Skip to main content

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.

2020 Small group plans

Copay and Deductible Copay
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
Platinum 25-95 CON-700.55-HPSE-1-20 BCH-700.55-SE-SE741C-20 PMD-700.55-SE-PED-95C-1-20 Platinum 25-95 Open Access Platinum 25-95 Perform Platinum 25-95 Achieve Platinum 25-95 CentraChoice
Gold 30/60 P-S CON-700.55-HPSE-1-20 BCH-700.55-SE-SE777C-20 PMD-700.55-SE-PED100C-1-20 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-700.55-HPSE-1-20 BCH-700.55-SE-SE781C-20 PMD-700.55-SE-PED100C-1-20 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-700.55-HPSE-1-20 BCH-700.55-SE-SE745C-20 PMD-700.55-SE-PED80C-1-20 Platinum 500-20 Open Access Platinum 500-20 Perform Platinum 500-20 Achieve Platinum 500-20 CentraChoice
Gold 500-40 CON-700.55-HPSE-1-20 BCH-700.55-SE-SE749C-20 PMD-700.55-SE-PED75C-1-20 Gold 500-40 Open Access Gold 500-40 Perform Gold 500-40 Achieve Gold 500-40 CentraChoice
Gold 750-40 CON-700.55-HPSE-1-20 BCH-700.55-SE-SE753C-20 PMD-700.55-SE-PED75C-1-20 Gold 750-40 Open Access Gold 750-40 Perform Gold 750-40 Achieve Gold 750-40 CentraChoice
Gold 1000-40 CON-700.55-HPSE-1-20 BCH-700.55-SE-SE757C-20 PMD-700.55-SE-PED75C-1-20 Gold 1000-40 Open Access Gold 1000-40 Perform Gold 1000-40 Achieve Gold 1000-40 CentraChoice
Gold 1500-40 CON-700.55-HPSE-1-20 BCH-700.55-SE-SE761C-20 PMD-700.55-SE-PED75C-1-20 Gold 1500-40 Open Access Gold 1500-40 Perform Gold 1500-40 Achieve Gold 1500-40 CentraChoice
Gold 2000-50 CON-700.55-HPSE-1-20 BCH-700.55-SE-SE765C-20 PMD-700.55-SE-PED75C-1-20 Gold 2000-50 Open Access Gold 2000-50 Perform Gold 2000-50 Achieve Gold 2000-50 CentraChoice
Gold 3000-50 CON-700.55-HPSE-1-20 BCH-700.55-SE-SE769C-20 PMD-700.55-SE-PED75C-1-20 Gold 3000-50 Open Access Gold 3000-50 Perform Gold 3000-50 Achieve Gold 3000-50 CentraChoice
Silver 5000-60 CON-700.55-HPSE-1-20 BCH-700.55-SE-SE773C-20 PMD-700.55-SE-PED70C-1-20 Silver 5000-60 Open Access Silver 5000-60 Perform Silver 5000-60 Achieve Silver 5000-60 CentraChoice
Deductible Copay P-S
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
Gold 500-30/50 P-S CON-700.55-HPSE-1-20 BCH-700.55-SE-SE785C-20 PMD-700.55-SE-PED75C-1-20 Gold 500-30/50 P-S Open Access Gold 500-30/50 P-S Perform Gold 500-30/50 P-S Achieve Gold 500-30/50 P-S CentraChoice
Gold 1000-30/50 P-S CON-700.55-HPSE-1-20 BCH-700.55-SE-SE789C-20 PMD-700.55-SE-PED75C-1-20 Gold 1000-30/50 P-S Open Access Gold 1000-30/50 P-S Perform Gold 1000-30/50 P-S Achieve Gold 1000-30/50 P-S CentraChoice
Gold 2000-30/50 P-S CON-700.55-HPSE-1-20 BCH-700.55-SE-SE793C-20 PMD-700.55-SE-PED75C-1-20 Gold 2000-30/50 P-S Open Access Gold 2000-30/50 P-S Perform Gold 2000-30/50 P-S Achieve Gold 2000-30/50 P-S CentraChoice
Three For Free
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
Gold 500-70% Three for Free CON-700.55-HPSE-1-20 BCH-700.55-SE-SE797C-20 PMD-700.55-SE-PED70C-1-20 Gold 500-70% Three for Free Open Access Gold 500-70% Three for Free Perform Gold 500-70% Three for Free Achieve Gold 500-70% Three for Free CentraChoice
Gold 1000-70% Three for Free CON-700.55-HPSE-1-20 BCH-700.55-SE-SE801C-20 PMD-700.55-SE-PED70C-1-20 Gold 1000-70% Three for Free Open Access Gold 1000-70% Three for Free Perform Gold 1000-70% Three for Free Achieve Gold 1000-70% Three for Free CentraChoice
Gold 2000-70% Three for Free CON-700.55-HPSE-1-20 BCH-700.55-SE-SE805C-20 PMD-700.55-SE-PED70C-1-20 Gold 2000-70% Three for Free Open Access Gold 2000-70% Three for Free Perform Gold 2000-70% Three for Free Achieve Gold 2000-70% Three for Free CentraChoice
Silver 3500-70% Three for Free CON-700.55-HPSE-1-20 BCH-700.55-SE-SE809C-20 PMD-700.55-SE-PED70C-1-20 Silver 3500-70% Three for Free Open Access Silver 3500-70% Three for Free Perform Silver 3500-70% Three for Free Achieve Silver 3500-70% Three for Free CentraChoice
Silver 5000-70% Three for Free CON-700.55-HPSE-1-20 BCH-700.55-SE-SE813C-20 PMD-700.55-SE-PED70C-1-20 Silver 5000-70% Three for Free Open Access Silver 5000-70% Three for Free Perform Silver 5000-70% Three for Free Achieve Silver 5000-70% Three for Free CentraChoice
HSA w/Copay P-S
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice SmartCare
HSA w/Copay Gold 2000-100 CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE817C-20 PMD-700.55-SE-PED-100CC-1-20R HSA w/Copay Gold 2000-100 Open Access HSA w/Copay Gold 2000-100 Perform HSA w/Copay Gold 2000-100 Achieve HSA w/Copay Gold 2000-100 CentraChoice HSA w/Copay Gold 2000-100 SmartCare
HSA Embedded w/Copay Silver 3000-100 CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE822C-20 PMD-700.55-SE-PED100C-1-20 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
HSA Embedded w/Copay Bronze 5000-100 CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE827C-20 PMD-700.55-SE-PED100C-1-20 HSA Embedded w/Copay Bronze 5000-100 Open Access HSA Embedded w/Copay Bronze 5000-100 Perform HSA Embedded w/Copay Bronze 5000-100 Achieve HSA Embedded w/Copay Bronze 5000-100 CentraChoice HSA Embedded w/Copay Bronze 5000-100 SmartCare
HSA
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice SmartCare
HSA Gold 2000-100 CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE832C-20 PMD-700.55-SE-PED-100CC-1-20R HSA Gold 2000-100 Open Access HSA Gold 2000-100 Perform HSA Gold 2000-100 Achieve HSA Gold 2000-100 CentraChoice HSA Gold 2000-100 SmartCare
HSA Gold 2500-100 CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE837C-20 PMD-700.55-SE-PED-100CC-1-20R HSA Gold 2500-100 Open Access HSA Gold 2500-100 Perform HSA Gold 2500-100 Achieve HSA Gold 2500-100 CentraChoice HSA Gold 2500-100 SmartCare
HSA Silver 3900-100 CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE842C-20 PMD-700.55-SE-PED-100CC-1-20R HSA Silver 3900-100 Open Access HSA Silver 3900-100 Perform HSA Silver 3900-100 Achieve HSA Silver 3900-100 CentraChoice HSA Silver 3900-100 SmartCare

Embedded HSA
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice SmartCare
HSA Embedded Gold 3000-100 CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE847C-20 PMD-700.55-SE-PED100C-1-20 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 Gold 3000-100 SmartCare
HSA Embedded Silver 4100-100 CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE852C-20 PMD-700.55-SE-PED100C-1-20 HSA Embedded Silver 4100-100 Open Access HSA Embedded Silver 4100-100 Perform HSA Embedded Silver 4100-100 Achieve HSA Embedded Silver 4100-100 CentraChoice HSA Embedded Silver 4100-100 SmartCare
HSA Embedded Silver 4500-100 CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE857C-20 PMD-700.55-SE-PED100C-1-20 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 4500-100 SmartCare
HSA Embedded Silver 5000-100 CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE862C-20 PMD-700.55-SE-PED100C-1-20 HSA Embedded Silver 5000-100 Open Access HSA Embedded Silver 5000-100 Perform HSA Embedded Silver 5000-100 Achieve HSA Embedded Silver 5000-100 CentraChoice HSA Embedded Silver 5000-100 SmartCare
HSA Embedded Bronze 6000-100 CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE867C-20 PMD-700.55-SE-PED100C-1-20 HSA Embedded Bronze 6000-100 Open Access HSA Embedded Bronze 6000-100 Perform HSA Embedded Bronze 6000-100 Achieve HSA Embedded Bronze 6000-100 CentraChoice HSA Embedded Bronze 6000-100 SmartCare
HSA Embedded Bronze 6500-100 CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE872C-20 PMD-700.55-SE-PED100C-1-20 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 6500-100 SmartCare
HSA Embedded Silver 3000-80 CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE877C-20 PMD-700.55-SE-PED80C-1-20 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 Silver 3000-80 SmartCare
HSA Embedded Silver 4500-80 CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE882C-20 PMD-700.55-SE-PED80C-1-20 HSA Embedded Silver 4500-80 Open Access HSA Embedded Silver 4500-80 Perform HSA Embedded Silver 4500-80 Achieve HSA Embedded Silver 4500-80 CentraChoice HSA Embedded Silver 4500-80 SmartCare
HSA Embedded Bronze 5500-70 CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE887C-20 PMD-700.55-SE-PED70C-1-20 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 5500-70 SmartCare
HSA Embedded Bronze 6250-70 CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE892C-20 PMD-700.55-SE-PED70C-1-20 HSA Embedded Bronze 6250-70 Open Access HSA Embedded Bronze 6250-70 Perform HSA Embedded Bronze 6250-70 Achieve HSA Embedded Bronze 6250-70 CentraChoice HSA Embedded Bronze 6250-70 SmartCare
HSA Rx Plus
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice SmartCare
HSA Gold 2100-100 Rx Plus CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE897C-20 PMD-700.55-SE-PED-100CC-1-20R HSA Gold 2100-100 Rx Plus Open Access HSA Gold 2100-100 Rx Plus Perform HSA Gold 2100-100 Rx Plus Achieve HSA Gold 2100-100 Rx Plus CentraChoice HSA Gold 2100-100 Rx Plus SmartCare
