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.
2022 Small Employer plans
Copay and Deductible-Copay Plans
| SBC by Network | ||||||||
|---|---|---|---|---|---|---|---|---|
| $25-90% Platinum | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $500-$25 Platinum | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $500-$45 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $1,000-$45 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $2,000-$50 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $3,500-$60 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $5,000-$65 Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
Three for Free Plans
| SBC by Network | ||||||||
|---|---|---|---|---|---|---|---|---|
| $1,000-70% Three for Free Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $2,000-70% Three for Free Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $3,500-70% Three for Free Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $5,000-70% Three for Free Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
HSA Non-Embedded Plans
| SBC by Network | ||||||||
|---|---|---|---|---|---|---|---|---|
| $2400-100% HSA Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $4100-100% HSA Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
HSA Embedded Plans
| SBC by Network | ||||||||
|---|---|---|---|---|---|---|---|---|
| $3000-100% HSA Embedded Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $4,300-100% HSA Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $5,750-100% HSA Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $7,000-100% HSA Embedded Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
HSA Plus Non-Embedded Plans
| SBC by Network | ||||||||
|---|---|---|---|---|---|---|---|---|
| $2,500-100% HSA Plus Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
HSA Plus Embedded Plans
| SBC by Network | ||||||||
|---|---|---|---|---|---|---|---|---|
| $3,000-100% HSA Plus Embedded Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $4,600-100% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $6,500-100% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $3,000-70% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $5,500-70% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
HRA Embedded Plans
| SBC by Network | ||||||||
|---|---|---|---|---|---|---|---|---|
| $7,000-100% HRA Embedded Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
| $8,700-100% HRA Embedded Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform | CentraChoice | Achieve | Select |
Tiered Deductible-Copay Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $500-$60 Tiered Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | TieredChoice |
| $1,000-$50 Tiered Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | TieredChoice |
| $1,500-$50 Tiered Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | TieredChoice |
| $3,000-$60 Tiered Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | TieredChoice |
| $5,800-$70 Tiered Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | TieredChoice |
Tiered HSA Plus Non-Embedded Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $3,500-100% Tiered HSA Plus Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | TieredChoice |
| $3,750-100% Tiered HSA Plus Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | TieredChoice |
Tiered HSA Plus Embedded Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $5,500-100% Tiered HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | TieredChoice |
| $7,000-100% Tiered HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | TieredChoice |
Copay and Deductible-Copay Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $25-90% Platinum | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $500-$25 Platinum | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $500-$45 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $1,000-$45 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $2,000-$50 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $3,500-$60 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $5,000-$65 Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
Three for Free Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $1,000-70% Three for Free Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $2,000-70% Three for Free Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $3,500-70% Three for Free Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $5,000-70% Three for Free Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
