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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 Small group plans


Embedded HSA
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
HSA Embedded Gold 3000-100       HSA Embedded Gold 3000-100 Open Access HSA Embedded Gold 3000-100 Perform HSA Embedded Gold 3000-100 Achieve HSA Embedded Gold 3000-100 CentraChoice
HSA Embedded Silver 3850-100       HSA Embedded Silver 3850-100 Open Access HSA Embedded Silver 3850-100 Perform HSA Embedded Silver 3850-100 Achieve HSA Embedded Silver 3850-100 CentraChoice
HSA Embedded Silver 4000-100       HSA Embedded Silver 4000-100 Open Access HSA Embedded Silver 4000-100 Perform HSA Embedded Silver 4000-100 Achieve HSA Embedded Silver 4000-100 CentraChoice
HSA Embedded Silver 4500-100       HSA Embedded Silver 4500-100 Open Access HSA Embedded Silver 4500-100 Perform HSA Embedded Silver 4500-100 Achieve HSA Embedded Silver 4500-100 CentraChoice
HSA Embedded Silver 3000-80       HSA Embedded Silver 3000-80 Open Access HSA Embedded Silver 3000-80 Perform HSA Embedded Silver 3000-80 Achieve HSA Embedded Silver 3000-80 CentraChoice
HSA Embedded Bronze 6500-100       HSA Embedded Bronze 6500-100 Open Access HSA Embedded Bronze 6500-100 Perform HSA Embedded Bronze 6500-100 Achieve HSA Embedded Bronze 6500-100 CentraChoice
HSA Embedded Bronze 5500-70       HSA Embedded Bronze 5500-70 Open Access HSA Embedded Bronze 5500-70 Perform HSA Embedded Bronze 5500-70 Achieve HSA Embedded Bronze 5500-70 CentraChoice
HSA Embedded Bronze 6000-70       HSA Embedded Bronze 6000-70 Open Access HSA Embedded Bronze 6000-70 Perform HSA Embedded Bronze 6000-70 Achieve HSA Embedded Bronze 6000-70 CentraChoice
HSA Rx Plus
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
HSA Gold 2000-100 Rx Plus       HSA Gold 2000-100 Rx Plus Open Access HSA Gold 2000-100 Rx Plus Perform HSA Gold 2000-100 Rx Plus Achieve HSA Gold 2000-100 Rx Plus CentraChoice
HSA Gold 2500-100 Rx Plus       HSA Gold 2500-100 Rx Plus Open Access HSA Gold 2500-100 Rx Plus Perform HSA Gold 2500-100 Rx Plus Achieve HSA Gold 2500-100 Rx Plus CentraChoice
Copay and Deductible Copay
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
Platinum 25-95       Platinum 25-95 Open Access Platinum 25-95 Perform
Gold 30/60 P-S       Gold 30/60 P-S Open Access Gold 30/60 P-S Perform
Gold 45/90 P-S       Gold 45/90 P-S Open Access Gold 45/90 P-S Perform
Platinum 500-20       Platinum 500-20 Open Access Platinum 500-20 Perform
Gold 500-40       Gold 500-40 Open Access Gold 500-40 Perform
Gold 750-40       Gold 750-40 Open Access Gold 750-40 Perform
Gold 1000-40       Gold 1000-40 Open Access Gold 1000-40 Perform
Gold 2000-50       Gold 2000-50 Open Access Gold 2000-50 Perform
Silver 4000-60       Silver 4000-60 Open Access Silver 4000-60 Perform
Three For Free
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
Gold 500-70% Three for Free       Gold 500-70% Three for Free Open Access Gold 500-70% Three for Free Perform
Gold 1000-70% Three for Free       Gold 1000-70% Three for Free Open Access Gold 1000-70% Three for Free Perform
Gold 2000-70% Three for Free       Gold 2000-70% Three for Free Open Access Gold 2000-70% Three for Free Perform
Silver 3500-70% Three for Free       Silver 3500-70% Three for Free Open Access Silver 3500-70% Three for Free Perform
Silver 5000-70% Three for Free       Silver 5000-70% Three for Free Open Access Silver 5000-70% Three for Free Perform
HSA
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
