Summary of Benefits and Coverage

Large Employer Group Plans

To ensure you are selecting the appropriate Summary of Benefits and Copayments (SBC) that is applicable to your coverage period, please be aware that coverage periods are based on the employer anniversary date beginning on or after the dates listed below. Copayments may or may not change at the time of your group renewal. If you have any questions regarding your SBC, please call the Sales & Account Management Team.

Plan Name10/1/20 - 12/1/212022
Capital Selection 153050PDFPDF
Capital Selection 153050 + 20% ERPDFPDF
Capital Selection 1550100PDFPDF
Capital Selection 1550100 + 20% ERPDFPDF
Premier Plus 153050PDFPDF
Premier Plus 153050 + 20% ER PDF
Premier Selection 153050PDFPDF
Premier Selection 153050 + 20% ER PDF
Primary Selection 6 Tier RxPDFPDF
Principal Choice 1550100PDFPDF
Principal Choice 1550100 + 25% ERPDFPDF
Quality Choice 1550100PDFPDF
Quality Choice 1550100 + 25% ERPDFPDF
Uniform GlossaryView HereView Here

Small Employer Group Plans

Plan Name20212022
3101 - Platinum 153050PDFPDF
3102 - Platinum 204060PDFPDF
3104 - Gold 2065100PDFPDF
3106 - Gold 156080  
3107 - Gold 6 Tier RxPDFPDF
Basic Option I 1050100PDFPDF
Basic Option II 1050100PDFPDF
Essential Selection 153050PDFPDF
Essential Selection No RxPDFPDF
Standard Option I 103050PDFPDF
Tiered PCP 153050PDFPDF
Tiered PCP No RxPDFPDF
Uniform GlossaryView HereView Here