HSA Non-Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $2400-100% HSA Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $4100-100% HSA Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
HSA Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $3000-100% HSA Embedded Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $4,300-100% HSA Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $5,750-100% HSA Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $7,000-100% HSA Embedded Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
HSA Plus Non-Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $2,500-100% HSA Plus Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
HSA Plus Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $3,000-100% HSA Plus Embedded Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $4,600-100% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $6,500-100% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $3,000-70% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $5,500-70% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
HRA Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $7,000-100% HRA Embedded Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
| $8,700-100% HRA Embedded Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Perform |
Copay and Deductible-Copay Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $30/$60 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $500-$30/$50 Platinum | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $1,000-$30/$50 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $2,000-$30/$50 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $3,000-$30/$50 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $4,000-$30/$50 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $5,000-$45/$90 Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
Three for Free Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $500-70% Three for Free Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $1,000-70% Three for Free Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $2,000-70% Three for Free Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $3,500-70% Three for Free Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $4,000-70% Three for Free Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $4,000-70% Three for Free Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
HSA-Copay Non-Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $2,000-100% 30/$60 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
HSA-Copay Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $3,000-100% 30/$60 Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $5,000-100% $30/$60 Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $6,250-100% $30/$60 Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
HSA Non-Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $2,300-100% HSA Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $2,500-100% HSA Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
HSA Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $3000-100% HSA Embedded Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $4,200-100% HSA Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $5,000-100% HSA Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $6,000-100% HSA Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $6,850-100% HSA Embedded Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $3,000-70% HSA Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $6,500-70% HSA Embedded Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
HSA Plus Non-Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $2,500-100% HSA Plus Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
HSA Plus Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $3,000-100% HSA Plus Embedded Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $4,550-100% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
| $5,500-100% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
HRA Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $6,900-100% HRA Embedded Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Broad | Focused |
Copay and Deductible-Copay Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $25-90% Platinum | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $500-$25 Platinum | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $500-$45 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $1,000-$45 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $2,000-$50 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $3,500-$60 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $5,000-$65 Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
