Plan Benefit - AZ
Cap/Eligibility CP7810
Assigned Plan Benefit Codes & Descriptions
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
22A
22D
22F
22G
2AA
2AC
2AD
2AE
2AF
2AG
2AH
2AN
2AX
2AY
2BL
2DK
2FH
2FL
2GH
2HH
2JH
2KH
2MH
2NH
2PH
2QH
2UH
2VH
2WH
2XH
2YH
2ZA
2ZB
2ZC
2ZD
2ZE
2ZF
32B
33B
3AA
3AB
3AC
Plan / Benefit Description
3/3 BO IAM GR-RX05
7/7 BOEING GR-RX05
7/20 ADOA GR-RX05
10/20 ASRS GR-RX05
5/15L SH-RX05
7/14 GR-RX05
10/20 GR-RX05
10/25L GR-RX05
7/14 I GR-RX05
10/20 I GR-RX05
10/25L I GR-RX05
4/20/40 LO GR-RX07
20/40 GR-RX07
4/25/50 HI GR-RX07
10/25/50 RX-GR08
20/40 GR-RX07
4/15/30 RX-GR08
5/20/45 RX-GR08
4/20/40 RX-GR08
4/15/30 RX-GR08
4/20/40 RX-GR08
4/25/50 RX-GR08
4/25/45 RX-GR08
4/28/55 RX-GR08
4/2/58 RX-GR08
4/25/50 RX-GR08
10/25/50 RX-GR08
10/25/50 RX-GR08
5/20/45 RX-GR08
5/20/45 RX-GR08
4/10/20 RX-GR08
0/0 GR-RX07
2/40 GR-RX07
5/25 GR-RX07
5/65 GR-RX07
5/10 GR-RX07
10/20 GR-RX07
5/15/30 BO GR-RX05
5/15/30 BO RX-GR08
10/25/50L SH-RX05
10/30/55L SH-RX05
10/20/40 GR-RX05
1 of 640
Plan Benefit - AZ
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
3AD
3AE
3AG
3AH
3AJ
3BK
3LL
3ZE
3ZF
3ZG
3ZH
3ZJ
3ZK
3ZL
3ZM
42G
42H
43D
43H
4AA
4XQ
6AA
6AB
6AH
6AL
6AQ
6BH
6BL
6DH
6DL
6ED
6EH
6EL
6EP
6ER
6FH
6FL
6FP
6GP
6HH
6HL
6HP
6JH
6JL
6KH
6KL
6KP
6LH
6LL
6MA
Plan / Benefit Description
15/25/40L GR-RX05
15/25/40 GR-RX05
10/20/40 I GR-RX05
15/25/40L I GR-X05
15/25/40 I GR-RX05
10/30/50 GR-RX07
10/20/50 GR-RX07
5/10/20 GR-RX07
10/20/35 GR-RX07
10/20/35 GR-RX07
10/25/55 GR-RX07
10/40/75 GR-RX07
7/20/50% GR-RX07
2/30/60 GR-RX07
10/25/50 GR-RX07
MCC 1 PIMA GR08
MCC 1 PIMA DLX GR08
MCC 3 MCOPA GR08
MCC 3 MCOPA DLX GR08
SV 15/30/250A NAT'L 05
5/29/60 W/G GR-RX7
SV 10/100% 05
SP 10/100% 05
0/0 HI GR-RX07
0/0 LO GR-RX07
7/20 GR-RX06
2/30/60 HI GR-RX07
2/30/60 LO GR-RX07
2/40 HI GR-RX07
2/40 LO GR-RX07
7/7 GR-RX06
5/25 HI GR-RX07
5/25 LO GR-RX07
8.50/26.40/50% SH6
10/20 GR-RX06
5/65 HI GR-RX07
5/65 LO GR-RX07
8.50/26.40/50% SH6
8.50/26.45/50% SH6
5/10 HI GR-RX07
5/10 LO GR-RX07
8.50/26.45/50% SH6
5/10/20 HI GR-RX07
5/10/20 LO GR-RX07
7/14 HI GR-RX07
7/14 LO GR-RX07
8.50/26.70/50% SH6
7/20/50% HI GR-RX7
7/20/50% LO GR-RX7
10/25%/40% RX-GR06
2 of 640
Plan Benefit - AZ
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
6MH
6MI
6ML
6MR
6NH
6NL
6NM
6PH
6PL
6PP
6QH
6QL
6QP
6RH
6RL
6SH
6SL
6TH
6TL
6TP
6UH
6UL
6VM
6VP
6WH
6XM
6YM
6ZR
7AA
7AQ
7AR
7BD
7BH
7BI
7BL
7BR
7CD
7CI
7CM
7DD
7DH
7DL
7DM
7DR
7ED
7EH
7EL
7EM
7ER
7FD
Plan / Benefit Description
10/20 HI GR-RX07