HSA Gold 2000-100       HSA Gold 2000-100 Open Access HSA Gold 2000-100 Perform
HSA Gold 2500-100       HSA Gold 2500-100 Open Access HSA Gold 2500-100 Perform
HSA Silver 3600-100       HSA Silver 3600-100 Open Access HSA Silver 3600-100 Perform
Embedded HSA
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
HSA Embedded Gold 3000-100       HSA Embedded Gold 3000-100 Open Access HSA Embedded Gold 3000-100 Perform
HSA Embedded Silver 3850-100       HSA Embedded Silver 3850-100 Open Access HSA Embedded Silver 3850-100 Perform
HSA Embedded Silver 4000-100       HSA Embedded Silver 4000-100 Open Access HSA Embedded Silver 4000-100 Perform
HSA Embedded Silver 4500-100       HSA Embedded Silver 4500-100 Open Access HSA Embedded Silver 4500-100 Perform
HSA Embedded Silver 3000-80       HSA Embedded Silver 3000-80 Open Access HSA Embedded Silver 3000-80 Perform
HSA Embedded Bronze 6500-100       HSA Embedded Bronze 6500-100 Open Access HSA Embedded Bronze 6500-100 Perform
HSA Embedded Bronze 5500-70       HSA Embedded Bronze 5500-70 Open Access HSA Embedded Bronze 5500-70 Perform
HSA Embedded Bronze 6000-70       HSA Embedded Bronze 6000-70 Open Access HSA Embedded Bronze 6000-70 Perform
HSA Rx Plus
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
HSA Gold 2000-100 Rx Plus       HSA Gold 2000-100 Rx Plus Open Access HSA Gold 2000-100 Rx Plus Perform
HSA Gold 2500-100 Rx Plus       HSA Gold 2500-100 Rx Plus Open Access HSA Gold 2500-100 Rx Plus Perform
HSA Rx Plus Embedded
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
HSA Embedded Silver 3000-100 Rx Plus       HSA Embedded Silver 3000-100 Rx Plus Open Access HSA Embedded Silver 3000-100 Rx Plus Perform
HSA Embedded Silver 4250-100 Rx Plus       HSA Embedded Silver 4250-100 Rx Plus Open Access HSA Embedded Silver 4250-100 Rx Plus Perform
HSA Embedded Silver 5000-100 Rx Plus       HSA Embedded Silver 5000-100 Rx Plus Open Access HSA Embedded Silver 5000-100 Rx Plus Perform
HSA Embedded Silver 3000-80 Rx Plus       HSA Embedded Silver 3000-80 Rx Plus Open Access HSA Embedded Silver 3000-80 Rx Plus Perform
HRA Embedded
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
HRA Embedded Silver 4000-100       HRA Embedded Silver 4000-100 Open Access HRA Embedded Silver 4000-100 Perform
HRA Embedded Silver 5000-100       HRA Embedded Silver 5000-100 Open Access HRA Embedded Silver 5000-100 Perform
HRA Embedded Bronze 6500-100       HRA Embedded Bronze 6500-100 Open Access HRA Embedded Bronze 6500-100 Perform
Copay and Deductible Copay
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused
Platinum 25-95       Platinum 25-95 Focused
Gold 30/60 P-S       Gold 30/60 P-S Focused
Gold 45/90 P-S       Gold 45/90 P-S Focused
Platinum 500-20       Platinum 500-20 Focused
Gold 500-40       Gold 500-40 Focused
Gold 750-40       Gold 750-40 Focused
Gold 1000-40       Gold 1000-40 Focused
Gold 2000-50       Gold 2000-50 Focused
Silver 4000-60       Silver 4000-60 Focused
Three For Free
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused
Gold 500-70% Three for Free       Gold 500-70% Three for Free Focused
Gold 1000-70% Three for Free       Gold 1000-70% Three for Free Focused
Gold 2000-70% Three for Free       Gold 2000-70% Three for Free Focused
Silver 3500-70% Three for Free       Silver 3500-70% Three for Free Focused
Silver 5000-70% Three for Free       Silver 5000-70% Three for Free Focused
HSA
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused
HSA Gold 2000-100       HSA Gold 2000-100 Focused
HSA Gold 2500-100       HSA Gold 2500-100 Focused
