Monthly Premiums
Office Visits for Primary Doctor
Office Visits for Specialist
Doctor Choice
Annual Deductible
Drug Coverage
Emergency Care
Outpatient Lab/X-Ray
Outpatient Surgery
Urgent Care

Hospitalization

Dental Services
Hearing Services

Vision Services



Plan Documents

Summary of Benefits (English)

Summary of Benefits (Spanish)

Evidence of Coverage (English)

Evidence of Coverage (Spanish)

Drug List (English)   

Drug List (Spanish)   

CMS Plan Rating Information (English)

CMS Plan Rating Information (Spanish)

Plan Premiums for People with Extra Help
(only for plans with prescription drug coverage)



The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
 
Limitations, copayments, and restrictions may apply.
 
Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.