Plan Documents
We are truly invested in your health and can help you access the health care services you need including doctors, hospitals, and community resources. Please read the plan documents below to understand what is covered under your health plan.
You can request plan documents be mailed to you, free of charge, by calling Member Services at (210) 358-6400.
Definition of Terms
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- Summary of Benefit and Coverage (SBC): The SBC is an easy-to-read summary document that allows comparison between health plans. This document lists important information about the plan such as cost-sharing, coverage limitations, exceptions and benefits scenarios.
- Formulary: A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Also called a drug list.
- Summary of Benefit and Coverage (SBC): The SBC is an easy-to-read summary document that allows comparison between health plans. This document lists important information about the plan such as cost-sharing, coverage limitations, exceptions and benefits scenarios.
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All Members receive:
– Free preventive care
– 24/7/365 Nurse Line
– Access to a trusted network of health care providers and hospitals
Questions?
Our hours of operation are
Monday through Friday, 8:30 a.m. to 5 p.m.
Contact Us
Local: (210) 358-6400
Toll-Free: 1-888-512-2347
2024 Plan Documents
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- Member Handbook (English)
- Member Handbook (Spanish)
- Network
- Summary of Benefits and Coverage
- Transparency in Coverage
- Plan Description
- Plan Brochure
- Prescription Rider
- Formulary
- Payment
- Balance Billing
- Prescription Copay Overview Flyer (English)
- Prescription Copay Overview Flyer (Spanish)
- Privacy Policy
- Designation of a Personal Representative Form
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Evidence of Insurance
- Gold Plan
- Gold (Limited-Cost Share) Plan
- Gold (Zero-Cost Share) Plan
- Gold – Standard Plan
- Gold – Standard (Limited-Cost Share) Plan
- Gold – Standard (Zero-Cost Share) Plan
- Silver Plan
- Silver (Limited-Cost Share) Plan
- Silver (Zero-Cost Share) Plan
- Silver – Standard Plan
- Silver – Standard (Limited-Cost Share) Plan
- Silver – Standard (Zero-Cost Share) Plan
Individual Plans
Schedule of Benefits
- Gold Plan
- Gold (Limited-Cost Share) Plan
- Gold (Zero-Cost Share) Plan
- Gold – Standard Plan
- Gold – Standard (Limited-Cost Share) Plan
- Gold – Standard (Zero-Cost Share) Plan
- Silver Plan
- Silver (Limited-Cost Share) Plan
- Silver (Zero-Cost Share) Plan
- Silver – Standard Plan
- Silver – Standard (Limited-Cost Share) Plan
- Silver – Standard (Zero-Cost Share) Plan
- Silver Plan 73
- Silver Plan 73 – Standard
- Silver Plan 87
- Silver Plan 87 – Standard
- Silver Plan 94
- Silver Plan 94 – Standard
Referral & Prior Authorization
2023 Plan Documents
Evidence of Insurance
- Gold Plan
- Gold (Limited-Cost Share) Plan
- Gold (Zero-Cost Share) Plan
- Gold – Standard Plan
- Gold – Standard (Limited-Cost Share) Plan
- Gold – Standard (Zero-Cost Share) Plan
- Silver Plan
- Silver (Limited-Cost Share) Plan
- Silver (Zero-Cost Share) Plan
- Silver – Standard Plan
- Silver – Standard (Limited-Cost Share) Plan
- Silver – Standard (Zero-Cost Share) Plan
Individual Plans
Schedule of Benefits
- Gold Plan
- Gold (Limited-Cost Share) Plan
- Gold (Zero-Cost Share) Plan
- Gold – Standard Plan
- Gold – Standard (Limited-Cost Share) Plan
- Gold – Standard (Zero-Cost Share) Plan
- Silver Plan
- Silver (Limited-Cost Share) Plan
- Silver (Zero-Cost Share) Plan
- Silver – Standard Plan
- Silver – Standard (Limited-Cost Share) Plan
- Silver – Standard (Zero-Cost Share) Plan
- Silver Plan 73
- Silver Plan 73 – Standard
- Silver Plan 87
- Silver Plan 87 – Standard
- Silver Plan 94
- Silver Plan 94 – Standard