HSA Silver 3600-100       HSA Silver 3600-100 Focused
HSA Copay
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused
HSA Gold 2000-100 w/Copay       HSA Gold 2000-100 w/Copay Focused
HSA Embedded Silver 3000-100 w/Copay       HSA Embedded Silver 3000-100 w/Copay Focused
HSA Embedded Bronze 5000-100 w/Copay       HSA Embedded Bronze 5000-100 w/Copay Focused
Embedded HSA
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused
HSA Embedded Gold 3000-100       HSA Embedded Gold 3000-100 Focused
HSA Embedded Silver 3850-100       HSA Embedded Silver 3850-100 Focused
HSA Embedded Silver 4000-100       HSA Embedded Silver 4000-100 Focused
HSA Embedded Silver 4500-100       HSA Embedded Silver 4500-100 Focused
HSA Embedded Silver 3000-80       HSA Embedded Silver 3000-80 Focused
HSA Embedded Bronze 6450-100       HSA Embedded Bronze 6450-100 Focused
HSA Embedded Bronze 5500-70       HSA Embedded Bronze 5500-70 Focused
HSA Embedded Bronze 6000-70       HSA Embedded Bronze 6000-70 Focused
HSA Rx Plus
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused
HSA Gold 2000-100 Rx Plus       HSA Gold 2000-100 Rx Plus Focused
HSA Gold 2500-100 Rx Plus       HSA Gold 2500-100 Rx Plus Focused
HSA Rx Plus Embedded
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused
HSA Embedded Gold 3000-100 Rx Plus       HSA Embedded Gold 3000-100 Rx Plus Focused
HSA Embedded Silver 4250-100 Rx Plus       HSA Embedded Silver 4250-100 Rx Plus Focused
HSA Embedded Silver 5000-100 Rx Plus       HSA Embedded Silver 5000-100 Rx Plus Focused
HSA Embedded Silver 3000-80 Rx Plus       HSA Embedded Silver 3000-80 Rx Plus Focused
HRA Embedded
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused
HRA Embedded Silver 4000-100       HRA Embedded Silver 4000-100 Focused
HRA Embedded Silver 5000-100       HRA Embedded Silver 5000-100 Focused
HRA Embedded Bronze 6500-100       HRA Embedded Bronze 6500-100 Focused
Copay and Deductible Copay
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
Platinum 25-95       Platinum 25-95 Open Access
Gold 30/60 P-S       Gold 30/60 P-S Open Access
Gold 45/90 P-S       Gold 45/90 P-S Open Access
Platinum 500-20       Platinum 500-20 Open Access
Gold 500-40       Gold 500-40 Open Access
Gold 750-40       Gold 750-40 Open Access
Gold 1000-40       Gold 1000-40 Open Access
Gold 2000-50       Gold 2000-50 Open Access
Silver 4000-60       Silver 4000-60 Open Access
Three For Free
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
Gold 500-70% Three for Free       Gold 500-70% Three for Free Open Access
Gold 1000-70% Three for Free       Gold 1000-70% Three for Free Open Access
Gold 2000-70% Three for Free       Gold 2000-70% Three for Free Open Access
Silver 3500-70% Three for Free       Silver 3500-70% Three for Free Open Access
Silver 5000-70% Three for Free       Silver 5000-70% Three for Free Open Access
HSA
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
HSA Gold 2000-100       HSA Gold 2000-100 Open Access
HSA Gold 2500-100       HSA Gold 2500-100 Open Access
HSA Silver 3600-100       HSA Silver 3600-100 Open Access
 
Embedded HSA
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
HSA Embedded Gold 3000-100       HSA Embedded Gold 3000-100 Open Access
HSA Embedded Silver 3850-100       HSA Embedded Silver 3850-100 Open Access
HSA Embedded Silver 4000-100       HSA Embedded Silver 4000-100 Open Access
HSA Embedded Silver 4500-100       HSA Embedded Silver 4500-100 Open Access
HSA Embedded Silver 3000-80       HSA Embedded Silver 3000-80 Open Access