HSA Gold 2500-100 Rx Plus CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE902C-20 PMD-700.55-SE-PED-100CC-1-20R 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 HSA Gold 2500-100 Rx Plus SmartCare
HSA Rx Plus Embedded
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice SmartCare
HSA Embedded Gold 3000-100 Rx Plus CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE907C-20 PMD-700.55-SE-PED100C-1-20 HSA Embedded Gold 3000-100 Rx Plus Open Access HSA Embedded Gold 3000-100 Rx Plus Perform HSA Embedded Gold 3000-100 Rx Plus Achieve HSA Embedded Gold 3000-100 Rx Plus CentraChoice HSA Embedded Gold 3000-100 Rx Plus SmartCare
HSA Embedded Gold 3500-100 Rx Plus CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE912C-20 PMD-700.55-SE-PED100C-1-20 HSA Embedded Gold 3500-100 Rx Plus Open Access HSA Embedded Gold 3500-100 Rx Plus Perform HSA Embedded Gold 3500-100 Rx Plus Achieve HSA Embedded Gold 3500-100 Rx Plus CentraChoice HSA Embedded Gold 3500-100 Rx Plus SmartCare
HSA Embedded Silver 4550-100 Rx Plus CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE917C-20 PMD-700.55-SE-PED100C-1-20 HSA Embedded Silver 4550-100 Rx Plus Open Access HSA Embedded Silver 4550-100 Rx Plus Perform HSA Embedded Silver 4550-100 Rx Plus Achieve HSA Embedded Silver 4550-100 Rx Plus CentraChoice HSA Embedded Silver 4550-100 Rx Plus SmartCare
HSA Embedded Silver 5500-100 Rx Plus CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE922C-20 PMD-700.55-SE-PED100C-1-20 HSA Embedded Silver 5500-100 Rx Plus Open Access HSA Embedded Silver 5500-100 Rx Plus Perform HSA Embedded Silver 5500-100 Rx Plus Achieve HSA Embedded Silver 5500-100 Rx Plus CentraChoice HSA Embedded Silver 5500-100 Rx Plus SmartCare
HSA Embedded Silver 6500-100 Rx Plus CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE927C-20 PMD-700.55-SE-PED100C-1-20 HSA Embedded Silver 6500-100 Rx Plus Open Access HSA Embedded Silver 6500-100 Rx Plus Perform HSA Embedded Silver 6500-100 Rx Plus Achieve HSA Embedded Silver 6500-100 Rx Plus CentraChoice HSA Embedded Silver 6500-100 Rx Plus SmartCare
HSA Embedded Silver 3000-80 Rx Plus CON-700.55-HSA-HPSE-1-20 BCH-700.55-SE-SE932C-20 PMD-700.55-SE-PED80C-1-20 HSA Embedded Silver 3000-80 Rx Plus Open Access HSA Embedded Silver 3000-80 Rx Plus Perform HSA Embedded Silver 3000-80 Rx Plus Achieve HSA Embedded Silver 3000-80 Rx Plus CentraChoice HSA Embedded Silver 3000-80 Rx Plus SmartCare
HRA Embedded
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice SmartCare
HRA Embedded Silver 4250-100 CON-700.55-HPSE-1-20 BCH-700.55-SE-SE937C-20 PMD-700.55-SE-PED100P-1-20 HRA Embedded Silver 4250-100 Open Access HRA Embedded Silver 4250-100 Perform HRA Embedded Silver 4250-100 Achieve HRA Embedded Silver 4250-100 CentraChoice HRA Embedded Silver 4250-100 SmartCare
HRA Embedded Silver 5500-100 CON-700.55-HPSE-1-20 BCH-700.55-SE-SE942C-20 PMD-700.55-SE-PED100P-1-20 HRA Embedded Silver 5500-100 Open Access HRA Embedded Silver 5500-100 Perform HRA Embedded Silver 5500-100 Achieve HRA Embedded Silver 5500-100 CentraChoice HRA Embedded Silver 5500-100 SmartCare
HRA Embedded Bronze 6500-100 CON-700.55-HPSE-1-20 BCH-700.55-SE-SE947C-20 PMD-700.55-SE-PED100P-1-20 HRA Embedded Bronze 6500-100 Open Access HRA Embedded Bronze 6500-100 Perform HRA Embedded Bronze 6500-100 Achieve HRA Embedded Bronze 6500-100 CentraChoice HRA Embedded Bronze 6500-100 SmartCare
Copay and Deductible Copay
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
Platinum 25-95 MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE440C-20 PMD-900.38-MN-SE-PED-95NC-1.20 Platinum 25-95 Open Access Platinum 25-95 Perform
Gold 30/60 P-S MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE458C-20 PMD-900.38-MN-SE-PED-100C-1-20 Gold 30/60 P-S Open Access Gold 30/60 P-S Perform
Gold 45/90 P-S MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE460C-20 PMD-900.38-MN-SE-PED-100C-1-20 Gold 45/90 P-S Open Access Gold 45/90 P-S Perform
Platinum 500-20 MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE442C-20 PMD-900.38-MN-SE-PED-80C-1-20 Platinum 500-20 Open Access Platinum 500-20 Perform
Gold 500-40 MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE444C-20 PMD-900.38-MN-SE-PED-75C-1.20 Gold 500-40 Open Access Gold 500-40 Perform
Gold 750-40 MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE446C-20 PMD-900.38-MN-SE-PED-75C-1.20 Gold 750-40 Open Access Gold 750-40 Perform
Gold 1000-40 MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE448C-20 PMD-900.38-MN-SE-PED-75C-1.20 Gold 1000-40 Open Access Gold 1000-40 Perform
Gold 1500-40 MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE450C-20 PMD-900.38-MN-SE-PED-75C-1.20 Gold 1500-40 Open Access Gold 1500-40 Perform
Gold 2000-50 MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE452C-20 PMD-900.38-MN-SE-PED-75C-1.20 Gold 2000-50 Open Access Gold 2000-50 Perform
Gold 3000-50 MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE454C-20 PMD-900.38-MN-SE-PED-75C-1.20 Gold 3000-50 Open Access Gold 3000-50 Perform
Silver 5000-60 MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE456C-20 PMD-900.38-MN-SE-PED-70C-1.20 Silver 5000-60 Open Access Silver 5000-60 Perform
Deductible Copay P-S
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
Gold 500-30/50 P-S MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE462C-20 PMD-900.38-MN-SE-PED-75C-1.20 Gold 500-30/50 P-S Open Access Gold 500-30/50 P-S Perform
Gold 1000-30/50 P-S MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE464C-20 PMD-900.38-MN-SE-PED-75C-1.20 Gold 1000-30/50 P-S Open Access Gold 1000-30/50 P-S Perform
Gold 2000-30/50 P-S MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE466C-20 PMD-900.38-MN-SE-PED-75C-1.20 Gold 2000-30/50 P-S Open Access Gold 2000-30/50 P-S Perform
Three For Free
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
Gold 500-70% Three for Free MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE468C-20 PMD-900.38-MN-SE-PED-70C-1.20 Gold 500-70% Three for Free Open Access Gold 500-70% Three for Free Perform
Gold 1000-70% Three for Free MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE470C-20 PMD-900.38-MN-SE-PED-70C-1.20 Gold 1000-70% Three for Free Open Access Gold 1000-70% Three for Free Perform
Gold 2000-70% Three for Free MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE472C-20 PMD-900.38-MN-SE-PED-70C-1.20 Gold 2000-70% Three for Free Open Access Gold 2000-70% Three for Free Perform
Silver 3500-70% Three for Free MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE474C-20 PMD-900.38-MN-SE-PED-70C-1.20 Silver 3500-70% Three for Free Open Access Silver 3500-70% Three for Free Perform
Silver 5000-70% Three for Free MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE476C-20 PMD-900.38-MN-SE-PED-70C-1.20 Silver 5000-70% Three for Free Open Access Silver 5000-70% Three for Free Perform
HSA w/Copay P-S
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
Gold 2000-100 HSA w/Copay MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE478C-20 PMD-900.38-MN-SE-PED-100CC-1-20 Gold 2000-100 HSA w/Copay Open Access Gold 2000-100 HSA w/Copay Perform
Silver 3000-100 HSA Embedded w/Copay MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE480C-20 PMD-900.38-MN-SE-PED-100C-1-20 Silver 3000-100 HSA Embedded w/Copay Open Access Silver 3000-100 HSA Embedded w/Copay Perform
Bronze 5000-100 HSA Embedded w/Copay MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE482C-20 PMD-900.38-MN-SE-PED-100C-1-20 Bronze 5000-100 HSA Embedded w/Copay Open Access Bronze 5000-100 HSA Embedded w/Copay Perform
HSA
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
HSA Gold 2000-100 MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE484C-20 PMD-900.38-MN-SE-PED-100CC-1-20 HSA Gold 2000-100 Open Access HSA Gold 2000-100 Perform
HSA Gold 2500-100 MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE486C-20 PMD-900.38-MN-SE-PED-100CC-1-20 HSA Gold 2500-100 Open Access HSA Gold 2500-100 Perform
HSA Silver 3900-100 MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE488C-20 PMD-900.38-MN-SE-PED-100CC-1-20 HSA Silver 3900-100 Open Access HSA Silver 3900-100 Perform
Embedded HSA
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
HSA Embedded Gold 3000-100 MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE490C-20 PMD-900.38-MN-SE-PED-100C-1-20 HSA Embedded Gold 3000-100 Open Access HSA Embedded Gold 3000-100 Perform
HSA Embedded Silver 4100-100 MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE492C-20 PMD-900.38-MN-SE-PED-100C-1-20 HSA Embedded Silver 4100-100 Open Access HSA Embedded Silver 4100-100 Perform
HSA Embedded Silver 4500-100 MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE494C-20 PMD-900.38-MN-SE-PED-100C-1-20 HSA Embedded Silver 4500-100 Open Access HSA Embedded Silver 4500-100 Perform
