Commercial Members – ICHRA Plans

• Certificate of Coverage
  • COC – 10006-00 INNOVATION – Pediatric Dental Benefits
  • COC – 10016-00 INNOVATION – No Pediatric Dental Benefits
• Summary of Benefits and Coverage
  • SBC – 10006-00 INNOVATION – Pediatric Dental Benefits
  • SBC – 10016-00 INNOVATION – No Pediatric Dental Benefits
• INNOVATION – Price Information for Pharmacy Benefits
• INNOVATION – Credible Coverage Disclosure Notice

• Certificate of Coverage
  • COC – 10004-00 ECONOMY – Pediatric Dental Benefits
  • COC – 10014-00 ECONOMY – No Pediatric Dental Benefits
• Summary of Benefits and Coverage
  • SBC – 10004-00 ECONOMY – Pediatric Dental Benefits
  • SBC – 10014-00 ECONOMY – No Pediatric Dental Benefits
• ECONOMY – Price Information for Pharmacy Benefits
• ECONOMY – Credible Coverage Disclosure Notice

• Certificate of Coverage
  • COC – 10020-00 COMMUNITY – Pediatric Dental Benefits
  • COC – 10013-00 COMMUNITY – No Pediatric Dental Benefits
• Summary of Benefits and Coverage
  • SBC – 10020-00 COMMUNITY – Pediatric Dental Benefits
  • SBC – 10013-00 COMMUNITY – No Pediatric Dental Benefits
• COMMUNITY – Price Information for Pharmacy Benefits
• COMMUNITY – Credible Coverage Disclosure Notice

• Certificate of Coverage
  • COC – 10021-00 VALUE – Pediatric Dental Benefits
  • COC – 10018-00 VALUE – No Pediatric Dental Benefits
  • *COC – 10019-00 VALUE – Pediatric Dental Benefits
  • *COC – 10012-00 VALUE – No Pediatric Dental Benefits
• Summary of Benefits and Coverage
  • SBC – 10021-00 VALUE – Pediatric Dental Benefits
  • SBC – 10018-00 VALUE – No Pediatric Dental Benefits
  • *SBC – 10019-00 VALUE – Pediatric Dental Benefits
  • *SBC – 10012-00 VALUE – No Pediatric Dental Benefits

*This plan does not cover abortion except in limited situations.

• VALUE – Price Information for Pharmacy Benefits
• VALUE – Credible Coverage Disclosure Notice

• Certificate of Coverage
  • COC – 10010-00 PLUS – Pediatric Dental Benefits
  • COC – 10017-00 PLUS – No Pediatric Dental Benefits
• Summary of Benefits and Coverage
  • SBC – 10010-00 PLUS – Pediatric Dental Benefits
  • SBC – 10017-00 PLUS – No Pediatric Dental Benefits
• PLUS – Price Information for Pharmacy Benefits
• PLUS – Credible Coverage Disclosure Notice

• Certificate of Coverage
  • COC – 10005-00 ESSENTIAL – Pediatric Dental Benefits
  • COC – 10015-00 ESSENTIAL – No Pediatric Dental Benefits
• Summary of Benefits and Coverage
  • SBC – 10005-00 ESSENTIAL – Pediatric Dental Benefits
  • SBC – 10015-00 ESSENTIAL – No Pediatric Dental Benefits
• ESSENTIAL – Price Information for Pharmacy Benefits
• ESSENTIAL – Credible Coverage Disclosure Notice