Summary of Benefits and Coverage

To help you make an informed choice about your health care coverage, we are providing Summary of Benefits and Coverage (SBC) documents for each of our plans.

The SBC explains what a health insurance plan covers, what it doesn’t cover, and what your cost share will be. The plans vary by monthly premium costs, what portion of the bill you will pay for services like hospital visits or prescription medications, and how much your total out-of-pocket costs are.

Information in these SBCs is an overview of coverage. It is not a complete list of what is covered or excluded. Information is subject to change.

Please note that SBCs are not available for employer groups with more than 150 employees but can be obtained through your Human Resources department.

Individual and Family

Effective Date	Plan Name	Product Name
2020	Armor Health	Armor Health 2500 NB
2020	Armor Health	Armor Health 5000 NB
2020	Armor Health	Armor Health 7500 NB

Small Group (2-50)

Effective Date	Plan Name	Product Name
2021	BluePride	BluePride BHA21 Bronze HSA
2021	BluePride	BluePride SPB21 Silver
2021	BluePride	BluePride SPA21 Silver
2021	BluePride	BluePride SHA21 Silver HSA
2021	BluePride	BluePride SHB21 Silver HSA
2021	BluePride	BluePride GPA21 Gold
2021	BluePride	BluePride GPB21 Gold
2021	BluePride	BluePride GHA21 Gold HSA
2021	BluePride	BluePride GHB21 Gold HSA
2021	BluePride	BluePride GPC21 Gold
2021	BluePride	BluePride SPC21 Silver
2021	BluePride	BluePride SHC21 Silver HSA
2021	BlueFlex	BlueFlex FPA21
2021	BlueFlex	BlueFlex FPB21
2021	BlueFlex	BlueFlex FPC21
2021	BlueFlex	BlueFlex FPD21
2021	BlueFlex	BlueFlex FHA21
2021	BlueFlex	BlueFlex FHB21
2021	BlueFlex	BlueFlex FHC21
2021	BlueFlex	BlueFlex FHD21
2020	BluePride	BluePride BHA20 Bronze HSA
2020	BluePride	BluePride SPB20 Silver
2020	BluePride	BluePride SPA20 Silver
2020	BluePride	BluePride SHA20 Silver HSA
2020	BluePride	BluePride SHB20 Silver HSA
2020	BluePride	BluePride GPA20 Gold
2020	BluePride	BluePride GPB20 Gold
2020	BluePride	BluePride GHA20 Gold HSA
2020	BluePride	BluePride GHB20 Gold HSA
2020	BluePride	BluePride GPC20 Gold
2020	BluePride	BluePride SPC20 Silver
2020	BlueFlex	BlueFlex FPA20
2020	BlueFlex	BlueFlex FPB20
2020	BlueFlex	BlueFlex FPC20
2020	BlueFlex	BlueFlex FPD20
2020	BlueFlex	BlueFlex FHA20
2020	BlueFlex	BlueFlex FHB20
2020	BlueFlex	BlueFlex FHC20
2020	BlueFlex	BlueFlex FHD20

Mid-Size Group (51-150)

Effective Date	Plan Name	Product Name
2021	BlueFreedom	BlueFreedom Option 15 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 15 Rx Option 6
2021	BlueFreedom	BlueFreedom Option 18 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 18 Rx Option 6
2021	BlueFreedom	BlueFreedom Option 19 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 19 Rx Option 6
2021	BlueFreedom	BlueFreedom Option 20 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 20 Rx Option 6
2021	BlueFreedom	BlueFreedom Option 23 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 23 Rx Option 6
2021	BlueFreedom	BlueFreedom Option 25 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 25 Rx Option 6
2021	BlueFreedom	BlueFreedom Option 26 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 26 Rx Option 6
2021	BlueFreedom	BlueFreedom Option 28 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 28 Rx Option 6
2021	BlueFreedom	BlueFreedom Option 29 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 29 Rx Option 6
2021	BlueFreedom	BlueFreedom Option 31 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 31 Rx Option 6
2021	BlueFreedom	BlueFreedom Option 34 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 34 Rx Option 6
2021	BlueFreedom	BlueFreedom Option 35 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 35 Rx Option 6
2021	BlueFreedom	BlueFreedom Option 39 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 39 Rx Option 6
2021	BlueFreedom	BlueFreedom Option 41 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 41 Rx Option 6
2021	BlueFreedom	BlueFreedom Option 42 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 42 Rx Option 6
2021	BlueFreedom	BlueFreedom Option 43 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 43 Rx Option 6
2021	BlueFreedom	BlueFreedom Option 44 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 44 Rx Option 6
2021	BlueFreedom	BlueFreedom HSA Opt 49
2021	BlueFreedom	BlueFreedom HSA Opt 52
2021	BlueFreedom	BlueFreedom HSA Opt 54
2021	BlueFreedom	BlueFreedom HSA Opt 55
2021	BlueFreedom	BlueFreedom HSA Opt 57
2021	BlueFreedom	BlueFreedom HSA Opt 60
2021	BlueFreedom	BlueFreedom Option 65 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 65 Rx Option 6
2021	BlueFreedom	BlueFreedom HSA Opt 66
2021	BlueFreedom	BlueFreedom Option 8 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 8 Rx Option 6
2021	BlueFreedom	BlueFreedom HSA Opt 58
2021	BlueFreedom	BlueFreedom Option 67 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 67 Rx Option 6
2021	BlueFreedom	BlueFreedom Option 68 Rx Option 1
2021	BlueFreedom	BlueFreedom Option 68 Rx Option 6
2021	BlueFreedom	BlueFreedom Opt 69 Rx Opt 1
2021	BlueFreedom	BlueFreedom Option 70 Rx Option 1
2021	BlueFreedom	BlueFreedom Opt 69 Rx Opt 6
2021	BlueFreedom	BlueFreedom Option 70 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 15 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 15 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 18 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 18 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 19 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 19 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 20 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 20 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 23 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 23 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 25 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 25 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 26 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 26 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 28 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 28 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 29 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 29 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 31 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 31 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 34 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 34 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 35 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 35 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 39 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 39 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 41 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 41 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 42 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 42 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 43 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 43 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 44 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 44 Rx Option 6
2020	BlueFreedom	BlueFreedom HSA Opt 49
2020	BlueFreedom	BlueFreedom HSA Opt 52
2020	BlueFreedom	BlueFreedom HSA Opt 54
2020	BlueFreedom	BlueFreedom HSA Opt 55
2020	BlueFreedom	BlueFreedom HSA Opt 57
2020	BlueFreedom	BlueFreedom HSA Opt 60
2020	BlueFreedom	BlueFreedom Option 65 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 65 Rx Option 6
2020	BlueFreedom	BlueFreedom HSA Opt 66
2020	BlueFreedom	BlueFreedom Option 8 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 8 Rx Option 6
2020	BlueFreedom	BlueFreedom HSA Opt 58
2020	BlueFreedom	BlueFreedom Option 67 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 67 Rx Option 6
2020	BlueFreedom	BlueFreedom Option 68 Rx Option 1
2020	BlueFreedom	BlueFreedom Option 68 Rx Option 6
2020	BlueFreedom	BlueFreedom Opt 69 Rx Opt 1
2020	BlueFreedom	BlueFreedom Option 70 Rx Option 1
2020	BlueFreedom	BlueFreedom Opt 69 Rx Opt 6
2020	BlueFreedom	BlueFreedom Option 70 Rx Option 6