HSA Embedded Silver 5000-100 MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE496C-20 PMD-900.38-MN-SE-PED-100C-1-20 HSA Embedded Silver 5000-100 Open Access HSA Embedded Silver 5000-100 Perform
HSA Embedded Bronze 6000-100 MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE498C-20 PMD-900.38-MN-SE-PED-100C-1-20 HSA Embedded Bronze 6000-100 Open Access HSA Embedded Bronze 6000-100 Perform
HSA Embedded Bronze 6500-100 MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE500C-20 PMD-900.38-MN-SE-PED-100C-1-20 HSA Embedded Bronze 6500-100 Open Access HSA Embedded Bronze 6500-100 Perform
HSA Embedded Silver 3000-80 MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE502C-20 PMD-900.38-MN-SE-PED-80C-1-20 HSA Embedded Silver 3000-80 Open Access HSA Embedded Silver 3000-80 Perform
HSA Embedded Silver 4500-80 MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE504C-20 PMD-900.38-MN-SE-PED-80C-1-20 HSA Embedded Silver 4500-80 Open Access HSA Embedded Silver 4500-80 Perform
HSA Embedded Bronze 5500-70 MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE506C-20 PMD-900.38-MN-SE-PED-70C-1.20 HSA Embedded Bronze 5500-70 Open Access HSA Embedded Bronze 5500-70 Perform
HSA Embedded Bronze 6250-70 MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE508C-20 PMD-900.38-MN-SE-PED-70C-1.20 HSA Embedded Bronze 6250-70 Open Access HSA Embedded Bronze 6250-70 Perform
HSA Rx Plus
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
HSA Gold 2100-100 Rx Plus MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE510C-20 PMD-900.38-MN-SE-PED-100CC-1-20 HSA Gold 2100-100 Rx Plus Open Access HSA Gold 2100-100 Rx Plus Perform
HSA Gold 2500-100 Rx Plus MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE512C-20 PMD-900.38-MN-SE-PED-100CC-1-20 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 Gold 3000-100 Rx Plus MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE514C-20 PMD-900.38-MN-SE-PED-100C-1-20 HSA Embedded Gold 3000-100 Rx Plus Open Access HSA Embedded Gold 3000-100 Rx Plus Perform
HSA Embedded Gold 3500-100 Rx Plus MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE516C-20 PMD-900.38-MN-SE-PED-100C-1-20 HSA Embedded Gold 3500-100 Rx Plus Open Access HSA Embedded Gold 3500-100 Rx Plus Perform
HSA Embedded Silver 4550-100 Rx Plus MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE518C-20 PMD-900.38-MN-SE-PED-100C-1-20 HSA Embedded Silver 4550-100 Rx Plus Open Access HSA Embedded Silver 4550-100 Rx Plus Perform
HSA Embedded Silver 5500-100 Rx Plus MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE520C-20 PMD-900.38-MN-SE-PED-100C-1-20 HSA Embedded Silver 5500-100 Rx Plus Open Access HSA Embedded Silver 5500-100 Rx Plus Perform
HSA Embedded Bronze 6500-100 Rx Plus MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE522C-20 PMD-900.38-MN-SE-PED-100C-1-20 HSA Embedded Bronze 6500-100 Rx Plus Open Access HSA Embedded Bronze 6500-100 Rx Plus Perform
HSA Embedded Silver 3000-80 Rx Plus MGC-900.38-MN-SE-HSA-20 BCH-900.38-MNSE-CE524C-20 PMD-900.38-MN-SE-PED-80C-1-20 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 4250-100 MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE526P-20 PMD-900.38-MN-SE-PED-100P-1-20 HRA Embedded Silver 4250-100 Open Access HRA Embedded Silver 4250-100 Perform
HRA Embedded Silver 5500-100 MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE528P-20 PMD-900.38-MN-SE-PED-100P-1-20 HRA Embedded Silver 5500-100 Open Access HRA Embedded Silver 5500-100 Perform
HRA Embedded Bronze 6500-100 MGC-900.38-MN-SE-MEB-20 BCH-900.38-MNSE-CE530P-20 PMD-900.38-MN-SE-PED-100P-1-20 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 Broad
Platinum 25-95 MGC-900.20-WI-SE-ROBIN-COB-20 BCH-900.20-WI-SE-WL039C-20 PMD-900.20-WISEPED95NC-1-20 Platinum 25-95 Focused Platinum 25-95 Broad
Gold 30/60 P-S MGC-900.20-WI-SE-ROBIN-COB-20 BCH-900.20-WI-SE-WK789-WL041C-20 PMD-900.20-WISEPED100C-1-20 Gold 30/60 P-S Focused Gold 30/60 P-S Broad
Gold 45/90 P-S MGC-900.20-WI-SE-ROBIN-COB-20 BCH-900.20-WI-SE-WK790-WL043C-20 PMD-900.20-WISEPED100C-1-20 Gold 45/90 P-S Focused Gold 45/90 P-S Broad
Deductible Copay P-S
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused Broad
Gold 1000-30/50 P-S MGC-900.20-WI-SE-ROBIN-COB-20 BCH-900.20-WI-SE-WL045C-20 PMD-900.20-WISEPED75C-1-20 Gold 1000-30/50 P-S Focused Gold 1000-30/50 P-S Broad
Gold 2000-30/50 P-S MGC-900.20-WI-SE-ROBIN-COB-20 BCH-900.20-WI-SE-WL047C-20 PMD-900.20-WISEPED75C-1-20 Gold 2000-30/50 P-S Focused Gold 2000-30/50 P-S Broad
Gold 3000-30/50 P-S MGC-900.20-WI-SE-ROBIN-COB-20 BCH-900.20-WI-SE-WL049C-20 PMD-900.20-WISEPED75C-1-20 Gold 3000-30/50 P-S Focused Gold 3000-30/50 P-S Broad
Gold 4000-30/50 P-S MGC-900.20-WI-SE-ROBIN-COB-20 BCH-900.20-WI-SE-WL053C-20 PMD-900.20-WISEPED75C-1-20 Gold 4000-30/50 P-S Focused Gold 4000-30/50 P-S Broad
Silver 5000-45/90 P-S MGC-900.20-WI-SE-ROBIN-COB-20 BCH-900.20-WI-SE-WL053C-20 PMD-900.20-WISEPED70C-1-20 Silver 5000-45/90 P-S Focused Silver 5000-45/90 P-S Broad
Three For Free
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused Broad
Gold 500-70% Three for Free MGC-900.20-WI-SE-ROBIN-COB-20 BCH-900.20-WI-SE-WL055C-20 PMD-900.20-WISEPED70C-1-20 Gold 500-70% Three for Free Focused Gold 500-70% Three for Free Broad
Gold 1000-70% Three for Free MGC-900.20-WI-SE-ROBIN-COB-20 BCH-900.20-WI-SE-WL057C-20 PMD-900.20-WISEPED70C-1-20 Gold 1000-70% Three for Free Focused Gold 1000-70% Three for Free Broad
Gold 2000-70% Three for Free MGC-900.20-WI-SE-ROBIN-COB-20 BCH-900.20-WI-SE-WK793-WL059C-20 PMD-900.20-WISEPED70C-1-20 Gold 2000-70% Three for Free Focused Gold 2000-70% Three for Free Broad
Silver 3500-70% Three for Free MGC-900.20-WI-SE-ROBIN-COB-20 BCH-900.20-WI-SE-WK794-WL061C-20 PMD-900.20-WISEPED70C-1-20 Silver 3500-70% Three for Free Focused Silver 3500-70% Three for Free Broad
Silver 4000-70% Three for Free MGC-900.20-WI-SE-ROBIN-COB-20 BCH-900.20-WI-SE-WL063C-20 PMD-900.20-WISEPED70C-1-20 Silver 4000-70% Three for Free Focused Silver 4000-70% Three for Free Broad
Silver 5000-70% Three for Free MGC-900.20-WI-SE-ROBIN-COB-20 BCH-900.20-WI-SE-WK795-WL065C-20 PMD-900.20-WISEPED70C-1-20 Silver 5000-70% Three for Free Focused Silver 5000-70% Three for Free Broad
HSA
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused Broad
HSA Gold 2000-100 MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WK799-WL077C-20 PMD-900.20-WISEPED100C-1-20 HSA Gold 2000-100 Focused HSA Gold 2000-100 Broad
HSA Gold 2500-100 MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WK800-WL079C-20 PMD-900.20-WISEPED100C-1-20 HSA Gold 2500-100 Focused HSA Gold 2500-100 Broad
HSA Silver 3900-100 MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WK801-WL081C-20 PMD-900.20-WISEPED100C-1-20 HSA Silver 3900-100 Focused HSA Silver 3900-100 Broad
HSA w/Copay P-S
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused Broad
HSA Gold 2000-100 w/Copay MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WL067C-20 PMD-900.20-WISEPED100C-1-20 HSA Gold 2000-100 w/Copay Focused HSA Gold 2000-100 w/Copay Broad
HSA Embedded Silver 3000-100 w/Copay MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WL069C-20 PMD-900.20-WISEPED100C-1-20 HSA Embedded Silver 3000-100 w/Copay Focused HSA Embedded Silver 3000-100 w/Copay Broad
HSA Embedded Silver 4000-100 w/Copay MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WL071C-20 PMD-900.20-WISEPED100C-1-20 HSA Embedded Silver 4000-100 w/Copay Focused HSA Embedded Silver 4000-100 w/Copay Broad
HSA Embedded Bronze 5000-100 w/Copay MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WL073C-20 PMD-900.20-WISEPED100C-1-20 HSA Embedded Bronze 5000-100 w/Copay Focused HSA Embedded Bronze 5000-100 w/Copay Broad
HSA Embedded Bronze 6000-100 w/Copay MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WL075C-20 PMD-900.20-WISEPED100C-1-20 HSA Embedded Bronze 6000-100 w/Copay Focused HSA Embedded Bronze 6000-100 w/Copay Broad
Embedded HSA
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused Broad
HSA Embedded Gold 3000-100 MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WK802-WL083C-20 PMD-900.20-WISEPED100C-1-20 HSA Embedded Gold 3000-100 Focused HSA Embedded Gold 3000-100 Broad
HSA Embedded Gold 4100-100 MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WK803-WL085C-20 PMD-900.20-WISEPED100C-1-20 HSA Embedded Gold 4100-100 Focused HSA Embedded Gold 4100-100 Broad
HSA Embedded Silver 4500-100 MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WK804-WL087C-20 PMD-900.20-WISEPED100C-1-20 HSA Embedded Silver 4500-100 Focused HSA Embedded Silver 4500-100 Broad
HSA Embedded Silver 5000-100 MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WK805-WL089C-20 PMD-900.20-WISEPED100C-1-20 HSA Embedded Silver 5000-100 Focused HSA Embedded Silver 5000-100 Broad
