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 1/1/18 – 9/1/18 10/1/18 – 12/1/18 1/1/19 - 9/1/19 10/1/19 - 9/1/20
Capital Selection 153050 PDF PDF PDF PDF
Capital Selection 153050 + 20% ER       PDF
Capital Selection 1550100 PDF PDF PDF PDF
Capital Selection 1550100 + 20% ER       PDF
Premier Plus 153050 PDF PDF PDF PDF
Premier Plus 153050 + 20% ER       PDF
Premier Selection 153050 PDF PDF PDF PDF
Premier Selection 153050 + 20% ER       PDF
Principal Choice 1550100 PDF PDF PDF PDF
Principal Choice 1550100 + 25% ER       PDF
Quality Choice 1550100 PDF PDF 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 2018 2019 2020
3101 - Platinum 153050 PDF PDF PDF
3101 - Platinum 153050 - Religious Exemption PDF PDF  
3102 - Platinum 153050 PDF    
3102 - Platinum 204060 PDF PDF PDF
3104 - Gold 1550100 PDF    
3104 - Gold 2060100 PDF 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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