Three for Free Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $1,000-70% Three for Free Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $1,000-70% Three for Free Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $3,500-70% Three for Free Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $5,000-70% Three for Free Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
HSA Non-Embedded Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $2500-100% HSA Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $4100-100% HSA Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
HSA Embedded Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $3000-100% HSA Embedded Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $4,300-100% HSA Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $5,750-100% HSA Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $6,850-100% HSA Embedded Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
HSA Plus Non-Embedded Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $2,500-100% HSA Plus Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
HSA Plus Embedded Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $3,000-100% HSA Plus Embedded Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $4,550-100% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $6,500-100% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $3,000-70% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $5,500-70% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
HRA Embedded Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $6,850-100% HRA Embedded Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $8,400-100% HRA Embedded Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
Copay and Deductible-Copay Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $500-$25 Platinum | Contract | Benefit Chart | Amendments / Pediatric Dental | Bridges | |
| $500-$50 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $1,500-$30/$60 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $3,000-$30/$60 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $4,000-$30/$70 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $5,000-$40/$80 Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $6,000-$40/$80 Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $7,500-$50/$100 Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
Three for Free Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $3,500-70% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $5,000-70% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
HSA-Copay Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $3,000-100% $40/$80 Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $6,250-100% $30/$60 Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
HSA Non-Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $2,500-100% Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $4,100-100% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
HSA Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $3,000-100% Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $5,000-100% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $6,850-100% Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $3,000-70% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $6,500-70% Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
HSA Plus Non-Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $3,000-100% Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
HSA Plus Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $3,000-100% Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $4,500-100% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $6,000-100% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $3,000-70% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $5,000-70% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
| $5,500-70% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
HRA Embedded Plans
| SBC by Network | |||||
|---|---|---|---|---|---|
| $6,850-100% Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access | Bridges |
