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 Name 1/1/19 - 9/1/19 10/1/19 - 9/1/20
Capital Selection 153050 PDF PDF
Capital Selection 153050 + 20% ER   PDF
Capital Selection 1550100 PDF PDF
Capital Selection 1550100 + 20% ER   PDF
Premier Plus 153050 PDF PDF
Premier Plus 153050 + 20% ER   PDF
Premier Selection 153050 PDF PDF
Premier Selection 153050 + 20% ER   PDF
Principal Choice 1550100 PDF PDF
Principal Choice 1550100 + 25% ER   PDF
Quality Choice 1550100 PDF PDF
Quality Choice 1550100 + 25% ER   PDF
Quality Choice Exclusive 6 Tier Rx    PDF
Quality Choice Exclusive 6 Tier Rx + $750 ER   PDF
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Small Employer Group Plans

Plan Name 2019 2020
3101 - Platinum 153050 PDF PDF
3101 - Platinum 153050 - Religious Exemption PDF  
3102 - Platinum 153050    
3102 - Platinum 204060 PDF PDF
3104 - Gold 1550100    
3104 - Gold 2060100 PDF  
3104 - Gold 2065100   PDF
3106 - Gold 156080   PDF
Basic Option I 1050100 PDF PDF
Basic Option II 1050100 PDF PDF
Essential Selection 153050 PDF PDF
Essential Selection No Rx PDF PDF
Standard Option I 103050 PDF PDF
Tiered PCP 153050 PDF PDF
Tiered PCP No Rx PDF PDF
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