus 2000-80       EZ Empower HSA Rx Plus 2000-80 Open Access EZ Empower HSA Rx Plus 2000-80 Open Access
Empower HSA Rx Plus Embedded
Plan name Contract Benefit charts Amendments Open Access (ND) Open Access (SD)
EZ Empower HSA Rx Plus Embedded 2700-100       EZ Empower HSA Rx Plus Embedded 2700-100 Open Access EZ Empower HSA Rx Plus Embedded 2700-100 Open Access
EZ Empower HSA Rx Plus Embedded 3500-100       EZ Empower HSA Rx Plus Embedded 3500-100 Open Access EZ Empower HSA Rx Plus Embedded 3500-100 Open Access
EZ Empower HSA Rx Plus Embedded 3500-80       EZ Empower HSA Rx Plus Embedded 3500-80 Open Access EZ Empower HSA Rx Plus Embedded 3500-80 Open Access
Empower HRA Embedded
Plan name Contract Benefit charts Amendments Open Access (ND) Open Access (SD)
EZ Empower HRA Embedded 2500-100       EZ Empower HRA Embedded 2500-100 Open Access EZ Empower HRA Embedded 2500-100 Open Access
EZ Empower HRA Embedded 5000-100       EZ Empower HRA Embedded 5000-100 Open Access EZ Empower HRA Embedded 5000-100 Open Access
Summary Benefits
Amendments Summary benefits chart SBC
  Empower HSA 2700-100 Empower HSA 2700-100
  Empower HSA 2750-100 Empower HSA 2750-100

2018 Large group plans

Distinctions Tiered Plans
Plan name Contract Benefit charts Amendments/ pediatric dental Distinctions Network
EZ Distinctions Tiered II 1000-25 80/70 MGC-900.36-EZ-N1-18 BCH-900.36-EZ-ZC812-CT-18   EZ Distinctions Tiered II 1000-25 80/70
EZ Distinctions Tiered II HSA Embedded 3000-100/75 MGC-900.36-EZ-N1-EHSA-18 BCH-900.36-EZ-ZC813-CT-18   EZ Distinctions Tiered II HSA Embedded 3000-100/75
Empower Embedded HSA
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve
EZ Empower HSA Embedded 2700-100 MGC-900.36-EZ-N1-EHSA-18 BCH-900.36-EZ-ZC767-CT-18   EZ Empower HSA Embedded 2700-100 Open Access EZ Empower HSA Embedded 2700-100 Perform EZ Empower HSA Embedded 2700-100 Achieve
EZ Empower HSA Embedded 3000-100 MGC-900.36-EZ-N1-EHSA-18 BCH-900.36-EZ-ZC768-CT-18   EZ Empower HSA Embedded 3000-100 Open Access EZ Empower HSA Embedded 3000-100 Perform EZ Empower HSA Embedded 3000-100 Achieve
EZ Empower HSA Embedded 3500-100 MGC-900.36-EZ-N1-EHSA-18 BCH-900.36-EZ-ZC769-CT-18   EZ Empower HSA Embedded 3500-100 Open Access EZ Empower HSA Embedded 3500-100 Perform EZ Empower HSA Embedded 3500-100 Achieve
EZ Empower HSA Embedded 4000-100 MGC-900.36-EZ-N1-EHSA-18 BCH-900.36-EZ-ZC770-CT-18   EZ Empower HSA Embedded 4000-100 Open Access EZ Empower HSA Embedded 4000-100 Perform EZ Empower HSA Embedded 4000-100 Achieve
EZ Empower HSA Embedded 4500-100 MGC-900.36-EZ-N1-EHSA-18 BCH-900.36-EZ-ZC771-CT-18   EZ Empower HSA Embedded 4500-100 Open Access EZ Empower HSA Embedded 4500-100 Perform EZ Empower HSA Embedded 4500-100 Achieve
EZ Empower HSA Embedded 5000-100 MGC-900.36-EZ-N1-EHSA-18 BCH-900.36-EZ-ZC772-CT-18   EZ Empower HSA Embedded 5000-100 Open Access EZ Empower HSA Embedded 5000-100 Perform EZ Empower HSA Embedded 5000-100 Achieve
EZ Empower HSA Embedded 6350-100 MGC-900.36-EZ-N1-EHSA-18 BCH-900.36-EZ-ZC773-CT-18   EZ Empower HSA Embedded 6350-100 Open Access EZ Empower HSA Embedded 6350-100 Perform EZ Empower HSA Embedded 6350-100 Achieve
Plan name Contract Benefit charts Amendments Summary benefits chart
Minnesota Large Group        
Wisconsin Large Group        
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