Copay and Deductible-Copay Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $300-$25 Platinum | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $500-$25 Platinum | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $1,000-$45 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $2,000-$25 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $3,000-$45 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $1,500-$30/$60 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $3,000-$30/$60 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $4,500-$30/$60 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $5,500-$30/$60 Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
Three for Free Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $1,000-70% Three for Free Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $2,000-70% Three for Free Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $3,500-70% Three for Free Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
HSA Embedded Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $6,850-100% Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
HSA Plus Non-Embedded Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $2,500-100% Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
HSA Plus Embedded Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $3,000-100% HSA Plus Embedded Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $3,700-100% HSA Plus Embedded Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $4,500-100% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $6,500-100% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $3,000-70% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $5,500-70% HSA Plus Embedded Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
Copay and Deductible-Copay Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $1,500-$30/$60 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $3,500-$35/$70 Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $5,000-$50/$100 Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $6,250-$70/50% Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
Three for Free Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $2,000-70% Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $3,500-70% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $4,500-70% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $6,000-70% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
HSA-Copay Embedded Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $3,500-100% $0/$60 Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $4,500-100% $0/$60 Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $6,250-100% $30/$60 Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
HSA Non-Embedded Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $2,500-100% Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $4,100-100% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
HSA Embedded Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $6,850-100% Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
HSA Plus Non-Embedded Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $3,000-100% Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
HSA Plus Embedded Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $3,000-100% Gold | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $4,500-100% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $6,000-100% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $3,000-70% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $5,000-70% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $5,500-70% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
HRA Embedded Plans
| SBC by Network | ||||
|---|---|---|---|---|
| $5,000-100% Silver | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $6,850-100% Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
| $6,850-100% Bronze | Contract | Benefit Chart | Amendments / Pediatric Dental | Open Access |
2021 Small group plans
| Plan name | Contract | Benefit charts | Amendments/ pediatric dental | Open Access | Perform | Achieve | CentraChoice |
|---|---|---|---|---|---|---|---|
| P-S Gold 1500-30/60 | CON-700.56-HPSE-1-21 | BCH-700.56-SE-SL025C-21 | PMD-700.56-SE-PED70C-1-21 | P-S Gold 1500-30/60 Open Access | P-S Gold 1500-30/60 Perform | P-S Gold 1500-30/60 Achieve | P-S Gold 1500-30/60 CentraChoice |
| P-S Gold 3000-30/60 | CON-700.56-HPSE-1-21 | BCH-700.56-SE-SL029C-21 | PMD-700.56-SE-PED70C-1-21 | P-S Gold 3000-30/60 Open Access | P-S Gold 3000-30/60 Perform | P-S Gold 3000-30/60 Achieve | P-S Gold 3000-30/60 CentraChoice |
