Resources and Forms

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Individual & Family Plans

Summary of Benefits and Coverage (SBC)
Bronze Specialist Saver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health) - OffEx
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Bronze Specialist Saver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health) - OnEx
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Bronze Specialist Saver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health) - OnEx ZCS
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Bronze Specialist Saver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health) - OnEx LCS
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OffEx
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx ZCS
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx LCS
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx CSR 73%
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx CSR 87%
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx CSR 94%
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Gold 0000 $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs & X-Rays) 50% Coinsurance - OffEx
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Gold 0000 $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs & X-Rays) 50% Coinsurance - OnEx
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Gold 0000 $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs & X-Rays) 50% Coinsurance - OnEx ZCS
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Gold 0000 $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs & X-Rays) 50% Coinsurance - OnEx LCS
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Clear Choice Enhanced Bronze 9100 - OffEx
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Clear Choice Enhanced Bronze 9100 - OnEx
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Clear Choice Enhanced Bronze 9100 - OnEx ZCS
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Clear Choice Enhanced Bronze 9100 - OnEx LCS
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Clear Choice Silver 3000 - OffEx
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Clear Choice Silver 3000 - OnEx
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Clear Choice Silver 3000 - OnEx ZCS
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Clear Choice Silver 3000 - OnEx LCS
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Clear Choice Silver 3000 - OnEx CSR 73%
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Clear Choice Silver 3000 - OnEx CSR 87%
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Clear Choice Silver 3000 - OnEx CSR 94%
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Clear Choice Gold 1500 - OffEx
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Clear Choice Gold 1500 - OnEx
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Clear Choice Gold 1500 - OnEx ZCS
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Clear Choice Gold 1500 - OnEx LCS
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Schedule of Benefits (SOB)
Bronze Specialist Saver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health) - OffEx
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Bronze Specialist Saver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health) - OnEx
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Bronze Specialist Saver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health) - OnEx ZCS
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Bronze Specialist Saver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health) - OnEx LCS
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OffEx
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx ZCS
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx LCS
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx CSR 73%
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx CSR 87%
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx CSR 94%
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Gold 0000 $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs & X-Rays) 50% Coinsurance - OffEx
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Gold 0000 $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs & X-Rays) 50% Coinsurance - OnEx
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Gold 0000 $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs & X-Rays) 50% Coinsurance - OnEx ZCS
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Gold 0000 $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs & X-Rays) 50% Coinsurance - OnEx LCS
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Clear Choice Enhanced Bronze 9100 - OffEx
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Clear Choice Enhanced Bronze 9100 - OnEx
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Clear Choice Enhanced Bronze 9100 - OnEx ZCS
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Clear Choice Enhanced Bronze 9100 - OnEx LCS
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Clear Choice Silver 3000 - OffEx
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Clear Choice Silver 3000 - OnEx
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Clear Choice Silver 3000 - OnEx ZCS
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Clear Choice Silver 3000 - OnEx LCS
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Clear Choice Silver 3000 - OnEx CSR 73%
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Clear Choice Silver 3000 - OnEx CSR 87%
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Clear Choice Silver 3000 - OnEx CSR 94%
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Clear Choice Gold 1500 - OffEx
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Clear Choice Gold 1500 - OnEx
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Clear Choice Gold 1500 - OnEx ZCS
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Clear Choice Gold 1500 - OnEx LCS
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Evidence of Coverage (EOC)
Bronze Specialist Saver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health) - OffEx
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Bronze Specialist Saver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health) - OnEx
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Bronze Specialist Saver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health) - OnEx ZCS
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Bronze Specialist Saver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health) - OnEx LCS
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OffEx
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx ZCS
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx LCS
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx CSR 73%
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx CSR 87%
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Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OnEx CSR 94%
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Gold 0000 $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs & X-Rays) 50% Coinsurance - OffEx
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Gold 0000 $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs & X-Rays) 50% Coinsurance - OnEx
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Gold 0000 $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs & X-Rays) 50% Coinsurance - OnEx ZCS
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Gold 0000 $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs & X-Rays) 50% Coinsurance - OnEx LCS
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Clear Choice Enhanced Bronze 9100 - OffEx
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Clear Choice Enhanced Bronze 9100 - OnEx
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Clear Choice Enhanced Bronze 9100 - OnEx ZCS
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Clear Choice Enhanced Bronze 9100 - OnEx LCS
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Clear Choice Silver 3000 - OffEx
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Clear Choice Silver 3000 - OnEx
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Clear Choice Silver 3000 - OnEx ZCS
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Clear Choice Silver 3000 - OnEx LCS
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Clear Choice Silver 3000 - OnEx CSR 73%
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Clear Choice Silver 3000 - OnEx CSR 87%
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Clear Choice Silver 3000 - OnEx CSR 94%
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Clear Choice Gold 1500 - OffEx
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Clear Choice Gold 1500 - OnEx
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Clear Choice Gold 1500 - OnEx ZCS
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Clear Choice Gold 1500 - OnEx LCS
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Small Group Plans

Summary of Benefits and Coverage (SBC)
Bronze Specialist Saver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health) - OffEx
Download PDF
Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OffEx
Download PDF
Gold 0000 $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs & X-Rays) 50% Coinsurance - OffEx
Download PDF
Clear Choice Enhanced Bronze 9100 - OffEx
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Clear Choice Silver 3000 - OffEx
Download PDF
Clear Choice Gold 1500 - OffEx
Download PDF
Schedule of Benefits (SOB)
Bronze Specialist Saver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health) - OffEx
Download PDF
Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OffEx
Download PDF
Gold 0000 $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs & X-Rays) 50% Coinsurance - OffEx
Download PDF
Clear Choice Enhanced Bronze 9100 - OffEx
Download PDF
Clear Choice Silver 3000 - OffEx
Download PDF
Clear Choice Gold 1500 - OffEx
Download PDF
Evidence of Coverage (EOC)
Bronze Specialist Saver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health) - OffEx
Download PDF
Silver $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs) - OffEx
Download PDF
Gold 0000 $0 Direct Primary Care + $0 Copays (Telehealth + Mental Health + Generic Drugs + Labs & X-Rays) 50% Coinsurance - OffEx
Download PDF
Clear Choice Enhanced Bronze 9100 - OffEx
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Clear Choice Silver 3000 - OffEx
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Clear Choice Gold 1500 - OffEx
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