10/20/40 I GR-RX06
10/20 LO GR-RX07
10/20/40 GR-RX06
10/20/40 HI GR-RX7
10/20/40 LO GR-RX7
5/15/30 GR-RX06
10/20 HI GR-RX07
10/20 LO GR-RX07
8.50/26.85/50% SH6
10/20/35 HI GR-RX7
10/20/35 LO GR-RX7
8.50/26.85/50% SH6
10/20/35 HI GR-RX7
10/20/35 LO GR-RX7
10/25/55 HI GR-RX7
10/25/55 LO GR-RX7
10/40/75 HI GR-RX7
10/40/75 LO GR-RX7
4.50/14.50/50% SH6
15/25/40 HI GR-RX7
15/25/40 LO GR-RX7
5/5 GR-RX06
25%/25%/25% SH6
10/25/50 HI GR-RX7
7/14 GR-RX06
7/14 GR-RX06
15/25/40 GR-RX06
SV 15-25/250A PIMA 05
7/20 GR-RX07
0/0 GR-RX07
7/14 GR-RX07
4/10/20 T1A H GRX7
7/14 I GR-RX07
4/10/20 T1A L GRX7
0/0 FLAT GR-RX07
7/14 GR-RX07
7/14 I GR-RX07
15/25/40 GR-RX07
7/20/30 GR-RX07
4/15/30 T1B H GRX7
4/15/30 T1B L GRX7
15/25/40 GR-RX07
10/10 FLAT GR-RX07
7/7 GR-RX07
4/20/40 T1C H GRX7
4/20/40 T1C L GRX7
3/3 FLAT GR-RX07
10/20 GR-RX07
7/7 C GR-RX07
3 of 640
Plan Benefit - AZ
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
7FH
7FL
7FM
7FR
7GD
7GM
7GR
7HH
7HI
7HL
7HR
7JH
7JL
7JM
7JR
7KH
7KI
7KL
7KM
7KR
7LH
7LL
7LM
7LR
7MA
7MH
7MI
7ML
7MR
7NH
7NL
7NM
7PH
7PI
7PL
7PM
7PR
7Q2
7Q3
7Q4
7QH
7QI
7QL
7QM
7QR
7RA
7RB
7RC
7RD
7RH
Plan / Benefit Description
4/25/50 T1D H GRX7
4/25/50 T1D L GRX7
3/3/3 GR-RX07
10/20 GR-RX07
10/20/30 GR-RX07
5/10 GR-RX07
10/20 GR-RX07
4/15/30 T2A H GRX7
10/20 I GR-RX07
4/15/30 T2A L GRX7
10/20 GR-RX07
4/28/58 T3C H GRX7
4/28/58 T3C L GRX7
5/10 GR-RX07
10/10 GR-RX07
4/28/55 T3B H GRX7
10/20/35 I GR-RX07
4/28/55 T3B L GRX7
5/10/20 GR-RX07
10/20/35 GR-RX07
4/25/45 T3A H GRX7
4/25/45 T3A L GRX7
5/15 GR-RX07
15/25/40 GR-RX07
10/25%/40% GR-RX07
4/20/40 T2B H GRX7
10/20/40 I GR-RX07
4/20/40 T2B L GRX7
10/20/40 GR-RX07
4/25/50 T2C H GRX7
4/25/50 T2C L GRX7
5/15/30 GR-RX07
4/25/50 T2C H GRX7
10/20/40 I GR-RX07
4/25/50 T2C L GRX7
5/15/30 GR-RX07
10/20/40 GR-RX07
5/29/56.25W/G SHX7
5/29/55.40W/G SHX7
5/29/56.20W/G SHX7
4/20/40 T2B H GRX7
10/20/40 I GR-RX07
4/20/40 T2B L GRX7
5/15/30 GR-RX07
10/20/40 GR-RX07
10/20/35 RDS GRX7
10/20 RDS GR-RX07
10/20/35 RDS GRX7
10/20 RDS GR-RX07
4/15/30 T2A H GRX7
4 of 640
Plan Benefit - AZ
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
7RL
7RM
7SB
7SI
7SR
7TH
7TL
7TM
7TR
7UH
7UL
7UM
7UR
7VH
7VL
7VM
7WH
7WI
7WL
7WM
7WR
7XA
7XB
7XC
7XD
7XE
7XF
7XG
7XH
7XJ
7XL
7XM
7XP
7XZ
7YH
7YI
7YL
7YM
7YR
7ZH
7ZL
7ZM
7ZR
82A
82B
82C
82D
82E
82F
82G
Plan / Benefit Description
4/15/30 T2A L GRX7
5/15/30 GR-RX07
10/25%/40% GR-RX07
10/20/40 I GR-RX07
10/20/40 GR-RX07
4/28/55 T3B H GRX7
4/28/55 T3B L GRX7
5/5 GR-RX07
10/25/40 GR-RX07