| Plan name | Contract | Benefit charts | Amendments/ pediatric dental | Open Access | Perform | Achieve | CentraChoice | SmartCare |
|---|---|---|---|---|---|---|---|---|
| HSA Gold 2400-100 | CON-700.56-HSA-HPSE-1-21 CON-700.56-HSA-HPSE-SC-1-21 |
BCH-700.56-SE-SL054C-21 | PMD-700.56-SE-PED100CC-1-21 | HSA Gold 2400-100 Open Access | HSA Gold 2400-100 Perform | HSA Gold 2400-100 Achieve | HSA Gold 2400-100 CentraChoice | HSA Gold 2400-100 SmartCare |
| HSA Silver 4100-100 | CON-700.56-HSA-HPSE-1-21 CON-700.56-HSA-HPSE-SC-1-21 |
BCH-700.56-SE-SL059C-21 | PMD-700.56-SE-PED100CC-1-21 | HSA Silver 4100-100 Open Access | HSA Silver 4100-100 Perform | HSA Silver 4100-100 Achieve | HSA Silver 4100-100 CentraChoice | HSA Silver 4100-100 SmartCare |
HSA w/Copay
| Plan name | Contract | Benefit charts | Amendments/ pediatric dental | Open Access | Perform | Achieve | CentraChoice | SmartCare |
|---|---|---|---|---|---|---|---|---|
| HSA Embedded w/Copay Silver 3000-100 | CON-700.56-HSA-HPSE-1-21 CON-700.56-HSA-HPSE-SC-1-21 |
BCH-700.56-SE-SL049C-21 | PMD-700.56-SE-PED100C-1-21 | HSA Embedded w/Copay Silver 3000-100 Open Access | HSA Embedded w/Copay Silver 3000-100 Perform | HSA Embedded w/Copay Silver 3000-100 Achieve | HSA Embedded w/Copay Silver 3000-100 CentraChoice | HSA Embedded w/Copay Silver 3000-100 SmartCare |
| Plan name | Contract | Benefit charts | Amendments/ pediatric dental | Open Access | Perform | Achieve | CentraChoice | SmartCare |
|---|---|---|---|---|---|---|---|---|
| HSA Plus Gold 2500-100 | CON-700.56-HSA-HPSE-1-21 CON-700.56-HSA-HPSE-SC-1-21 |
BCH-700.56-SE-SL084C-21 | PMD-700.56-SE-PED100CC-1-21 | HSA Plus Gold 2500-100 Open Access | HSA Plus Gold 2500-100 Perform | HSA Plus Gold 2500-100 Achieve | HSA Plus Gold 2500-100 CentraChoice | HSA Plus Gold 2500-100 SmartCare |
| Plan name | Contract | Benefit charts | Amendments/ pediatric dental | Open Access | Perform | Achieve | CentraChoice | SmartCare |
|---|---|---|---|---|---|---|---|---|
| HRA Embedded Bronze 8550-100 | CON-700.56-HPSE-1-21 CON-700.56-HPSE-SC-1-21 |
BCH-700.56-SE-SL114C-21 | PMD-700.56-SE-PED100C-1-21 | HRA Embedded Bronze 8550-100 Open Access | HRA Embedded Bronze 8550-100 Perform | HRA Embedded Bronze 8550-100 Achieve | HRA Embedded Bronze 8550-100 CentraChoice | HRA Embedded Bronze 8550-100 SmartCare |
| Plan name | Contract | Benefit charts | Amendments/ pediatric dental | Open Access | Perform |
|---|---|---|---|---|---|
| Platinum 25-90 | MGC-900.39-MN-SE-MEB-21 | BCH-900.39-MNSE-CE532C-21 | PMD-900.39-MN-SE-PED-90NC-1-21 | Platinum 25-90 Open Access | Platinum 25-90 Perform |
| Platinum 500-25 | MGC-900.39-MN-SE-MEB-21 | BCH-900.39-MNSE-CE534C-21 | PMD-900.39-MN-SE-PED-80C-1-21 | Platinum 500-25 Open Access | Platinum 500-25 Perform |
| Gold 500-45 | MGC-900.39-MN-SE-MEB-21 | BCH-900.39-MNSE-CE536C-21 | PMD-900.39-MN-SE-PED-70C-1-21 | Gold 500-45 Open Access | Gold 500-45 Perform |
| Gold 1000-45 | MGC-900.39-MN-SE-MEB-21 | BCH-900.39-MNSE-CE538C-21 | PMD-900.39-MN-SE-PED-70C-1-21 | Gold 1000-45 Open Access | Gold 1000-45 Perform |
| Gold 2000-50 | MGC-900.39-MN-SE-MEB-21 | BCH-900.39-MNSE-CE540C-21 | PMD-900.39-MN-SE-PED-70C-1-21 | Gold 2000-50 Open Access | Gold 2000-50 Perform |
| Silver 5000-65 | MGC-900.39-MN-SE-MEB-21 | BCH-900.39-MNSE-CE542C-21 | PMD-900.39-MN-SE-PED-70C-1-21 | Silver 5000-65 Open Access | Silver 5000-65 Perform |
| Plan name | Contract | Benefit charts | Amendments/ pediatric dental | Open Access | Perform |
|---|---|---|---|---|---|
| Gold P-S 1500-30/60 | MGC-900.39-MN-SE-MEB-21 | BCH-900.39-MNSE-CE544C-21 | PMD-900.39-MN-SE-PED-70C-1-21 | Gold P-S 1500-30/60 Open Access | Gold P-S 1500-30/60 Perform |
| Gold P-S 3000-30/60 | MGC-900.39-MN-SE-MEB-21 | BCH-900.39-MNSE-CE546C-21 | PMD-900.39-MN-SE-PED-70C-1-21 | Gold P-S 3000-30/60 Open Access | Gold P-S 3000-30/60 Perform |
| Plan name | Contract | Benefit charts | Amendments/ pediatric dental | Open Access | Perform |
|---|---|---|---|---|---|
| Gold 1000-70% Three for Free | MGC-900.39-MN-SE-MEB-21 | BCH-900.39-MNSE-CE548C-21 | PMD-900.39-MN-SE-PED-70C-1-21 | Gold 1000-70% Three for Free Open Access | Gold 1000-70% Three for Free Perform |
| Gold 2000-70% Three for Free | MGC-900.39-MN-SE-MEB-21 | BCH-900.39-MNSE-CE550C-21 | PMD-900.39-MN-SE-PED-70C-1-21 | Gold 2000-70% Three for Free Open Access | Gold 2000-70% Three for Free Perform |