HSA Embedded Bronze 6000-100 MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WK806-WL091C-20 PMD-900.20-WISEPED100C-1-20 HSA Embedded Bronze 6000-100 Focused HSA Embedded Bronze 6000-100 Broad
HSA Embedded Bronze 6450-100 MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WK807-WL093C-20 PMD-900.20-WISEPED100C-1-20 HSA Embedded Bronze 6450-100 Focused HSA Embedded Bronze 6450-100 Broad
HSA Embedded Silver 3000-70 MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WL095C-20 PMD-900.20-WISEPED70C-1-20 HSA Embedded Silver 3000-70 Focused HSA Embedded Silver 3000-70 Broad
HSA Embedded Silver 4500-70 MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WL097C-20 PMD-900.20-WISEPED70C-1-20 HSA Embedded Silver 4500-70 Focused HSA Embedded Silver 4500-70 Broad
HSA Embedded Bronze 5500-70 MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WK810-WL099C-20 PMD-900.20-WISEPED70C-1-20 HSA Embedded Bronze 5500-70 Focused HSA Embedded Bronze 5500-70 Broad
HSA Embedded Bronze 6250-70 MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WK811-WL101C-20 PMD-900.20-WISEPED70C-1-20 HSA Embedded Bronze 6250-70 Focused HSA Embedded Bronze 6250-70 Broad
HSA Rx Plus
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused Broad
HSA Gold 2100-100 Rx Plus MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WK812-WL103C-20 PMD-900.20-WISEPED100C-1-20 HSA Gold 2100-100 Rx Plus Focused HSA Gold 2100-100 Rx Plus Broad
HSA Gold 2500-100 Rx Plus MGC-900.20-WI-SE-ROBIN-HSA-20 BCH-900.20-WI-SE-WK813-WL105C-20 PMD-900.20-WISEPED100C-1-20 HSA Gold 2500-100 Rx Plus Focused HSA Gold 2500-100 Rx Plus Broad
HSA Rx Plus Embedded
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused Broad
HSA Embedded Gold 3000-100 Rx Plus BCH-900.20-WI-SE-WK814-WL107C-20 BCH-900.20-WI-SE-WK814-WL107C-20 PMD-900.20-WISEPED100C-1-20 HSA Embedded Gold 3000-100 Rx Plus Focused HSA Embedded Gold 3000-100 Rx Plus Broad
HSA Embedded Gold 3450-100 Rx Plus BCH-900.20-WI-SE-WK814-WL107C-20 BCH-900.20-WI-SE-WK815-WL109C-20 PMD-900.20-WISEPED100C-1-20 HSA Embedded Gold 3450-100 Rx Plus Focused HSA Embedded Gold 3450-100 Rx Plus Broad
HSA Embedded Silver 4550-100 Rx Plus BCH-900.20-WI-SE-WK814-WL107C-20 BCH-900.20-WI-SE-WK816-WL111C-20 PMD-900.20-WISEPED100C-1-20 HSA Embedded Silver 4550-100 Rx Plus Focused HSA Embedded Silver 4550-100 Rx Plus Broad
HSA Embedded Silver 5500-100 Rx Plus BCH-900.20-WI-SE-WK814-WL107C-20 BCH-900.20-WI-SE-WK817-WL113C-20 PMD-900.20-WISEPED100C-1-20 HSA Embedded Silver 5500-100 Rx Plus Focused HSA Embedded Silver 5500-100 Rx Plus Broad
HSA Embedded Silver 6500-100 Rx Plus BCH-900.20-WI-SE-WK814-WL107C-20 BCH-900.20-WI-SE-WK818-WL115C-20 PMD-900.20-WISEPED100C-1-20 HSA Embedded Silver 6500-100 Rx Plus Focused HSA Embedded Silver 6500-100 Rx Plus Broad
HSA Embedded Silver 3000-70 Rx Plus BCH-900.20-WI-SE-WK814-WL107C-20 BCH-900.20-WI-SE-WL117C-20 PMD-900.20-WISEPED70C-1-20 HSA Embedded Silver 3000-70 Rx Plus Focused HSA Embedded Silver 3000-70 Rx Plus Broad
HSA Embedded Silver 4000-70 Rx Plus BCH-900.20-WI-SE-WK814-WL107C-20 BCH-900.20-WI-SE-WL119C-20 PMD-900.20-WISEPED70C-1-20 HSA Embedded Silver 4000-70 Rx Plus Focused HSA Embedded Silver 4000-70 Rx Plus Broad
HSA Embedded Silver 5000-70 Rx Plus BCH-900.20-WI-SE-WK814-WL107C-20 BCH-900.20-WI-SE-WL121C-20 PMD-900.20-WISEPED70C-1-20 HSA Embedded Silver 5000-70 Rx Plus Focused HSA Embedded Silver 5000-70 Rx Plus Broad
HRA Embedded
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused Broad
HRA Embedded Silver 4250-100 MGC-900.20-WI-SE-ROBIN-COB-20 BCH-900.20-WI-SE-WK820-WL123C-20 PMD-900.20-WISEPED-100P-1-20 HRA Embedded Silver 4250-100 Focused HRA Embedded Silver 4250-100 Broad
HRA Embedded Silver 5550-100 MGC-900.20-WI-SE-ROBIN-COB-20 BCH-900.20-WI-SE-WK821-WL125C-20 PMD-900.20-WISEPED-100P-1-20 HRA Embedded Silver 5550-100 Focused HRA Embedded Silver 5550-100 Broad
HRA Embedded Bronze 6500-100 MGC-900.20-WI-SE-ROBIN-COB-20 BCH-900.20-WI-SE-WK822-WL127C-20 PMD-900.20-WISEPED-100P-1-20 HRA Embedded Bronze 6500-100 Focused HRA Embedded Bronze 6500-100 Broad
Copay and Deductible Copay
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
Platinum 25-95 MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK777C-20 PMD-900.20-WISEPED-95NC-1-20 Platinum 25-95 Open Access
Gold 30/60 P-S MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK789-WL041C-20 PMD-900.20-WISEPED-100C-1-20 Gold 30/60 P-S Open Access
Gold 45/90 P-S MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK790-WL043C-20 PMD-900.20-WISEPED-100C-1-20 Gold 45/90 P-S Open Access
Platinum 500-20 MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK778C-20 PMD-900.20-WISEPED-80NC-1-20 Platinum 500-20 Open Access
Gold 500-40 MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK779C-20 PMD-900.20-WISEPED-75C-1-20 Gold 500-40 Open Access
Gold 750-40 MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK780C-20 PMD-900.20-WISEPED-75C-1-20 Gold 750-40 Open Access
Gold 1000-40 MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK781C-20 PMD-900.20-WISEPED-75C-1-20 Gold 1000-40 Open Access
Gold 1500-40 MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK782C-20 PMD-900.20-WISEPED-75C-1-20 Gold 1500-40 Open Access
Gold 2000-50 MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK783C-20 PMD-900.20-WISEPED-75C-1-20 Gold 2000-50 Open Access
Gold 3000-50 MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK784C-20 PMD-900.20-WISEPED-75C-1-20 Gold 3000-50 Open Access
Silver 5000-60 MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK785C-20 PMD-900.20-WISEPED-70C-1-20 Silver 5000-60 Open Access
Deductible Copay P-S
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
Gold 500-30/50 P-S MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK786C-20 PMD-900.20-WISEPED-75C-1-20 Gold 500-30/50 P-S Open Access
Gold 1000-30/50 P-S MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK787C-20 PMD-900.20-WISEPED-75C-1-20 Gold 1000-30/50 P-S Open Access
Gold 2000-30/50 P-S MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK788C-20 PMD-900.20-WISEPED-75C-1-20 Gold 2000-30/50 P-S Open Access
Three For Free
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
Gold 500-70% Three for Free MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK791C-20 PMD-900.20-WISEPED-70C-1-20 Gold 500-70% Three for Free Open Access
Gold 1000-70% Three for Free MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK792C-20 PMD-900.20-WISEPED-70C-1-20 Gold 1000-70% Three for Free Open Access
Gold 2000-70% Three for Free MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK793-WL059C-20 PMD-900.20-WISEPED-70C-1-20 Gold 2000-70% Three for Free Open Access
Silver 3500-70% Three for Free MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK794-WL061C-20 PMD-900.20-WISEPED-70C-1-20 Silver 3500-70% Three for Free Open Access
Silver 5000-70% Three for Free MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK795-WL065C-20 PMD-900.20-WISEPED-70C-1-20 Silver 5000-70% Three for Free Open Access
HSA w/Copay P-S
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
HSA w/Copay 2000-100 MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK796C-20 PMD-900.20-WISEPED-100C-1-20 HSA w/Copay 2000-100 Open Access
HSA Embedded w/Copay Silver 3000-100 MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK797C-20 PMD-900.20-WISEPED-100C-1-20 HSA Embedded w/Copay Silver 3000-100 Open Access
HSA Embedded w/Copay Bronze 5000-100 MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK798C-20 PMD-900.20-WISEPED-100C-1-20 HSA Embedded w/Copay Bronze 5000-100 Open Access
HSA
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
HSA Gold 2000-100 MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK799-WL077C-20 PMD-900.20-WISEPED-100C-1-20 HSA Gold 2000-100 Open Access
HSA Gold 2500-100 MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK800-WL079-20 PMD-900.20-WISEPED-100C-1-20 HSA Gold 2500-100 Open Access
HSA Silver 3900-100 MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK801-WL081C-20 PMD-900.20-WISEPED-100C-1-20 HSA Silver 3900-100 Open Access
Embedded HSA
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
HSA Embedded Gold 3000-100 MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK802-WL083C-20 PMD-900.20-WISEPED-100C-1-20 HSA Embedded Gold 3000-100 Open Access
HSA Embedded Silver 4100-100 MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK803-WL085C-20 PMD-900.20-WISEPED-100C-1-20 HSA Embedded Silver 4100-100 Open Access
HSA Embedded Silver 4500-100 MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK804-WL087C-20 PMD-900.20-WISEPED-100C-1-20 HSA Embedded Silver 4500-100 Open Access
HSA Embedded Silver 5000-100 MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK805-WL089C-20 PMD-900.20-WISEPED-100C-1-20 HSA Embedded Silver 5000-100 Open Access
HSA Embedded Bronze 6000-100 MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK806-WL091C-20 PMD-900.20-WISEPED-100C-1-20 HSA Embedded Bronze 6000-100 Open Access