4/28/58 T3C H GRX7
4/28/58 T3C L GRX7
5/5 GR-RX07
15/25/40 GR-RX07
4/25/50 T1D H GRX7
4/25/50 T1D L GRX7
5/5 GR-RX07
4/20/40 T1C H GRX7
15/25/40 I GR-RX07
4/20/40 T1C L GRX7
5/7.50 GR-RX07
15/25/40 GR-RX07
4/10/20 RDS GR-RX7
4/15/30 RDS GR-RX7
4/20/40 RDS GR-RX7
4/25/50 RDS GR-RX7
4/10/20 RDS GR-RX7
4/15/30 RDS GR-RX7
4/20/40 RDS GR-RX7
4/15/30 T1B H GRX7
4/25/50 RDS GR-RX7
4/15/30 T1B L GRX7
7/14 GR-RX07
5/29/60 N/G SH-RX7
5/35/65 NGE SH-RX7
4/10/20 T1A H GRX7
15/25/40 I GR-RX07
4/10/20 T1A L GRX7
7/14 GR-RX07
15/25/40 GR-RX07
4/25/45 T3A H GRX7
4/25/45 T3A L GRX7
7/14 GR-RX07
15/25/40 GR-RX07
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5 of 640
Plan Benefit - AZ
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
82H
82J
82K
82L
82M
82N
82P
82Q
82R
82S
82T
82U
82V
82W
82X
82Y
82Z
83A
83B
83C
83D
83E
83F
83G
83H
83J
83K
83L
83M
8AA
8AB
8AC
8AH
8AR
8B8
8BH
8CH
8D8
8DD
8DH
8DR
8ED
8EH
8EM
8ER
8FD
8FH
8GH
8GM
8HD
Plan / Benefit Description
5-20/100A T1B AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
SV 20-40/500A 05
SP 20-40/500A 05
SV 20-40/80%A 05
0/0 HI C GR-RX07
0/0 C GR-RX07
5/29/60NG RX-SH08
DO NOT USE
2/30/60 HI C GRX07
6/40/80NG RX-SH08
7/20/30 C GR-RX07
2/40 HI C GR-RX07
10/10 FLAT C GRX07
7/7 C GR-RX07
5/25 HI C GR-RX07
3/3 FLAT C GR-RX07
10/20 C GR-RX07
7/7 C GR-RX07
5/65 HI C GR-RX07
5/10 HI C GR-RX07
5/10 C GR-RX07
10/20/30 C GR-RX07
6 of 640
Plan Benefit - AZ
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
8HH
8KM
8LH
8LM
8MA
8NM
8PH
8PM
8RH
8RM
8SH
8TH
8TM
8TR
8UM
8UR
8VM
8WH
91H
92H
93H
94H
95H
9AN
9AQ
9AR
9AX
9AY
9BE
9BH
9BK
9BL
9CM
9DH
9DK
9DL
9DR
9EH
9EL
9ER
9FD
9FH
9FL
9GE
9GM
9HD
9HH
9HK
9HL
9HN
Plan / Benefit Description
DO NOT USE
5/10/20 C GR-RX07
7/20/50% HI C GRX7
5/15 C GR-RX07
10/25%/40% C GRX07
5/15/30 C GR-RX07
10/20 HI C GR-RX07
5/15/30 C GR-RX07
10/20/35 HI C GRX7
5/15/30 C GR-RX07
10/25/55 HI C GRX7
10/40/75 HI C GRX7
5/5 C GR-RX07
10/25/40 C GR-RX07
5/5 C GR-RX07
15/25/40 C GR-RX07
5/7.50 C GR-RX07
10/25/50 HI C GRX7
15/25/40 HI GR-RX8
10/25/50 HI GR-RX8
10/20/40 HI GR-RX8
10/20 HI GR-RX08
10/40/75 HI C GRX8
4/20/40 LO GR-RX08
7/20 GR-RX08
0/0 GR-RX08
20/40 GR-RX08
4/25/50 HI GR-RX08
7/14 GR-RX08
4/10/20 T1A H GRX8
10/30/50 GR-RX08
4/10/20 T1A L GRX8
15/25/40 GR-RX08
4/15/30 T1B H GRX8
20/40 GR-RX08
4/15/30 T1B L GRX8
10/10 FLAT C GRX08
4/20/40 T1C H GRX8
4/20/40 T1C L GRX8
10/20 GR-RX08
7/7 C GR-RX08
4/25/50 T1D H GRX8
4/25/50 T1D L GRX8
10/20/30 GR-RX08
5/10 GR-RX08
10/20/30 C GR-RX08