| Silver 3500-70% Three for Free | MGC-900.39-MN-SE-MEB-21 | BCH-900.39-MNSE-CE552C-21 | PMD-900.39-MN-SE-PED-70C-1-21 | Silver 3500-70% Three for Free Open Access | Silver 3500-70% Three for Free Perform |
| Silver 5000-70% Three for Free | MGC-900.39-MN-SE-MEB-21 | BCH-900.39-MNSE-CE554C-21 | PMD-900.39-MN-SE-PED-70C-1-21 | Silver 5000-70% Three for Free Open Access | Silver 5000-70% Three for Free Perform |
| Plan name | Contract | Benefit charts | Amendments/ pediatric dental | Open Access | Perform |
|---|---|---|---|---|---|
| HSA Embedded w/Copay Silver 3000-100 | MGC-900.39-MN-SE-HSA-21 | BCH-900.39-MNSE-CE556C-21 | PMD-900.39-MN-SE-PED-70C-1-21 | HSA Embedded w/Copay Silver 3000-100 Open Access | HSA Embedded w/Copay Silver 3000-100 Perform |
| Plan name | Contract | Benefit charts | Amendments/ pediatric dental | Open Access | Perform |
|---|---|---|---|---|---|
| HSA Plus Gold 2500-100 | MGC-900.39-MN-SE-HSA-21 | BCH-900.39-MNSE-CE570C-21 | PMD-900.39-MN-SE-PED-100CC-1-21 | HSA Plus Gold 2500-100 Open Access | HSA Plus Gold 2500-100 Perform |
| Plan name | Contract | Benefit charts | Amendments/ pediatric dental | Open Access | Perform |
|---|---|---|---|---|---|
| HRA Embedded Bronze 8550-100 | MGC-900.39-MN-SE-MEB-21 | BCH-900.39-MNSE-CE582C-21 | PMD-900.39-MN-SE-PED-100C-1-21 | HRA Embedded Bronze 8550-100 Open Access | HRA Embedded Bronze 8550-100 Perform |
| Plan name | Contract | Benefit charts | HPIC Amendments/ Pediatric dental | Focused | Broad |
|---|---|---|---|---|---|
| P-S Gold 30/60 | MGC-900.20-WI-SE-ROBIN-COB-20 | BCH-900.21-WI-SE-WL129C-21 | PMD-900.21-WISEPED-100NC-1-21 | P-S Gold 30/60 Focused | P-S Gold 30/60 Broad |
| Plan name | Contract | Benefit charts | HPIC Amendments/ Pediatric dental | Focused | Broad |
|---|---|---|---|---|---|
| P-S Gold 1000-30/50 | MGC-900.20-WI-SE-ROBIN-COB-20 | BCH-900.21-WI-SE-WL131C-21 | PMD-900.21-WISEPED-75C-1-21 | P-S Gold 1000-30/50 Focused | P-S Gold 1000-30/50 Broad |
| P-S Gold 2000-30/50 | MGC-900.20-WI-SE-ROBIN-COB-20 | BCH-900.21-WI-SE-WL133C-21 | PMD-900.21-WISEPED-75C-1-21 | P-S Gold 2000-30/50 Focused | P-S Gold 2000-30/50 Broad |
| P-S Gold 3000-30/50 | MGC-900.20-WI-SE-ROBIN-COB-20 | BCH-900.21-WI-SE-WL135C-21 | PMD-900.21-WISEPED-75C-1-21 | P-S Gold 3000-30/50 Focused | P-S Gold 3000-30/50 Broad |
| P-S Gold 4000-30/50 | MGC-900.20-WI-SE-ROBIN-COB-20 | BCH-900.21-WI-SE-WL137C-21 | PMD-900.21-WISEPED-75C-1-21 | P-S Gold 4000-30/50 Focused | P-S Gold 4000-30/50 Broad |
| P-S Silver 5000-45/90 | MGC-900.20-WI-SE-ROBIN-COB-20 | BCH-900.21-WI-SE-WL139C-21 | PMD-900.21-WISEPED-75C-1-21 | P-S Silver 5000-45/90 Focused | P-S Silver 5000-45/90 Broad |
| Plan name | Contract | Benefit charts | HPIC Amendments/ Pediatric dental | Focused | Broad |
|---|---|---|---|---|---|
| HSA Gold 2300-100 | MGC-900.20-WI-SE-ROBIN-HSA-20 | BCH-900.21-WI-SE-WL163C-21 | PMD-900.21-WISEPED-100CC-1-21 | HSA Gold 2300-100 Focused | HSA Gold 2300-100 Broad |
| HSA Gold 2500-100 | MGC-900.20-WI-SE-ROBIN-HSA-20 | BCH-900.21-WI-SE-WL165C-21 | PMD-900.21-WISEPED-100CC-1-21 | HSA Gold 2500-100 Focused | HSA Gold 2500-100 Broad |
| HSA Gold 4100-100 | MGC-900.20-WI-SE-ROBIN-HSA-20 | BCH-900.21-WI-SE-WK837-WL167C-21 | PMD-900.21-WISEPED-100CC-1-21 | HSA Gold 4100-100 Focused | HSA Gold 4100-100 Broad |
| Plan name | Contract | Benefit charts | HPIC Amendments/ Pediatric dental | Focused | Broad |
|---|---|---|---|---|---|
| HSA Plus Gold 2500-100 | MGC-900.20-WI-SE-ROBIN-HSA-20 | BCH-900.21-WI-SE-WK842-WL183C-21 | PMD-900.21-WISEPED-100CC-1-21 | HSA Plus Gold 2500-100 Focused | HSA Plus Gold 2500-100 Broad |
| Plan name | Contract | Benefit charts | HPIC Amendments/ Pediatric dental | Focused | Broad |
|---|---|---|---|---|---|
| HRA Embedded Bronze 6900-100 | MGC-900.20-WI-SE-ROBIN-HSA-20 | BCH-900.21-WI-SE-WL195C-21 | PMD-900.21-WISEPED-100C-1-21 | HRA Embedded Bronze 6900-100 Focused | HRA Embedded Bronze 6900-100 Broad |
| Plan name | Contract | Benefit charts | HPIC Amendments/ Pediatric dental | Open Access |
|---|---|---|---|---|
| Platinum 25-90 | MGC-900.21-WI-SE-COB-21 | BCH-900.21-WI-SE-WK823C-21 | PMD-900.21-WISEPED-90NC-1-21 | Platinum 25-90 Open Access |
| Platinum 500-25 | MGC-900.21-WI-SE-COB-21 | BCH-900.21-WI-SE-WK824C-21 | PMD-900.21-WISEPED-80C-1-21 | Platinum 500-25 Open Access |
| Gold 500-45 | MGC-900.21-WI-SE-COB-21 | BCH-900.21-WI-SE-WK825C-21 | PMD-900.21-WISEPED-70C-1-21 | Gold 500-45 Open Access |
| Gold 1000-45 | MGC-900.21-WI-SE-COB-21 | BCH-900.21-WI-SE-WK826C-21 | PMD-900.21-WISEPED-70C-1-21 | Gold 1000-45 Open Access |
