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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

Copay and Deductible Copay
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
Platinum 25-95 CON-700.54-HPSE-1-19 BCH-700.54-SE-SE605C-19 PMD-700.54-SE-PED-95C-1-19 Platinum 25-95 Open Access Platinum 25-95 Perform Platinum 25-95 Achieve Platinum 25-95 CentraChoice
Gold 30/60 P-S CON-700.54-HPSE-1-19 BCH-700.54-SE-SE633C-19 PMD-700.54-SE-PED-80C-1-19 Gold 30/60 P-S Open Access Gold 30/60 P-S Perform Gold 30/60 P-S Achieve Gold 30/60 P-S CentraChoice
Gold 45/90 P-S CON-700.54-HPSE-1-19 BCH-700.54-SE-SE637C-19 PMD-700.54-SE-PED-80C-1-19 Gold 45/90 P-S Open Access Gold 45/90 P-S Perform Gold 45/90 P-S Achieve Gold 45/90 P-S CentraChoice
Platinum 500-20 CON-700.54-HPSE-1-19 BCH-700.54-SE-SE609C-19 PMD-700.54-SE-PED-80C-1-19 Platinum 500-20 Open Access Platinum 500-20 Perform Platinum 500-20 Achieve Platinum 500-20 CentraChoice
Gold 500-40 CON-700.54-HPSE-1-19 BCH-700.54-SE-SE613C-19 PMD-700.54-SE-PED-75C-1-19 Gold 500-40 Open Access Gold 500-40 Perform Gold 500-40 Achieve Gold 500-40 CentraChoice
Gold 750-40 CON-700.54-HPSE-1-19 BCH-700.54-SE-SE617C-19 PMD-700.54-SE-PED-75C-1-19 Gold 750-40 Open Access Gold 750-40 Perform Gold 750-40 Achieve Gold 750-40 CentraChoice
Gold 1000-40 CON-700.54-HPSE-1-19 BCH-700.54-SE-SE621C-19 PMD-700.54-SE-PED-75C-1-19 Gold 1000-40 Open Access Gold 1000-40 Perform Gold 1000-40 Achieve Gold 1000-40 CentraChoice
Gold 2000-50 CON-700.54-HPSE-1-19 BCH-700.54-SE-SE625C-19 PMD-700.54-SE-PED-75C-1-19 Gold 2000-50 Open Access Gold 2000-50 Perform Gold 2000-50 Achieve Gold 2000-50 CentraChoice
Silver 4000-60 CON-700.54-HPSE-1-19 BCH-700.54-SE-SE629C-19 PMD-700.54-SE-PED-70C-1-19 Silver 4000-60 Open Access Silver 4000-60 Perform Silver 4000-60 Achieve Silver 4000-60 CentraChoice

Embedded HSA
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
HSA Embedded Gold 3000-100 CON-700.54-HSA-HPSE-1-19 BCH-700.54-SE-SE673C-19 PMD-700.54-SE-PED-100C-1-19 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 CON-700.54-HSA-HPSE-1-19 BCH-700.54-SE-SE677C-19 PMD-700.54-SE-PED-100C-1-19 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 CON-700.54-HSA-HPSE-1-19 BCH-700.54-SE-SE681C-19 PMD-700.54-SE-PED-100C-1-19 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 CON-700.54-HSA-HPSE-1-19 BCH-700.54-SE-SE685C-19 PMD-700.54-SE-PED-100C-1-19 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 CON-700.54-HSA-HPSE-1-19 BCH-700.54-SE-SE693C-19 PMD-700.54-SE-PED-80C-1-19 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-700.54-HSA-HPSE-1-19 BCH-700.54-SE-SE689C-19 PMD-700.54-SE-PED-100C-1-19 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 CON-700.54-HSA-HPSE-1-19 BCH-700.54-SE-SE697C-19 PMD-700.54-SE-PED-70C-1-19 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 CON-700.54-HSA-HPSE-1-19 BCH-700.54-SE-SE701C-19 PMD-700.54-SE-PED-70C-1-19 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
Embedded HSA
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
HSA Embedded Gold 3000-100 MGC-900.37-SE-HSA-19 BCH-900.37-SE-CE406C-19 PMD-900.37-SE-PED-100C-1-19 HSA Embedded Gold 3000-100 Open Access HSA Embedded Gold 3000-100 Perform
HSA Embedded Silver 3850-100 MGC-900.37-SE-HSA-19 BCH-900.37-SE-CE408C-19 PMD-900.37-SE-PED-100C-1-19 HSA Embedded Silver 3850-100 Open Access HSA Embedded Silver 3850-100 Perform
HSA Embedded Silver 4000-100 MGC-900.37-SE-HSA-19 BCH-900.37-SE-CE410C-19 PMD-900.37-SE-PED-100C-1-19 HSA Embedded Silver 4000-100 Open Access HSA Embedded Silver 4000-100 Perform
HSA Embedded Silver 4500-100 MGC-900.37-SE-HSA-19 BCH-900.37-SE-CE412C-19 PMD-900.37-SE-PED-100C-1-19 HSA Embedded Silver 4500-100 Open Access HSA Embedded Silver 4500-100 Perform
HSA Embedded Silver 3000-80 MGC-900.37-SE-HSA-19 BCH-900.37-SE-CE416C-19 PMD-900.37-SE-PED-80C-1-19 HSA Embedded Silver 3000-80 Open Access HSA Embedded Silver 3000-80 Perform
HSA Embedded Bronze 6500-100 MGC-900.37-SE-HSA-19 BCH-900.37-SE-CE414C-19 PMD-900.37-SE-PED-100C-1-19 HSA Embedded Bronze 6500-100 Open Access HSA Embedded Bronze 6500-100 Perform
HSA Embedded Bronze 5500-70 MGC-900.37-SE-HSA-19 BCH-900.37-SE-CE418C-19 PMD-900.37-SE-PED-70C-1-19 HSA Embedded Bronze 5500-70 Open Access HSA Embedded Bronze 5500-70 Perform
HSA Embedded Bronze 6000-70 MGC-900.37-SE-HSA-19 BCH-900.37-SE-CE420C-19 PMD-900.37-SE-PED-70C-1-19 HSA Embedded Bronze 6000-70 Open Access HSA Embedded Bronze 6000-70 Perform
 

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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