Plan Documents and Coverage

Benefits Summary (PDF) July 1, 2021
A detailed list of the level of coverage for covered services (e.g. copay, coinsurance)

Benefits Summary (PDF) July 1, 2020
A detailed list of the level of coverage for covered services (e.g. copay, coinsurance)

Summary of Benefits & Coverage ("SBC") (PDF) July 1, 2021 
A summary of the level of coverage for some services (e.g. copay, coinsurance)

Summary of Benefits & Coverage ("SBC") (PDF) July 1, 2020
A summary of the level of coverage for some services (e.g. copay, coinsurance)

Plan Booklet - Medical (PDF) July 1, 2021
A detailed description of what medical services the plan covers

Plan Booklet - Medical (PDF) July 1, 2020
A detailed description of what medical services the plan covers 

Plan Booklet - Prescription (PDF) July 1, 2021 
A detailed description of what prescription services the plan covers

Plan Booklet - Prescription (PDF) July 1, 2020 
A detailed description of what prescription services the plan covers

Rx Copays - Prescription (PDF) July 1, 2021

Rx Copays - Prescription (PDF)  July 1, 2020