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Mid-Sized Business and Balanced Funding Plan Documents April 2022

Pharmacy

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3 & 4 Tier Standard Plans
Coinsurance & Brand-Generic Standard Plans

Benefit Books

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Group PPO Base Benefit Book
Group Ascend HMO Plus Base Benefit Book
Group Ascend HSA HMO Base Benefit Book
Group BP PPO January Rider
Group Ascend HMO January Rider
Group Ascend HMO Plus 70 3000
Group Ascend HMO Plus 70 5000
Group Ascend HMO Plus 70 6000
Group Ascend HMO Plus 70 7000
Group Ascend HMO Plus 70 8000
Group Ascend HMO Plus 80 3000
Group Ascend HMO Plus 80 5000
Group Ascend HMO Plus 80 6000
Group Ascend HMO Plus 80 7000
Group Ascend HSA HMO 70 3000
Group Ascend HSA HMO 70 5000
Group Ascend HSA HMO 70 6000
Group Ascend HSA HMO 80 3000
Group Ascend HSA HMO 80 5000
Group Ascend HSA HMO 80 6000
Group Ascend HSA HMO 90 3000
Group Ascend HSA HMO 90 5000
Group Ascend HSA HMO 90 6000
Group Ascend HMO Plus 100 8300
Group BP PPO 100 1000
Group BP PPO 100 1500
Group BP PPO 100 2000
Group BP PPO 100 250
Group BP PPO 100 2500
Group BP PPO 100 3000
Group BP PPO 100 4000
Group BP PPO 100 500
Group BP PPO 100 5000
Group BP PPO 100 6000
Group BP PPO 100 8300
Group BP PPO 70 1000
Group BP PPO 70 1500
Group BP PPO 70 2000
Group BP PPO 70 2500
Group BP PPO 70 3000
Group BP PPO 70 4000
Group BP PPO 70 5000
Group BP PPO 70 6000
Group BP PPO 70 7000
Group BP PPO 70 8000
Group BP PPO 80 1000
Group BP PPO 80 1500
Group BP PPO 80 2000
Group BP PPO 80 2500
Group BP PPO 80 3000
Group BP PPO 80 4000
Group BP PPO 80 500
Group BP PPO 80 5000
Group BP PPO 80 6000
Group BP PPO 80 7000
Group BP PPO 90 1000
Group BP PPO 90 1500
Group BP PPO 90 2000
Group BP PPO 90 250
Group BP PPO 90 2500
Group BP PPO 90 3000
Group BP PPO 90 4000
Group BP PPO 90 500
Group BP PPO 90 5000
Group BP PPO 90 6000
Group BP PPO HSA Plus 100 2800
Group BP PPO HSA Plus 100 3000
Group BP PPO HSA Plus 100 4000
Group BP PPO HSA Plus 100 5000
Group BP PPO HSA Plus 100 6000
Group BP PPO HSA Plus 100 7000
Group BP PPO HSA Plus 70 2800
Group BP PPO HSA Plus 70 3000
Group BP PPO HSA Plus 70 4000
Group BP PPO HSA Plus 70 5000
Group BP PPO HSA Plus 70 6000
Group BP PPO HSA Plus 80 2800
Group BP PPO HSA Plus 80 3000
Group BP PPO HSA Plus 80 4000
Group BP PPO HSA Plus 80 5000
Group BP PPO HSA Plus 80 6000
Group BP PPO HSA Plus 90 1500
Group BP PPO HSA Plus 90 2800
Group BP PPO HSA Plus 90 3000
Group BP PPO HSA Plus 90 4000
Group BP PPO HSA Plus 90 5000
Group BP PPO HSA Plus 90 6000

Employer Health Plan Product Guide

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Balanced Funding
Mid-Sized Business

Summary of Benefits and Coverage (SBC)

The Summary of Benefits and Coverage (SBC) provides a concise description of what services your plan covers along with what you will pay for covered benefits.