HSA Embedded Bronze 6450-100       HSA Embedded Bronze 6450-100 Open Access
HSA Embedded Bronze 5500-70       HSA Embedded Bronze 5500-70 Open Access
HSA Embedded Bronze 6000-70       HSA Embedded Bronze 6000-70 Open Access
HSA Rx Plus
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
HSA Gold 2000-100 Rx Plus       HSA Gold 2000-100 Rx Plus Open Access
HSA Gold 2500-100 Rx Plus       HSA Gold 2500-100 Rx Plus Open Access
HSA Rx Plus Embedded
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
HSA Embedded Gold 3000-100 Rx Plus       HSA Embedded Gold 3000-100 Rx Plus Open Access
HSA Embedded Silver 4250-100 Rx Plus       HSA Embedded Silver 4250-100 Rx Plus Open Access
HSA Embedded Silver 5000-100 Rx Plus       HSA Embedded Silver 5000-100 Rx Plus Open Access
HSA Embedded Silver 3000-80 Rx Plus       HSA Embedded Silver 3000-80 Rx Plus Open Access
HRA Embedded
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
HRA Embedded Silver 4000-100       HRA Embedded Silver 4000-100 Open Access
HRA Embedded Silver 5000-100       HRA Embedded Silver 5000-100 Open Access
HRA Embedded Bronze 6500-100       HRA Embedded Bronze 6500-100 Open Access

2018 Small group plans


Embedded HSA
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
HSA Embedded Gold 2800-100 CON-700.53-HSA-HPSE-1-18 BCH-700.53-SE-SE372-CT-18 PMD-700.53-SE-PED-100C-1-18 HSA Embedded Gold 2800-100 Open Access HSA Embedded Gold 2800-100 Perform HSA Embedded Gold 2800-100 Achieve HSA Embedded Gold 2800-100 CentraChoice
HSA Embedded Silver 3600-100 CON-700.53-HSA-HPSE-1-18 BCH-700.53-SE-SE376-CT-18 PMD-700.53-SE-PED-100C-1-18 HSA Embedded Silver 3600-100 Open Access HSA Embedded Silver 3600-100 Perform HSA Embedded Silver 3600-100 Achieve HSA Embedded Silver 3600-100 CentraChoice
HSA Embedded Silver 4000-100 CON-700.53-HSA-HPSE-1-18 BCH-700.53-SE-SE380-CT-18 PMD-700.53-SE-PED-100C-1-18 HSA Embedded Silver 4000-100 Open Access HSA Embedded Silver 4000-100 Perform HSA Embedded Silver 4000-100 Achieve HSA Embedded Silver 4000-100 CentraChoice
HSA Embedded Silver 3000-80 CON-700.53-HSA-HPSE-1-18 BCH-700.53-SE-SE388-CT-18 PMD-700.53-SE-PED-80C-1-18 HSA Embedded Silver 3000-80 Open Access HSA Embedded Silver 3000-80 Perform HSA Embedded Silver 3000-80 Achieve HSA Embedded Silver 3000-80 CentraChoice
HSA Embedded Bronze 6500-100 CON-700.53-HSA-HPSE-1-18 BCH-700.53-SE-SE384-CT-18 PMD-700.53-SE-PED-100C-1-18 HSA Embedded Bronze 6500-100 Open Access HSA Embedded Bronze 6500-100 Perform HSA Embedded Bronze 6500-100 Achieve HSA Embedded Bronze 6500-100 CentraChoice
HSA Embedded Bronze 5200-70 CON-700.53-HSA-HPSE-1-18 BCH-700.53-SE-SE392-CT-18 PMD-700.53-SE-PED-70C-1-18 HSA Embedded Bronze 5200-70 Open Access HSA Embedded Bronze 5200-70 Perform HSA Embedded Bronze 5200-70 Achieve HSA Embedded Bronze 5200-70 CentraChoice
HSA Embedded Bronze 6000-70 CON-700.53-HSA-HPSE-1-18 BCH-700.53-SE-SE396-CT-18 PMD-700.53-SE-PED-70C-1-18 HSA Embedded Bronze 6000-70 Open Access HSA Embedded Bronze 6000-70 Perform HSA Embedded Bronze 6000-70 Achieve HSA Embedded Bronze 6000-70 CentraChoice
HSA Rx Plus Embedded
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
HSA Embedded Silver 4000-100 Rx Plus MGC-900.18-WI-SE-HSA-18 BCH-900.18-WI-SE-WE434CT-18 PMD-900.18-WISEPED100C-1-18R HSA Embedded Silver 4000-100 Rx Plus Open Access
HSA Embedded Silver 3000-80 Rx Plus MGC-900.18-WI-SE-HSA-18 BCH-900.18-WI-SE-WE435CT-18 PMD-900.18-WISEPED80C-1-18R HSA Embedded Silver 3000-80 Rx Plus Open Access
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