HSA Embedded Bronze 6450-100 MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK807-WL093C-20 PMD-900.20-WISEPED-100C-1-20 HSA Embedded Bronze 6450-100 Open Access
HSA Embedded Silver 3000-80 MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK808C-20 PMD-900.20-WISEPED-80NC-1-20 HSA Embedded Silver 3000-80 Open Access
HSA Embedded Silver 4500-80 MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK809C-20 PMD-900.20-WISEPED-80NC-1-20 HSA Embedded Silver 4500-80 Open Access
HSA Embedded Bronze 5500-70 MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK810-WL099C-20 PMD-900.20-WISEPED-70C-1-20 HSA Embedded Bronze 5500-70 Open Access
HSA Embedded Bronze 6250-70 MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK811C-20 PMD-900.20-WISEPED-70C-1-20 HSA Embedded Bronze 6250-70 Open Access
HSA Rx Plus
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
HSA Gold 2100-100 Rx Plus MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK812-WL103C-20 PMD-900.20-WISEPED-100C-1-20 HSA Gold 2100-100 Rx Plus Open Access
HSA Gold 2500-100 Rx Plus MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK813-WL105C-20 PMD-900.20-WISEPED-100C-1-20 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 MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK814-WL107C-20 PMD-900.20-WISEPED-100C-1-20 HSA Embedded Gold 3000-100 Rx Plus Open Access
HSA Embedded Gold 3450-100 Rx Plus MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK815-WL109C-20 PMD-900.20-WISEPED-100C-1-20 HSA Embedded Gold 3450-100 Rx Plus Open Access
HSA Embedded Silver 4550-100 Rx Plus MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK816-WL111C-20 PMD-900.20-WISEPED-100C-1-20 HSA Embedded Silver 4550-100 Rx Plus Open Access
HSA Embedded Silver 5500-100 Rx Plus MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK817C-WL113C-20 PMD-900.20-WISEPED-100C-1-20 HSA Embedded Silver 5500-100 Rx Plus Open Access
HSA Embedded Silver 6500-100 Rx Plus MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK818-WL115C-20 PMD-900.20-WISEPED-100C-1-20 HSA Embedded Silver 6500-100 Rx Plus Open Access
HSA Embedded Silver 3000-80 Rx Plus MGC-900.20-WI-SE-HSA-20 BCH-900.20-WI-SE-WK819C-20 PMD-900.20-WISEPED-80NC-1-20 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 4250-100 MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK820-WL123P-20 PMD-900.20-WISEPED-100P-1-20 HRA Embedded Silver 4250-100 Open Access
HRA Embedded Silver 5500-100 MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK821-WL125P-20 PMD-900.20-WISEPED-100P-1-20 HRA Embedded Silver 5500-100 Open Access
HRA Embedded Bronze 6500-100 MGC-900.20-WI-SE-COB-20 BCH-900.20-WI-SE-WK822-WL127P-20 PMD-900.20-WISEPED-100P-1-20 HRA Embedded Bronze 6500-100 Open Access

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
Three For Free
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
Gold 500-70% Three for Free CON-700.54-HPSE-1-19 BCH-700.54-SE-SE641C-19 PMD-700.54-SE-PED-70C-1-19 Gold 500-70% Three for Free Open Access Gold 500-70% Three for Free Perform Gold 500-70% Three for Free Achieve Gold 500-70% Three for Free CentraChoice
Gold 1000-70% Three for Free CON-700.54-HPSE-1-19 BCH-700.54-SE-SE645C-19 PMD-700.54-SE-PED-70C-1-19 Gold 1000-70% Three for Free Open Access Gold 1000-70% Three for Free Perform Gold 1000-70% Three for Free Achieve Gold 1000-70% Three for Free CentraChoice
Gold 2000-70% Three for Free CON-700.54-HPSE-1-19 BCH-700.54-SE-SE649C-19 PMD-700.54-SE-PED-70C-1-19 Gold 2000-70% Three for Free Open Access Gold 2000-70% Three for Free Perform Gold 2000-70% Three for Free Achieve Gold 2000-70% Three for Free CentraChoice
Silver 3500-70% Three for Free CON-700.54-HPSE-1-19 BCH-700.54-SE-SE653C-19 PMD-700.54-SE-PED-70C-1-19 Silver 3500-70% Three for Free Open Access Silver 3500-70% Three for Free Perform Silver 3500-70% Three for Free Achieve Silver 3500-70% Three for Free CentraChoice
Silver 5000-70% Three for Free CON-700.54-HPSE-1-19 BCH-700.54-SE-SE657C-19 PMD-700.54-SE-PED-70C-1-19 Silver 5000-70% Three for Free Open Access Silver 5000-70% Three for Free Perform Silver 5000-70% Three for Free Achieve Silver 5000-70% Three for Free CentraChoice
HSA
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
HSA Gold 2000-100 CON-700.54-HSA-HPSE-1-19 BCH-700.54-SE-SE661C-19 PMD-700.54-SE-PED-100CC-1-19 HSA Gold 2000-100 Open Access HSA Gold 2000-100 Perform HSA Gold 2000-100 Achieve HSA Gold 2000-100 CentraChoice
HSA Gold 2500-100 CON-700.54-HSA-HPSE-1-19 BCH-700.54-SE-SE665C-19 PMD-700.54-SE-PED-100CC-1-19 HSA Gold 2500-100 Open Access HSA Gold 2500-100 Perform HSA Gold 2500-100 Achieve HSA Gold 2500-100 CentraChoice
HSA Silver 3600-100 CON-700.54-HSA-HPSE-1-19 BCH-700.54-SE-SE669C-19 PMD-700.54-SE-PED-100CC-1-19 HSA Silver 3600-100 Open Access HSA Silver 3600-100 Perform HSA Silver 3600-100 Achieve HSA Silver 3600-100 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
HSA Rx Plus
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
HSA Gold 2000-100 Rx Plus CON-700.54-HSA-HPSE-1-19 BCH-700.54-SE-SE705C-19 PMD-700.54-SE-PED-100CC-1-19 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 CON-700.54-HSA-HPSE-1-19 BCH-700.54-SE-SE709C-19 PMD-700.54-SE-PED-100CC-1-19 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
HSA Rx Plus Embedded
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
HSA Embedded Gold 3000-100 Rx Plus CON-700.54-HSA-HPSE-1-19 BCH-700.54-SE-SE713C-19 PMD-700.54-SE-PED-100C-1-19 HSA Embedded Gold 3000-100 Rx Plus Open Access HSA Embedded Gold 3000-100 Rx Plus Perform HSA Embedded Gold 3000-100 Rx Plus Achieve HSA Embedded Gold 3000-100 Rx Plus CentraChoice
HSA Embedded Silver 4250-100 Rx Plus CON-700.54-HSA-HPSE-1-19 BCH-700.54-SE-SE717C-19 PMD-700.54-SE-PED-100C-1-19 HSA Embedded Silver 4250-100 Rx Plus Open Access HSA Embedded Silver 4250-100 Rx Plus Perform HSA Embedded Silver 4250-100 Rx Plus Achieve HSA Embedded Silver 4250-100 Rx Plus CentraChoice
HSA Embedded Silver 5000-100 Rx Plus CON-700.54-HSA-HPSE-1-19 BCH-700.54-SE-SE721C-19 PMD-700.54-SE-PED-100C-1-19 HSA Embedded Silver 5000-100 Rx Plus Open Access HSA Embedded Silver 5000-100 Rx Plus Perform HSA Embedded Silver 5000-100 Rx Plus Achieve HSA Embedded Silver 5000-100 Rx Plus CentraChoice
HSA Embedded Silver 3000-80 Rx Plus CON-700.54-HSA-HPSE-1-19 BCH-700.54-SE-SE725C-19 PMD-700.54-SE-PED-80C-1-19 HSA Embedded Silver 3000-80 Rx Plus Open Access HSA Embedded Silver 3000-80 Rx Plus Perform HSA Embedded Silver 3000-80 Rx Plus Achieve HSA Embedded Silver 3000-80 Rx Plus CentraChoice
HRA Embedded
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
HRA Embedded Silver 4000-100 CON-700.54-HPSE-1-19 BCH-700.54-SE-SE729P-19 PMD-700.54-SE-PED-100P-1-19 HRA Embedded Silver 4000-100 Open Access HRA Embedded Silver 4000-100 Perform HRA Embedded Silver 4000-100 Achieve HRA Embedded Silver 4000-100 CentraChoice
HRA Embedded Silver 5000-100 CON-700.54-HPSE-1-19 BCH-700.54-SE-SE733P-19 PMD-700.54-SE-PED-100P-1-19 HRA Embedded Silver 5000-100 Open Access HRA Embedded Silver 5000-100 Perform HRA Embedded Silver 5000-100 Achieve HRA Embedded Silver 5000-100 CentraChoice
HRA Embedded Bronze 6500-100 CON-700.54-HPSE-1-19 BCH-700.54-SE-SE737P-19 PMD-700.54-SE-PED-100P-1-19 HRA Embedded Bronze 6500-100 Open Access HRA Embedded Bronze 6500-100 Perform HRA Embedded Bronze 6500-100 Achieve HRA Embedded Bronze 6500-100 CentraChoice
Copay and Deductible Copay
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
Platinum 25-95 MGC-900.37-SE-MEB-19 BCH-900.37-SE-CE372C-19 PMD-900.37-SE-PED-95C-1.19 Platinum 25-95 Open Access Platinum 25-95 Perform
Gold 30/60 P-S MGC-900.37-SE-MEB-19 BCH-900.37-SE-CE386C-19 PMD-900.37-SE-PED-80C-1.19 Gold 30/60 P-S Open Access Gold 30/60 P-S Perform
Gold 45/90 P-S MGC-900.37-SE-MEB-19 BCH-900.37-SE-CE388C-19 PMD-900.37-SE-PED-80C-1.19 Gold 45/90 P-S Open Access Gold 45/90 P-S Perform
Platinum 500-20 MGC-900.37-SE-MEB-19 BCH-900.37-SE-CE374C-19 PMD-900.37-SE-PED-80C-1.19 Platinum 500-20 Open Access Platinum 500-20 Perform
Gold 500-40 MGC-900.37-SE-MEB-19 BCH-900.37-SE-CE376C-19 PMD-900.37-SE-PED-75C-1.19 Gold 500-40 Open Access Gold 500-40 Perform
Gold 750-40 MGC-900.37-SE-MEB-19 BCH-900.37-SE-CE378C-19 PMD-900.37-SE-PED-75C-1.19 Gold 750-40 Open Access Gold 750-40 Perform
Gold 1000-40 MGC-900.37-SE-MEB-19 BCH-900.37-SE-CE380P-19 PMD-900.37-SE-PED-75C-1.19 Gold 1000-40 Open Access Gold 1000-40 Perform
Gold 2000-50 MGC-900.37-SE-MEB-19 BCH-900.37-SE-CE382C-19 PMD-900.37-SE-PED-75C-1.19 Gold 2000-50 Open Access Gold 2000-50 Perform
Silver 4000-60 MGC-900.37-SE-MEB-19 BCH-900.37-SE-CE384C-19 PMD-900.37-SE-PED-80C-1.19 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 MGC-900.37-SE-MEB-19 BCH-900.37-SE-CE390C-19 PMD-900.37-SE-PED-70C-1.19 Gold 500-70% Three for Free Open Access Gold 500-70% Three for Free Perform