| Gold 2000-50 | MGC-900.21-WI-SE-COB-21 | BCH-900.21-WI-SE-WK827C-21 | PMD-900.21-WISEPED-70C-1-21 | Gold 2000-50 Open Access |
| Silver 5000-65 | MGC-900.21-WI-SE-COB-21 | BCH-900.21-WI-SE-WK828C-21 | PMD-900.21-WISEPED-70C-1-21 | Silver 5000-65 Open Access |
| Plan name | Contract | Benefit charts | HPIC Amendments/ Pediatric dental | Open Access |
|---|---|---|---|---|
| P-S Gold 1500-30/60 | MGC-900.21-WI-SE-COB-21 | BCH-900.21-WI-SE-WK829C-21 | PMD-900.21-WISEPED-70C-1-21 | P-S Gold 1500-30/60 Open Access |
| P-S Gold 3000-30/60 | MGC-900.21-WI-SE-COB-21 | BCH-900.21-WI-SE-WK830C-21 | PMD-900.21-WISEPED-70C-1-21 | P-S Gold 3000-30/60 Open Access |
| Plan name | Contract | Benefit charts | HPIC Amendments/ Pediatric dental | Open Access |
|---|---|---|---|---|
| Gold 1000-70% Three for Free | MGC-900.21-WI-SE-COB-21 | BCH-900.21-WI-SE-WK831C-21 | PMD-900.21-WISEPED-70C-1-21 | Gold 1000-70% Three for Free Open Access |
| Gold 2000-70% Three for Free | MGC-900.21-WI-SE-COB-21 | BCH-900.21-WI-SE-WK832C-21 | PMD-900.21-WISEPED-70C-1-21 | >Gold 2000-70% Three for Free Open Access |
| Silver 3500-70% Three for Free | MGC-900.21-WI-SE-COB-21 | BCH-900.21-WI-SE-WK833-WL147C-21 | PMD-900.21-WISEPED-70C-1-21 | Silver 3500-70% Three for Free Open Access |
| Silver 5000-70% Three for Free | MGC-900.21-WI-SE-COB-21 | BCH-900.21-WI-SE-WK834-WL151C-21 | PMD-900.21-WISEPED-70C-1-21 | Silver 5000-70% Three for Free Open Access |
| Plan name | Contract | Benefit charts | HPIC Amendments/ Pediatric dental | Open Access |
|---|---|---|---|---|
| HSA Gold 2400-100 | MGC-900.21-WI-SE-HSA-21 | BCH-900.21-WI-SE-WK836C-21 | PMD-900.21-WISEPED-100CC-1-21 | HSA Gold 2400-100 Open Access |
| HSA Silver 4100-100 | MGC-900.21-WI-SE-HSA-21 | BCH-900.21-WI-SE-WK837-WL167C-21R | PMD-900.21-WISEPED-100CC-1-21 | HSA Silver 4100-100 Open Access |
| Plan name | Contract | Benefit charts | HPIC Amendments/ Pediatric dental | Open Access |
|---|---|---|---|---|
| HSA Embedded w/Copay Silver 3000-100 | MGC-900.21-WI-SE-HSA-21 | BCH-900.21-WI-SE-WK835C-21 | PMD-900.21-WISEPED-100C-1-21 | HSA Embedded w/Copay Silver 3000-100 Open Access |
| Plan name | Contract | Benefit charts | HPIC Amendments/ Pediatric dental | Open Access |
|---|---|---|---|---|
| HSA Embedded Gold 3000-100 | MGC-900.21-WI-SE-HSA-21 | BCH-900.21-WI-SE-WK838-WL169C-21 | PMD-900.21-WISEPED-100C-1-21 | HSA Embedded Gold 3000-100 Open Access |
| HSA Embedded Silver 4300-100 | MGC-900.21-WI-SE-HSA-21 | BCH-900.21-WI-SE-WK839C-21 | PMD-900.21-WISEPED-100C-1-21 | HSA Embedded Silver 4300-100 Open Access |
| HSA Embedded Bronze 5750-100 | MGC-900.21-WI-SE-HSA-21 | BCH-900.21-WI-SE-WK840C-21 | PMD-900.21-WISEPED-100C-1-21 | HSA Embedded Bronze 5750-100 Open Access |
| HSA Embedded Bronze 6850-100 | MGC-900.21-WI-SE-HSA-21 | BCH-900.21-WI-SE-WK841-WL177C-21 | PMD-900.21-WISEPED-100C-1-21 | HSA Embedded Bronze 6850-100 Open Access |
| Plan name | Contract | Benefit charts | HPIC Amendments/ Pediatric dental | Open Access |
|---|---|---|---|---|
| HSA Plus Gold 2500-100 | MGC-900.21-WI-SE-HSA-21 | BCH-900.21-WI-SE-WK842-WL183C-21 | PMD-900.21-WISEPED-100CC-1-21 | HSA Plus Gold 2500-100 Open Access |
| Plan name | Contract | Benefit charts | HPIC Amendments/ Pediatric dental | Open Access |
|---|---|---|---|---|
| HSA Plus Embedded Gold 3000-100 | MGC-900.21-WI-SE-HSA-21 | BCH-900.21-WI-SE-WK843-WL185C-21 | PMD-900.21-WISEPED-100C-1-21 | HSA Plus Embedded Gold 3000-100 Open Access |
| HSA Plus Embedded Silver 4550-100 | MGC-900.21-WI-SE-HSA-21 | BCH-900.21-WI-SE-WK844-WL187C-21 | PMD-900.21-WISEPED-100C-1-21 | HSA Plus Embedded Silver 4550-100 Open Access |
| HSA Plus Embedded Bronze 6500-100 | MGC-900.21-WI-SE-HSA-21 | BCH-900.21-WI-SE-WK845-WL191C-21 | PMD-900.21-WISEPED-100C-1-21 | HSA Plus Embedded Bronze 6500-100 Open Access |
| HSA Plus Embedded Silver 3000-70 | MGC-900.21-WI-SE-HSA-21 | BCH-900.21-WI-SE-WK846C-21 | PMD-900.21-WISEPED-70C-1-21 | HSA Plus Embedded Silver 3000-70 Open Access |
| HSA Plus Embedded Silver 5500-70 | MGC-900.21-WI-SE-HSA-21 | BCH-900.21-WI-SE-WK847C-21 | PMD-900.21-WISEPED-70C-1-21 | HSA Plus Embedded Silver 5500-70 Open Access |
| Plan name | Contract | Benefit charts | HPIC Amendments/ Pediatric dental | Open Access |
|---|---|---|---|---|
| HRA Embedded Bronze 8400-100 | MGC-900.21-WI-SE-COB-21 | BCH-900.21-WI-SE-WK848C-21 | PMD-900.21-WISEPED-100C-1-21 | HRA Embedded Bronze 8400-100 Open Access |