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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.

2023 Small Employer plans

Copay-Coinsurance Plans

        SBC by Network
$25-90% Platinum Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select

Deductible-Copay Plans

        SBC by Network
$500-$25 Platinum Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$600-$50 Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$1,000-$50 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
$3,000-$50 Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$4,000-$40 Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$6,100-$70 Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select

Three for Free Plans

        SBC by Network
$1,000-70% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$2,000-70% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$4,000-70% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$5,000-70% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select

HSA Non-Embedded Plans

        SBC by Network
$2400-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$4500-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select

HSA Embedded Plans

        SBC by Network
$3000-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$3,500-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$4,800-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$6,000-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$7,000-100% Bronze Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select

HSA Plus Non-Embedded Plans

        SBC by Network
$2,500-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select

HSA Plus Embedded Plans

        SBC by Network
$3,000-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$3,700-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$5,200-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$6,500-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$3,000-70% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$4,000-70% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$5,000-70% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select

HRA Embedded Plans

        SBC by Network
$5,000-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$7,000-100% Bronze Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select
$8,700-100% Bronze Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform CentraChoice Achieve Select

Tiered Deductible-Copay Plans

        SBC by Network
$500-$60 Gold Contract Benefit Chart Amendments / Pediatric Dental TieredChoice
$1,000-$60 Gold Contract Benefit Chart Amendments / Pediatric Dental TieredChoice
$1,500-$60 Gold Contract Benefit Chart Amendments / Pediatric Dental TieredChoice
$3,000-$60 Gold Contract Benefit Chart Amendments / Pediatric Dental TieredChoice
$6,000-$90 Silver Contract Benefit Chart Amendments / Pediatric Dental TieredChoice

Tiered HSA Plus Non-Embedded Plans

        SBC by Network
$3,000-100% Gold Contract Benefit Chart Amendments / Pediatric Dental TieredChoice
$3,500-100% Gold Contract Benefit Chart Amendments / Pediatric Dental TieredChoice

Tiered HSA Plus Embedded Plans

        SBC by Network
$6,000-100% Silver Contract Benefit Chart Amendments / Pediatric Dental TieredChoice
$7,000-100% Silver Contract Benefit Chart Amendments / Pediatric Dental TieredChoice

Copay-Coinsurance Plans

        SBC by Network
$25-90% Platinum Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone

Deductible-Copay Plans

        SBC by Network
$500-$25 Platinum Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$600-$50 Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$1,000-$50 Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$2,000-$50 Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$3,000-$50 Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$4,000-$40 Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$6,100-$70 Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone

Three for Free Plans

        SBC by Network
$1,000-70% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$2,000-70% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$4,000-70% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$5,000-70% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone

HSA Non-Embedded Plans

        SBC by Network
$2,400-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$4,500-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone

HSA Embedded Plans

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        SBC by Network
$3,000-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$3,500-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$4,800-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$6,000-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$7,000-100% Bronze Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone

HSA Plus Non-Embedded Plans

        SBC by Network
$2,500-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone

HSA Plus Embedded Plans

        SBC by Network
$3,000-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$3,700-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$5,200-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$6,500-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$3,000-70% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$4,000-70% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$5,000-70% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone

HRA Embedded Plans

        SBC by Network
$5,000-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$7,000-100% Bronze Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone
$8,700-100% Bronze Contract Benefit Chart Amendments / Pediatric Dental Open Access Perform Cornerstone

All-Copay Plans

        SBC by Network
$30/$60 Gold Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select

Deductible-Copay Primary-Specialty Plans

        SBC by Network
$500-$30/$50 Platinum Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$1,000-$30/$50 Gold Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$2,000-$30/$50 Gold Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$3,000-$30/$50 Gold Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$4,000-$30/$50 Gold Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select

Three for Free Plans

        SBC by Network
$500-70% Gold Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$1,000-70% Gold Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$2,000-70% Gold Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$4,000-70% Silver Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$5,000-70% Silver Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$6,500-70% Silver Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select

HSA-Copay Non-Embedded Plans

        SBC by Network
$2,000-100% 30/$60 Gold Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select

HSA-Copay Embedded Plans

        SBC by Network
$3,500-100% 30/$60 Silver Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$5,000-100% $30/$60 Silver Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$6,250-100% $30/$60 Bronze Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select

HSA Non-Embedded Plans

        SBC by Network
$2,300-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$2,500-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select

HSA Embedded Plans

        SBC by Network
$3,000-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$3,500-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$4,600-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$5,000-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$6,000-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$6,850-100% Bronze Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$3,500-70% Silver Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$6,500-70% Bronze Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select

HSA Plus Non-Embedded Plans

        SBC by Network
$2,500-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select

HSA Plus Embedded Plans

        SBC by Network
$3,000-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select
$5,500-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select

HRA Embedded Plans

        SBC by Network
$6,900-100% Bronze Contract Benefit Chart Amendments / Pediatric Dental Broad Focused Select

Copay-Coinsurance Plans

        SBC by Network
$25-90 Platinum Contract Benefit Chart Amendments / Pediatric Dental Open Access

Deductible-Copay Plans

        SBC by Network
$500-25 Platinum Contract Benefit Chart Amendments / Pediatric Dental Open Access
$600-$50 Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access
$1,000-$50 Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access
$2,000-$50 Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access
$3,000-$50 Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access
$4,000-$40 Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access
$6,100-$70 Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access

Three for Free Plans

        SBC by Network
$1,000-70% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access
$2,000-70% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access
$4,000-70% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access
$5,000-70% Silver 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
$4,500-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access

HSA Embedded Plans

        SBC by Network
$3,000-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access
$3,500-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access
$4,800-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access
$5,750-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access
$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% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access
$5,000-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access
$6,500-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access
$3,000-70% 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
$8,400-100% Bronze Contract Benefit Chart Amendments / Pediatric Dental Open Access
For more information, visit HealthPartners UnityPoint Health.

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
$5,600-$70 Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access

Deductible-Copay Primary-Specialty Plans

        SBC by Network
$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
$4,000-$30/$60 Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access
$6,000-$45/$90 Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access

Three for Free Plans

        SBC by Network
$1,000-70% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access
$2,000-70% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access
$4,000-70% 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% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access
$3,500-100% Gold Contract Benefit Chart Amendments / Pediatric Dental Open Access
$5,000-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access
$6,500-100% Silver Contract Benefit Chart Amendments / Pediatric Dental Open Access
$3,000-70% 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
$6,850-100% Bronze Contract Benefit Chart Amendments / Pediatric Dental Open Access

Deductible-Copay Primary-Specialty

        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
$3,600-70% 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
$7,000-70% 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
$4,500-100% 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
$5,000-100% 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

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
$8,500-100% Bronze Contract Benefit Chart Amendments / Pediatric Dental Open Access

2022 Small Employer plans


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

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 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

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

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

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
For more information, visit HealthPartners UnityPoint Health.

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

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
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