Gold 1000-70% Three for Free MGC-900.37-SE-MEB-19 BCH-900.37-SE-CE392C-19 PMD-900.37-SE-PED-70C-1.19 Gold 1000-70% Three for Free Open Access Gold 1000-70% Three for Free Perform
Gold 2000-70% Three for Free MGC-900.37-SE-MEB-19 BCH-900.37-SE-CE394P-19 PMD-900.37-SE-PED-70C-1.19 Gold 2000-70% Three for Free Open Access Gold 2000-70% Three for Free Perform
Silver 3500-70% Three for Free MGC-900.37-SE-MEB-19 BCH-900.37-SE-CE396P-19 PMD-900.37-SE-PED-70C-1.19 Silver 3500-70% Three for Free Open Access Silver 3500-70% Three for Free Perform
Silver 5000-70% Three for Free MGC-900.37-SE-MEB-19 BCH-900.37-SE-CE398C-19 PMD-900.37-SE-PED-70C-1.19 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 MGC-900.37-SE-HSA-19 BCH-900.37-SE-CE400C-19 PMD-900.37-SE-PED-100CC-1.19 HSA Gold 2000-100 Open Access HSA Gold 2000-100 Perform
HSA Gold 2500-100 MGC-900.37-SE-HSA-19 BCH-900.37-SE-CE402C-19 PMD-900.37-SE-PED-100CC-1.19 HSA Gold 2500-100 Open Access HSA Gold 2500-100 Perform
HSA Silver 3600-100 MGC-900.37-SE-HSA-19 BCH-900.37-SE-CE404C-19 PMD-900.37-SE-PED-100CC-1.19 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 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
HSA Rx Plus
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
HSA Gold 2000-100 Rx Plus MGC-900.37-SE-HSA-19 BCH-900.37-SE-CE422C-19 PMD-900.37-SE-PED-100CC-1-19 HSA Gold 2000-100 Rx Plus Open Access HSA Gold 2000-100 Rx Plus Perform
HSA Gold 2500-100 Rx Plus MGC-900.37-SE-HSA-19 BCH-900.37-SE-CE424C-19 PMD-900.37-SE-PED-100CC-1-19 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 MGC-900.37-SE-HSA-19 BCH-900.37-SE-CE426C-19 PMD-900.37-SE-PED-100C-1-19 HSA Embedded Silver 3000-100 Rx Plus Open Access HSA Embedded Silver 3000-100 Rx Plus Perform
HSA Embedded Silver 4250-100 Rx Plus MGC-900.37-SE-HSA-19 BCH-900.37-SE-CE428C-19 PMD-900.37-SE-PED-100C-1-19 HSA Embedded Silver 4250-100 Rx Plus Open Access HSA Embedded Silver 4250-100 Rx Plus Perform
HSA Embedded Silver 5000-100 Rx Plus MGC-900.37-SE-HSA-19 BCH-900.37-SE-CE430C-19 PMD-900.37-SE-PED-100C-1-19 HSA Embedded Silver 5000-100 Rx Plus Open Access HSA Embedded Silver 5000-100 Rx Plus Perform
HSA Embedded Silver 3000-80 Rx Plus MGC-900.37-SE-HSA-19 BCH-900.37-SE-CE432C-19 PMD-900.37-SE-PED-80C-1-19 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 MGC-900.37-SE-MEB-19 BCH-900.37-SE-CE434-19 PMD-900.37-SE-PED-100P-1-19 HRA Embedded Silver 4000-100 Open Access HRA Embedded Silver 4000-100 Perform
HRA Embedded Silver 5000-100 MGC-900.37-SE-MEB-19 BCH-900.37-SE-CE436-19 PMD-900.37-SE-PED-100P-1-19 HRA Embedded Silver 5000-100 Open Access HRA Embedded Silver 5000-100 Perform
HRA Embedded Bronze 6500-100 MGC-900.37-SE-MEB-19 BCH-900.37-SE-CE438-19 PMD-900.37-SE-PED-100P-1-19 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 MGC-900.19-WI-SE-MEB-ROBIN-19 BCH-900.19-WI-SE-WL001C-19 PMD-900.19-WISEPED95C-1-19 Platinum 25-95 Focused
Gold 30/60 P-S MGC-900.19-WI-SE-MEB-ROBIN-19 BCH-900.19-WI-SE-WK750C-WL008C-19 PMD-900.19-WISEPED80C-1-19 Gold 30/60 P-S Focused
Gold 45/90 P-S MGC-900.19-WI-SE-MEB-ROBIN-19 BCH-900.19-WI-SE-WK751C-WL009C-19 PMD-900.19-WISEPED80C-1-19 Gold 45/90 P-S Focused
Platinum 500-20 MGC-900.19-WI-SE-MEB-ROBIN-19 BCH-900.19-WI-SE-WL002C-19 PMD-900.19-WISEPED80C-1-19 Platinum 500-20 Focused
Gold 500-40 MGC-900.19-WI-SE-MEB-ROBIN-19 BCH-900.19-WI-SE-WL003C-19 PMD-900.19-WISEPED75C-1-19 Gold 500-40 Focused
Gold 750-40 MGC-900.19-WI-SE-MEB-ROBIN-19 BCH-900.19-WI-SE-WL004C-19 PMD-900.19-WISEPED75C-1-19 Gold 750-40 Focused
Gold 1000-40 MGC-900.19-WI-SE-MEB-ROBIN-19 BCH-900.19-WI-SE-WL005C-19 PMD-900.19-WISEPED75C-1-19 Gold 1000-40 Focused
Gold 2000-50 MGC-900.19-WI-SE-MEB-ROBIN-19 BCH-900.19-WI-SE-WL006C-19 PMD-900.19-WISEPED75C-1-19 Gold 2000-50 Focused
Silver 4000-60 MGC-900.19-WI-SE-MEB-ROBIN-19 BCH-900.19-WI-SE-WK749C-WL007C-19 PMD-900.37-SE-PED-70C-1-19 Silver 4000-60 Focused
Three For Free
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused
Gold 500-70% Three for Free MGC-900.19-WI-SE-MEB-ROBIN-19 BCH-900.19-WI-SE-WL010C-19 PMD-900.19-WISEPED70C-1-19 Gold 500-70% Three for Free Focused
Gold 1000-70% Three for Free MGC-900.19-WI-SE-MEB-ROBIN-19 BCH-900.19-WI-SE-WL011C-19 PMD-900.19-WISEPED70C-1-19 Gold 1000-70% Three for Free Focused
Gold 2000-70% Three for Free MGC-900.19-WI-SE-MEB-ROBIN-19 BCH-900.19-WI-SE-WL012C-19 PMD-900.19-WISEPED70C-1-19 Gold 2000-70% Three for Free Focused
Silver 3500-70% Three for Free MGC-900.19-WI-SE-MEB-ROBIN-19 BCH-900.19-WI-SE-WL013C-19 PMD-900.19-WISEPED70C-1-19 Silver 3500-70% Three for Free Focused
Silver 5000-70% Three for Free MGC-900.19-WI-SE-MEB-ROBIN-19 BCH-900.19-WI-SE-WL014C-19 PMD-900.19-WISEPED70C-1-19 Silver 5000-70% Three for Free Focused
HSA
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused
HSA Gold 2000-100 MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WK757C-WL018C-19 PMD-900.19-WISEPED100CC-1-19 HSA Gold 2000-100 Focused
HSA Gold 2500-100 MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WK758C-WL019C-19 PMD-900.19-WISEPED100CC-1-19 HSA Gold 2500-100 Focused
HSA Silver 3600-100 MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WK759C-WL020C-19 PMD-900.19-WISEPED100CC-1-19 HSA Silver 3600-100 Focused
HSA Copay
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Focused
HSA Gold 2000-100 w/Copay MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WL015C-19 PMD-900.19-WISEPED80C-1-19 HSA Gold 2000-100 w/Copay Focused
HSA Embedded Silver 3000-100 w/Copay MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WL016C-19 PMD-900.19-WISEPED80C-1-19 HSA Embedded Silver 3000-100 w/Copay Focused
HSA Embedded Bronze 5000-100 w/Copay MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WL017C-19 PMD-900.19-WISEPED80C-1-19 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 MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WK760C-WL021C-19 PMD-900.19-WISEPED100C-1-19 HSA Embedded Gold 3000-100 Focused
HSA Embedded Silver 3850-100 MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WK761C-WL022C-19 PMD-900.19-WISEPED100C-1-19 HSA Embedded Silver 3850-100 Focused
HSA Embedded Silver 4000-100 MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WK762C-WL023C-19 PMD-900.19-WISEPED100C-1-19 HSA Embedded Silver 4000-100 Focused
HSA Embedded Silver 4500-100 MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WK763C-WL024C-19 PMD-900.19-WISEPED100C-1-19 HSA Embedded Silver 4500-100 Focused
HSA Embedded Silver 3000-80 MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WK765C-WL026C-19 PMD-900.19-WISEPED80C-1-19 HSA Embedded Silver 3000-80 Focused
HSA Embedded Bronze 6450-100 MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WK764C-WL025C-19 PMD-900.19-WISEPED100C-1-19 HSA Embedded Bronze 6450-100 Focused
HSA Embedded Bronze 5500-70 MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WK766C-WL027C-19 PMD-900.19-WISEPED70C-1-19 HSA Embedded Bronze 5500-70 Focused
HSA Embedded Bronze 6000-70 MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WK767C-WL028C-19 PMD-900.19-WISEPED70C-1-19 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 MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WK768C-WL029C-19 PMD-900.19-WISEPED100CC-1-19 HSA Gold 2000-100 Rx Plus Focused
HSA Gold 2500-100 Rx Plus MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WK769C-WL030C-19 PMD-900.19-WISEPED100CC-1-19 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 MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WK770C-WL031C-19 PMD-900.19-WISEPED100C-1-19 HSA Embedded Gold 3000-100 Rx Plus Focused
HSA Embedded Silver 4250-100 Rx Plus MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WK771C-WL032C-19 PMD-900.19-WISEPED100C-1-19 HSA Embedded Silver 4250-100 Rx Plus Focused
HSA Embedded Silver 5000-100 Rx Plus MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WK772C-WL033C-19 PMD-900.19-WISEPED100C-1-19 HSA Embedded Silver 5000-100 Rx Plus Focused
HSA Embedded Silver 3000-80 Rx Plus MGC-900.19-WI-SE-HSA-ROBIN-19 BCH-900.19-WI-SE-WK773C-WL034C-19 PMD-900.19-WISEPED80C-1-19 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 MGC-900.19-WI-SE-MEB-ROBIN-19 BCH-900.19-WI-SE-WK774P-WL035P-19 PMD-900.19-WISEPED100P-1-19 HRA Embedded Silver 4000-100 Focused
HRA Embedded Silver 5000-100 MGC-900.19-WI-SE-MEB-ROBIN-19 BCH-900.19-WI-SE-WK775P-WL036P-19 PMD-900.19-WISEPED100P-1-19 HRA Embedded Silver 5000-100 Focused
HRA Embedded Bronze 6500-100 MGC-900.19-WI-SE-MEB-ROBIN-19 BCH-900.19-WI-SE-WK776P-WL037P-19 PMD-900.19-WISEPED100P-1-19 HRA Embedded Bronze 6500-100 Focused
Copay and Deductible Copay
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
Platinum 25-95 MGC-900.19-WI-SE-MEB-19 BCH-900.19-WI-SE-WK743C-19 PMD-900.19-WISEPED95C-1-19 Platinum 25-95 Open Access
Gold 30/60 P-S MGC-900.19-WI-SE-MEB-19 BCH-900.19-WI-SE-WK750C-WL008C-19 PMD-900.19-WISEPED80C-1-19 Gold 30/60 P-S Open Access
