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 Name1/1/18 – 9/1/1810/1/18 – 12/1/181/1/19 - 9/1/1910/1/19 - 9/1/20
Capital Selection 153050PDFPDFPDFPDF
Capital Selection 153050 + 20% ER   PDF
Capital Selection 1550100PDFPDFPDFPDF
Capital Selection 1550100 + 20% ER   PDF
Premier Plus 153050PDFPDFPDFPDF
Premier Plus 153050 + 20% ER   PDF
Premier Selection 153050PDFPDFPDFPDF
Premier Selection 153050 + 20% ER   PDF
Principal Choice 1550100PDFPDFPDFPDF
Principal Choice 1550100 + 25% ER   PDF
Quality Choice 1550100PDFPDFPDFPDF
Quality Choice 1550100 + 25% ER   PDF
Quality Choice Exclusive 6 Tier Rx    PDF
Quality Choice Exclusive 6 Tier Rx + $750 ER   PDF
Uniform GlossaryView HereView HereView HereView Here

Small Employer Group Plans

Plan Name201820192020
3101 - Platinum 153050PDFPDFPDF
3101 - Platinum 153050 - Religious ExemptionPDFPDF 
3102 - Platinum 153050PDF  
3102 - Platinum 204060PDFPDFPDF
3104 - Gold 1550100PDF  
3104 - Gold 2060100PDFPDF 
3104 - Gold 2065100  PDF
3106 - Gold 156080  PDF
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 HereView Here