Plan Summaries

You can find Medical & Rx, Dental, Vision, Life Insurance and Disability plan summaries and booklets here.

Medical & RX

Summary of Benefits and Coverage (SBC)

2023 PPO 20 SBC

2023 HMO 25 SBC

2023 PPO 25 SBC

2023 PPO HRA SBC

2023 PPO 2000 SBC

2023 HMO 3000 SBC

2023 PPO 3000 SBC

2023 PPO 4000 SBC

2023 PPO 5000 SBC

Understanding Cost Transparency (No Surprises Act)

Plan Booklets

PPO 20 Booklet

HMO 25 Booklet

PPO 25 Booklet

PPO HRA Booklet

PPO 2000 Booklet

PPO 3000 Booklet

HMO 3000 Booklet

PPO 4000 Booklet

PPO 5000 Booklet

VBA Rx Communications

ESI Barcode Mobile Flyer

ESI Claim Form

2023 ESI Standard Plus Preventive Medication List

2023 ESI National Preferred Drug List

VBA Rx Plan Summaries

2023 PPO 20 Rx Plan Summary

2023 HMO 25 Rx Plan Summary

2023 PPO 25 Rx Plan Summary

2023 PPO HRA Rx Plan Summary

2023 PPO 2000 Rx Plan Summary

2023 PPO 3000 Rx Plan Summary

2023 HMO 3000 Rx Plan Summary

2023 PPO 4000 Rx Plan Summary

2023 PPO 5000 Rx Plan Summary

Anthem BlueView Vision

Anthem BlueView Vision EOC

Blue View Vision HK Booklet

Blue View Vision PPO Booklet

Dental

Summaries

2023 Delta Dental Basic Plan

2023 Delta Dental Comprehensive Plan

2023 Delta Dental Enhanced Indemnity Plan

2023 Delta Dental Voluntary Plan

Booklets

Delta Dental Basic Booklet

Delta Dental Enhanced Indemnity Booklet

Delta Dental Comprehensive Booklet

Delta Dental Voluntary Booklet

Vision  

Summaries

2023 VSP Basic Plan Summary

2023 VSP Enhanced Plan Summary

2023 Vision Plan Comparison

Life Insurance

Life Insurance Summary

Life Insurance Booklet

Voluntary AD&D Certificate

Disability

LTD Cert Class 1: LTD 60-day 60% plan

LTD Cert Class 2: LTD 60-day 70% plan

LTD Cert Class 3: LTD 90-day 60% plan

LTD Cert Class 4: LTD 90-day 70% plan

LTD Cert Class 5: LTD 180-day 60% plan

LTD Cert Class 6: LTD 180-day 70% plan

ERISA Summary Plan Description Update 4-1-18