Gold 45/90 P-S MGC-900.19-WI-SE-MEB-19 BCH-900.19-WI-SE-WK751C-WL009C-19 PMD-900.19-WISEPED80C-1-19 Gold 45/90 P-S Open Access
Platinum 500-20 MGC-900.19-WI-SE-MEB-19 BCH-900.19-WI-SE-WK744C-19 PMD-900.19-WISEPED80C-1-19 Platinum 500-20 Open Access
Gold 500-40 MGC-900.19-WI-SE-MEB-19 BCH-900.19-WI-SE-WK745C-19 PMD-900.19-WISEPED75C-1-19 Gold 500-40 Open Access
Gold 750-40 MGC-900.19-WI-SE-MEB-19 BCH-900.19-WI-SE-WK746C-19 PMD-900.19-WISEPED75C-1-19 Gold 750-40 Open Access
Gold 1000-40 MGC-900.19-WI-SE-MEB-19 BCH-900.19-WI-SE-WK747C-19 PMD-900.19-WISEPED75C-1-19 Gold 1000-40 Open Access
Gold 2000-50 MGC-900.19-WI-SE-MEB-19 BCH-900.19-WI-SE-WK748C-19 PMD-900.19-WISEPED75C-1-19 Gold 2000-50 Open Access
Silver 4000-60 MGC-900.19-WI-SE-MEB-19 BCH-900.19-WI-SE-WK749C-WL007C-19 PMD-900.19-WISEPED70C-1-19 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 MGC-900.19-WI-SE-MEB-19 BCH-900.19-WI-SE-WK752C-19 PMD-900.19-WISEPED70C-1-19 Gold 500-70% Three for Free Open Access
Gold 1000-70% Three for Free MGC-900.19-WI-SE-MEB-19 BCH-900.19-WI-SE-WK753C-19 PMD-900.19-WISEPED70C-1-19 Gold 1000-70% Three for Free Open Access
Gold 2000-70% Three for Free MGC-900.19-WI-SE-MEB-19 BCH-900.19-WI-SE-WK754C-19 PMD-900.19-WISEPED70C-1-19 Gold 2000-70% Three for Free Open Access
Silver 3500-70% Three for Free MGC-900.19-WI-SE-MEB-19 BCH-900.19-WI-SE-WK755C-19 PMD-900.19-WISEPED70C-1-19 Silver 3500-70% Three for Free Open Access
Silver 5000-70% Three for Free MGC-900.19-WI-SE-MEB-19 BCH-900.19-WI-SE-WK756C-19 PMD-900.19-WISEPED70C-1-19 Silver 5000-70% Three for Free Open Access
HSA
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
HSA Gold 2000-100 MGC-900.19-WI-SE-HSA-19 BCH-900.19-WI-SE-WK757C-WL018C-19 PMD-900.19-WISEPED100CC-1-19 HSA Gold 2000-100 Open Access
HSA Gold 2500-100 MGC-900.19-WI-SE-HSA-19 BCH-900.19-WI-SE-WK758C-WL019C-19 PMD-900.19-WISEPED100CC-1-19 HSA Gold 2500-100 Open Access
HSA Silver 3600-100 MGC-900.19-WI-SE-HSA-19 BCH-900.19-WI-SE-WK759C-WL020C-19 PMD-900.19-WISEPED100CC-1-19 HSA Silver 3600-100 Open Access
 
Embedded HSA
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
HSA Embedded Gold 3000-100 MGC-900.19-WI-SE-HSA-19 BCH-900.19-WI-SE-WK760C-WL021C-19 PMD-900.19-WISEPED100C-1-19 HSA Embedded Gold 3000-100 Open Access
HSA Embedded Silver 3850-100 MGC-900.19-WI-SE-HSA-19 BCH-900.19-WI-SE-WK761C-WL022C-19 PMD-900.19-WISEPED100C-1-19 HSA Embedded Silver 3850-100 Open Access
HSA Embedded Silver 4000-100 MGC-900.19-WI-SE-HSA-19 BCH-900.19-WI-SE-WK762C-WL023C-19 PMD-900.19-WISEPED100C-1-19 HSA Embedded Silver 4000-100 Open Access
HSA Embedded Silver 4500-100 MGC-900.19-WI-SE-HSA-19 BCH-900.19-WI-SE-WK763C-WL024C-19 PMD-900.19-WISEPED100C-1-19 HSA Embedded Silver 4500-100 Open Access
HSA Embedded Silver 3000-80 MGC-900.19-WI-SE-HSA-19 BCH-900.19-WI-SE-WK765C-WL026C-19 PMD-900.19-WISEPED80C-1-19 HSA Embedded Silver 3000-80 Open Access
HSA Embedded Bronze 6450-100 MGC-900.19-WI-SE-HSA-19 BCH-900.19-WI-SE-WK764C-WL025C-19 PMD-900.19-WISEPED100C-1-19 HSA Embedded Bronze 6450-100 Open Access
HSA Embedded Bronze 5500-70 MGC-900.19-WI-SE-HSA-19 BCH-900.19-WI-SE-WK766C-WL027C-19 PMD-900.19-WISEPED70C-1-19 HSA Embedded Bronze 5500-70 Open Access
HSA Embedded Bronze 6000-70 MGC-900.19-WI-SE-HSA-19 BCH-900.19-WI-SE-WK767C-WL028C-19 PMD-900.19-WISEPED70C-1-19 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 MGC-900.19-WI-SE-HSA-19 BCH-900.19-WI-SE-WK768C-WL029C-19 PMD-900.19-WISEPED100CC-1-19 HSA Gold 2000-100 Rx Plus Open Access
HSA Gold 2500-100 Rx Plus MGC-900.19-WI-SE-HSA-19 BCH-900.19-WI-SE-WK769C-WL030C-19 PMD-900.19-WISEPED100CC-1-19 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 MGC-900.19-WI-SE-HSA-19 BCH-900.19-WI-SE-WK770C-WL031C-19 PMD-900.19-WISEPED100C-1-19 HSA Embedded Gold 3000-100 Rx Plus Open Access
HSA Embedded Silver 4250-100 Rx Plus MGC-900.19-WI-SE-HSA-19 BCH-900.19-WI-SE-WK771C-WL032C-19 PMD-900.19-WISEPED100C-1-19 HSA Embedded Silver 4250-100 Rx Plus Open Access
HSA Embedded Silver 5000-100 Rx Plus MGC-900.19-WI-SE-HSA-19 BCH-900.19-WI-SE-WK772C-WL033C-19 PMD-900.19-WISEPED100C-1-19 HSA Embedded Silver 5000-100 Rx Plus Open Access
HSA Embedded Silver 3000-80 Rx Plus MGC-900.19-WI-SE-HSA-19 BCH-900.19-WI-SE-WK773C-WL034C-19 PMD-900.19-WISEPED80C-1-19 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 MGC-900.19-WI-SE-MEB-19 BCH-900.19-WI-SE-WK774P-WL035P-19 PMD-900.19-WISEPED100P-1-19 HRA Embedded Silver 4000-100 Open Access
HRA Embedded Silver 5000-100 MGC-900.19-WI-SE-MEB-19 BCH-900.19-WI-SE-WK775P-WL036P-19 PMD-900.19-WISEPED100P-1-19 HRA Embedded Silver 5000-100 Open Access
HRA Embedded Bronze 6500-100 MGC-900.19-WI-SE-MEB-19 BCH-900.19-WI-SE-WK776P-WL037P-19 PMD-900.19-WISEPED100P-1-19 HRA Embedded Bronze 6500-100 Open Access

2018 Small group plans

Copay and Deductible Copay
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
Platinum 25-95 CON-700.53-HPSE-1-18 BCH-700.53-SE-SA817-CT-18 PMD-700.53-SE-PED-95C-1-18 Platinum 25-95 Open Access Platinum 25-95 Perform Platinum 25-95 Achieve Platinum 25-95 CentraChoice
Platinum 500-20 CON-700.53-HPSE-1-18 BCH-700.53-SE-SA821-CT-18 PMD-700.53-SE-PED-75C-1-18 Platinum 500-20 Open Access Platinum 500-20 Perform Platinum 500-20 Achieve Platinum 500-20 CentraChoice
Gold 500-40 CON-700.53-HPSE-1-18 BCH-700.53-SE-SA825-CT-18 PMD-700.53-SE-PED-80C-1-18 Gold 500-40 Open Access Gold 500-40 Perform Gold 500-40 Achieve Gold 500-40 CentraChoice
Gold 750-40 CON-700.53-HPSE-1-18 BCH-700.53-SE-SA829-CT-18 PMD-700.53-SE-PED-75C-1-18 Gold 750-40 Open Access Gold 750-40 Perform Gold 750-40 Achieve Gold 750-40 CentraChoice
Gold 1000-40 CON-700.53-HPSE-1-18 BCH-700.53-SE-SA833-CT-18 PMD-700.53-SE-PED-75C-1-18 Gold 1000-40 Open Access Gold 1000-40 Perform Gold 1000-40 Achieve Gold 1000-40 CentraChoice
Silver 3500-60 CON-700.53-HPSE-1-18 BCH-700.53-SE-SA837-CT-18 PMD-700.53-SE-PED-70C-1-18 Silver 3500-60 Open Access Silver 3500-60 Perform Silver 3500-60 Achieve Silver 3500-60 CentraChoice
Three For Free
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
Gold 500-70% Three for Free CON-700.53-HPSE-1-18 BCH-700.53-SE-SA841-CT-18 PMD-700.53-SE-PED-70C-1-18 Gold 500-70% Three for Free Open Access Gold 500-70% Three for Free Perform Gold 500-70% Three for Free Achieve Gold 500-70% Three for Free CentraChoice
Gold 1000-70% Three for Free CON-700.53-HPSE-1-18 BCH-700.53-SE-SA845-CT-18 PMD-700.53-SE-PED-70C-1-18 Gold 1000-70% Three for Free Open Access Gold 1000-70% Three for Free Perform Gold 1000-70% Three for Free Achieve Gold 1000-70% Three for Free CentraChoice
Silver 3000-70% Three for Free CON-700.53-HPSE-1-18 BCH-700.53-SE-SA849-CT-18 PMD-700.53-SE-PED-70C-1-18 Silver 3000-70% Three for Free Open Access Silver 3000-70% Three for Free Perform Silver 3000-70% Three for Free Achieve Silver 3000-70% Three for Free CentraChoice
HSA
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
HSA Gold 2000-100 CON-700.53-HSA-HPSE-1-18 BCH-700.53-SE-SE360-C-18 PMD-700.53-SE-PED-100CC-1-18 HSA Gold 2000-100 Open Access HSA Gold 2000-100 Perform HSA Gold 2000-100 Achieve HSA Gold 2000-100 CentraChoice
HSA Gold 2500-100 CON-700.53-HSA-HPSE-1-18 BCH-700.53-SE-SE364-C-18 PMD-700.53-SE-PED-100CC-1-18 HSA Gold 2500-100 Open Access HSA Gold 2500-100 Perform HSA Gold 2500-100 Achieve HSA Gold 2500-100 CentraChoice
HSA Silver 3500-100 CON-700.53-HSA-HPSE-1-18 BCH-700.53-SE-SE368-C-18 PMD-700.53-SE-PED-100CC-1-18 HSA Silver 3500-100 Open Access HSA Silver 3500-100 Perform HSA Silver 3500-100 Achieve HSA Silver 3500-100 CentraChoice

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
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
HSA Gold 2000-100 Rx Plus CON-700.53-HSA-HPSE-1-18 BCH-700.53-SE-SP270-C-18 PMD-700.53-SE-PED-100CC-1-18 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 CON-700.53-HSA-HPSE-1-18 <BCH-700.53-SE-SP274-C-18 PMD-700.53-SE-PED-100CC-1-18 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
HSA Rx Plus Embedded
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
HSA Embedded Silver 4000-100 Rx Plus CON-700.53-HSA-HPSE-1-18 BCH-700.53-SE-SP278-CT-18 PMD-700.53-SE-PED-100C-1-18 HSA Embedded Silver 4000-100 Rx Plus Open Access HSA Embedded Silver 4000-100 Rx Plus Perform HSA Embedded Silver 4000-100 Rx Plus Achieve HSA Embedded Silver 4000-100 Rx Plus CentraChoice
HSA Embedded Silver 3000-80 Rx Plus CON-700.53-HSA-HPSE-1-18 BCH-700.53-SE-SP282-CT-18 PMD-700.53-SE-PED-80C-1-18 HSA Embedded Silver 3000-80 Rx Plus Open Access HSA Embedded Silver 3000-80 Rx Plus Perform HSA Embedded Silver 3000-80 Rx Plus Achieve HSA Embedded Silver 3000-80 Rx Plus CentraChoice
HRA Embedded
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform Achieve CentraChoice
HRA Embedded Silver 4000-100 CON-700.53-HPSE-1-18 BCH-700.53-SE-SE057-CT-18 PMD-700.53-SE-PED-100C-1-18 HRA Embedded Silver 4000-100 Open Access HRA Embedded Silver 4000-100 Perform HRA Embedded Silver 4000-100 Achieve HRA Embedded Silver 4000-100 CentraChoice
HRA Embedded Silver 4750-100 CON-700.53-HPSE-1-18 BCH-700.53-SE-SE061-CT-18 PMD-700.53-SE-PED-100C-1-18 HRA Embedded Silver 4750-100 Open Access HRA Embedded Silver 4750-100 Perform HRA Embedded Silver 4750-100 Achieve HRA Embedded Silver 4750-100 CentraChoice
HRA Embedded Bronze 6000-100 CON-700.53-HPSE-1-18 BCH-700.53-SE-SE065-CT-18 PMD-700.53-SE-PED-100C-1-18 HRA Embedded Bronze 6000-100 Open Access HRA Embedded Bronze 6000-100 Perform HRA Embedded Bronze 6000-100 Achieve HRA Embedded Bronze 6000-100 CentraChoice
Copay and Deductible Copay
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
Platinum 25-95 MGC-900.36-SE-N1-18 BCH-900.36-SE-CA806-CT-18 PMD-900.36-SE-PED-95C-1-18 Platinum 25-95 Open Access Platinum 25-95 Perform
Platinum 500-20 MGC-900.36-SE-N1-18 BCH-900.36-SE-CA808-CT-18 PMD-900.36-SE-PED-95C-1-18 Platinum 500-20 Open Access Platinum 500-20 Perform
Gold 500-40 MGC-900.36-SE-N1-18 BCH-900.36-SE-CA810-CT-18 PMD-900.36-SE-PED-75C-1-18 Gold 500-40 Open Access Gold 500-40 Perform
Gold 750-40 MGC-900.36-SE-N1-18 BCH-900.36-SE-CA812-CT-18 PMD-900.36-SE-PED-75C-1-18 Gold 750-40 Open Access Gold 750-40 Perform
Gold 1000-40 MGC-900.36-SE-N1-18 BCH-900.36-SE-CA814-CT-18 PMD-900.36-SE-PED-75C-1-18 Gold 1000-40 Open Access Gold 1000-40 Perform
Silver 3500-60 MGC-900.36-SE-N1-18 BCH-900.36-SE-CA816-CT-18 PMD-900.36-SE-PED-70C-1-18 Silver 3500-60 Open Access Silver 3500-60 Perform
Three For Free
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
Gold 500-70% Three for Free MGC-900.36-SE-N1-18 BCH-900.36-SE-CA818-CT-18 PMD-900.36-SE-PED-70C-1-18 Gold 500-70% Three for Free Open Access Gold 500-70% Three for Free Perform
Gold 1000-70% Three for Free MGC-900.36-SE-N1-18 BCH-900.36-SE-CA820-CT-18 PMD-900.36-SE-PED-70C-1-18 Gold 1000-70% Three for Free Open Access Gold 1000-70% Three for Free Perform
Silver 3000-70% Three for Free MGC-900.36-SE-N1-18 BCH-900.36-SE-CA822-CT-18 PMD-900.36-SE-PED-70C-1-18 Silver 3000-70% Three for Free Open Access Silver 3000-70% Three for Free Perform
HSA
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
HSA Gold 2000-100 MGC-900.36-SE-N1-EHSA-18 BCH-900.36-SE-CE352-C-18 PMD-900.36-SE-PED-100CC-1-18 HSA Gold 2000-100 Open Access HSA Gold 2000-100 Perform
HSA Gold 2500-100 MGC-900.36-SE-N1-EHSA-18 BCH-900.36-SE-CE354-C-18 PMD-900.36-SE-PED-100CC-1-18 HSA Gold 2500-100 Open Access HSA Gold 2500-100 Perform
HSA Silver 3500-100 MGC-900.36-SE-N1-EHSA-18 BCH-900.36-SE-CE356-C-18 PMD-900.36-SE-PED-100CC-1-18 HSA Silver 3500-100 Open Access HSA Silver 3500-100 Perform
Embedded HSA
Plan name Contract Benefit charts Amendments/ pediatric dental Open Access Perform
HSA Embedded Gold 2800-100 MGC-900.36-SE-N1-EHSA-18 BCH-900.36-SE-CE358-CT-18 PMD-900.36-SE-PED-100C-1-18 HSA Embedded Gold 2800-100 Open Access HSA Embedded Gold 2800-100 Perform
HSA Embedded Silver 3600-100 MGC-900.36-SE-N1-EHSA-18 BCH-900.36-SE-CE360-CT-18 PMD-900.36-SE-PED-100C-1-18 HSA Embedded Silver 3600-100 Open Access HSA Embedded Silver 3600-100 Perform
HSA Embedded Silver 4000-100 MGC-900.36-SE-N1-EHSA-18 BCH-900.36-SE-CE362-CT-18 PMD-900.36-SE-PED-100C-1-18 HSA Embedded Silver 4000-100 Open Access HSA Embedded Silver 4000-100 Perform
HSA Embedded Silver 3000-80 MGC-900.36-SE-N1-EHSA-18 BCH-900.36-SE-CE366-CT-18 PMD-900.36-SE-PED-80C-1-18 HSA Embedded Silver 3000-80 Open Access HSA Embedded Silver 3000-80 Perform
HSA Embedded Bronze 6500-100 MGC-900.36-SE-N1-EHSA-18 BCH-900.36-SE-CE364-CT-18 PMD-900.36-SE-PED-100C-1-18 HSA Embedded Bronze 6500-100 Open Access HSA Embedded Bronze 6500-100 Perform
HSA Embedded Bronze 5200-70 MGC-900.36-SE-N1-EHSA-18 BCH-900.36-SE-CE368-CT-18 PMD-900.36-SE-PED-70C-1-18 HSA Embedded Bronze 5200-70 Open Access HSA Embedded Bronze 5200-70 Perform
HSA Embedded Bronze 6000-70 MGC-900.36-SE-N1-EHSA-18 BCH-900.36-SE-CE370-CT-18 PMD-900.36-SE-PED-70C-1-18 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 MGC-900.36-SE-N1-EHSA-18 BCH-900.36-SE-CP266-C-18 PMD-900.36-SE-PED-100CC-1-18 HSA Gold 2000-100 Rx Plus Open Access HSA Gold 2000-100 Rx Plus Perform
HSA Gold 2500-100 Rx Plus MGC-900.36-SE-N1-EHSA-18 BCH-900.36-SE-CP268-C-18 PMD-900.36-SE-PED-100CC-1-18 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 4000-100 Rx Plus MGC-900.36-SE-N1-EHSA-18 BCH-900.36-SE-CP270-CT-18 PMD-900.36-SE-PED-100CC-1-18 HSA Embedded Silver 4000-100 Rx Plus Open Access HSA Embedded Silver 4000-100 Rx Plus Perform
HSA Embedded Silver 3000-80 Rx Plus MGC-900.36-SE-N1-EHSA-18 BCH-900.36-SE-CP272-CT-18 PMD-900.36-SE-PED-80C-1-18 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 MGC-900.36-SE-N1-18 BCH-900.36-SE-CE054-CT-18 PMD-900.36-SE-PED-100C-1-18 HRA Embedded Silver 4000-100 Open Access HRA Embedded Silver 4000-100 Perform
HRA Embedded Silver 4750-100 MGC-900.36-SE-N1-18 BCH-900.36-SE-CE056-CT-18 PMD-900.36-SE-PED-100C-1-18 HRA Embedded Silver 4750-100 Open Access HRA Embedded Silver 4750-100 Perform
HRA Embedded Bronze 6000-100 MGC-900.36-SE-N1-18 BCH-900.36-SE-CE058-CT-18 PMD-900.36-SE-PED-100C-1-18 HRA Embedded Bronze 6000-100 Open Access HRA Embedded Bronze 6000-100 Perform
Copay and Deductible Copay
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
Platinum 25-95 MGC-900.18-WI-SE-N1-18 BCH-900.18-WI-SE-WK368CT-18 PMD-900.18-WISEPED95C-1-18R Platinum 25-95 Open Access
Platinum 500-20 MGC-900.18-WI-SE-N1-18 BCH-900.18-WI-SE-WK369CT-18 PMD-900.18-WISEPED80C-1-18R Platinum 500-20 Open Access
Gold 500-40 MGC-900.18-WI-SE-N1-18 BCH-900.18-WI-SE-WK370CT-18 PMD-900.18-WISEPED75C-1-18R Gold 500-40 Open Access
Gold 750-40 MGC-900.18-WI-SE-N1-18 BCH-900.18-WI-SE-WK371CT-18 PMD-900.18-WISEPED75C-1-18R Gold 750-40 Open Access
Gold 1000-40 MGC-900.18-WI-SE-N1-18 BCH-900.18-WI-SE-WK372CT-18 PMD-900.18-WISEPED75C-1-18R Gold 1000-40 Open Access
Silver 3500-60 MGC-900.18-WI-SE-N1-18 BCH-900.18-WI-SE-WK373CT-18 PMD-900.18-WISEPED70C-1-18R Silver 3500-60 Open Access
Three For Free
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
Gold 500-70% Three for Free MGC-900.18-WI-SE-N1-18 BCH-900.18-WI-SE-WK374CT-18 PMD-900.18-WISEPED70C-1-18R Gold 500-70% Three for Free Open Access
Gold 1000-70% Three for Free MGC-900.18-WI-SE-N1-18 BCH-900.18-WI-SE-WK375CT-18 PMD-900.18-WISEPED70C-1-18R Gold 1000-70% Three for Free Open Access
Silver 3000-70% Three for Free MGC-900.18-WI-SE-N1-18 BCH-900.18-WI-SE-WK376CT-18 PMD-900.18-WISEPED70C-1-18R Silver 3000-70% Three for Free Open Access
HSA
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
HSA Gold 2000-100 MGC-900.18-WI-SE-HSA-18 BCH-900.18-WI-SE-WE423C-18 PMD-900.18-WISEPED100CC-1-18R HSA Gold 2000-100 Open Access
HSA Gold 2500-100 MGC-900.18-WI-SE-HSA-18 BCH-900.18-WI-SE-WE424C-18 PMD-900.18-WISEPED100CC-1-18R HSA Gold 2500-100 Open Access
Embedded HSA
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
HSA Embedded Gold 2800-100 MGC-900.18-WI-SE-HSA-18 BCH-900.18-WI-SE-WE425CT-18 PMD-900.18-WISEPED100C-1-18R HSA Embedded Gold 2800-100 Open Access
HSA Embedded Silver 3600-100 MGC-900.18-WI-SE-HSA-18 BCH-900.18-WI-SE-WE426CT-18 PMD-900.18-WISEPED100C-1-18R HSA Embedded Silver 3600-100 Open Access
HSA Embedded Silver 4000-100 MGC-900.18-WI-SE-HSA-18 BCH-900.18-WI-SE-WE427CT-18 PMD-900.18-WISEPED100C-1-18R HSA Embedded Silver 4000-100 Open Access
HSA Embedded Silver 3000-80 MGC-900.18-WI-SE-HSA-18 BCH-900.18-WI-SE-WE429CT-18 PMD-900.18-WISEPED80C-1-18R HSA Embedded Silver 3000-80 Open Access
HSA Embedded Bronze 6400-100 MGC-900.18-WI-SE-HSA-18 BCH-900.18-WI-SE-WE428CT-18 PMD-900.18-WISEPED100C-1-18R HSA Embedded Bronze 6400-100 Open Access
HSA Embedded Bronze 5200-70 MGC-900.18-WI-SE-HSA-18 BCH-900.18-WI-SE-WE430CT-18 PMD-900.18-WISEPED70C-1-18R HSA Embedded Bronze 5200-70 Open Access
HSA Embedded Bronze 6000-70 MGC-900.18-WI-SE-HSA-18 BCH-900.18-WI-SE-WE431CT-18 PMD-900.18-WISEPED70C-1-18R 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 MGC-900.18-WI-SE-HSA-18 BCH-900.18-WI-SE-WE432C-18 PMD-900.18-WISEPED100CC-1-18R HSA Gold 2000-100 Rx Plus Open Access
HSA Gold 2500-100 Rx Plus MGC-900.18-WI-SE-HSA-18 BCH-900.18-WI-SE-WE433C-18 PMD-900.18-WISEPED100CC-1-18R 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 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
HRA Embedded
Plan name Contract Benefit charts HPIC Amendments/ Pediatric dental Open Access
HRA Embedded Silver 4000-100 MGC-900.18-WI-SE-N1-18 BCH-900.18-WI-SE-WE437CT-18 PMD-900.18-WISEPED100C-1-18R HRA Embedded Silver 4000-100 Open Access
HRA Embedded Silver 4750-100 MGC-900.18-WI-SE-N1-18 BCH-900.18-WI-SE-WE436CT-18 PMD-900.18-WISEPED100C-1-18R HRA Embedded Silver 4750-100 Open Access
HRA Embedded Bronze 6000-100 MGC-900.18-WI-SE-N1-18 BCH-900.18-WI-SE-WE438CT-18 PMD-900.18-WISEPED100C-1-18R HRA Embedded Bronze 6000-100 Open Access
Back to top