4/15/30 T2A H GRX8
4/10/20 RX-GR08
4/15/30 T2A L GRX8
4/15/30 RX-GR08
7 of 640
Plan Benefit - AZ
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
9JH
9JL
9KH
9KL
9KS
9KY
9LH
9LL
9LM
9LP
9LR
9LV
9MA
9MH
9MI
9ML
9MR
9NH
9NL
9NM
9PH
9PL
9PX
9QH
9QL
9RH
9RL
9RP
9RX
9TH
9TL
9UH
9UL
9VH
9VL
9VM
9WH
9WI
9WL
9WM
9XH
9XL
9YH
9YL
9ZH
9ZL
A3Q
A3R
A3T
A3U
Plan / Benefit Description
4/28/58 T3C H GRX8
4/28/58 T3C L GRX8
4/28/55 T3B H GRX8
4/28/55 T3B L GRX8
10/20/35 GR-RX08
10/20/40 RX-GR08
4/25/45 T3A H GRX8
4/25/45 T3A L GRX8
5/15 C GR-RX08
5/15 GR-RX08
10/20/50 GR-RX08
10/20/35 RX-GR08
10/25%/40% GR-RX08
4/20/40 T2B H GRX8
10/20/40 I GR-RX08
4/20/40 T2B L GRX8
10/20/40 GR-RX08
4/25/50 T2C H GRX8
4/25/50 T2C L GRX8
5/15/30 GR-RX08
4/25/50 T2C H GRX8
4/25/50 T2C L GRX8
5/29/60 P RX-GR08
4/20/40 T2B H GRX8
4/20/40 T2B L GRX8
4/15/30 T2A H GRX8
4/15/30 T2A L GRX8
5/15/30 GR-RX08
NO RX
4/28/55 T3B H GRX8
4/28/55 T3B L GRX8
4/28/58 T3C H GRX8
4/28/58 T3C L GRX8
4/25/50 T1D H GRX8
4/25/50 T1D L GRX8
5/5 GR-RX08
4/20/40 T1C H GRX8
15/25/40 I GR-RX08
4/20/40 T1C L GRX8
5/7.50 GR-RX08
4/15/30 T1B H GRX8
4/15/30 T1B L GRX8
4/10/20 T1A H GRX8
4/10/20 T1A L GRX8
4/25/45 T3A H GRX8
4/25/45 T3A L GRX8
ENHNCD CODE NOT USED
ENHNCD CODE NOT USED
ENHNCD CODE NOT USED
ENHNCD CODE NOT USED
8 of 640
Plan Benefit - AZ
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
A3V
A3W
A3X
A3Y
A4C
A4D
A4E
A4F
A4G
A4K
A4M
A4N
A4P
A4Q
A4R
A4S
A4T
A4U
A4V
A4X
A5A
A5B
A5C
A5D
A5E
A5F
A5G
A5H
A5K
A5M
A5N
A5P
A5Q
A5R
A5S
A5U
A6G
A6S
A6W
A6X
ADK
ADT
APF
APN
ARK
ASK
ASR
AT7
ATQ
ATU
Plan / Benefit Description
ENHNCD MARCOPA GR07
ENH MARCOPA GOLD GR07
ENH MARCOPA SILVER GR07
ENH MARCOPA DELUXE GR07
ENH PIMA GOLD GR07
ENH PIMA SILVER GR07
ENH PIMA DELUXE GR07
ENHNCD PIMA GR07
ENH PIMA GOLD GR07
ENH PIMA SILVER GR07
ENH PIMA DELUXE GR07
ENHNCD CODE NOT USED
ENHNCD CODE NOT USED
ENHNCD CODE NOT USED
ENHNCD CODE NOT USED
ENHNCD PIMA GR07
ATW-STD GR-WL07
ENH PIMA GOLD GR07
ENH PIMA SILVER GR07
ENH PIMA DELUXE GR07
ENHNCD PINAL GR07
ENH PINAL EP GR07
ENH PINAL PP GR07
ENH PINAL DELUXE GR07
ENHNCD PINAL GR07
ENH PINAL EP GR07
ENH PINAL PP GR07
ENH PINAL DELUXE GR07
ENHNCD CODE NOT USED
ENHNCD CODE NOT USED
ENHNCD CODE NOT USED
ENHNCD CODE NOT USED
ENHNCD PINAL GR07
ENH PINAL EP GR07
ENH PINAL PP GR07
ENH PINAL DELUXE GR07
ARP MCC 1 PIMA GLD SH08
ARP MCC 1 PIMA SLVR SH08
ARP MCC 1 PIMA SH08
ARP MCC 1 PIMA DLX SH08
10-20/500A ADOA GR07
10-20 ADOA NON-AARP GR08
10/12V 1YR ACU SH07
10/12V 1YR ACU SH08
ENHNCD PINAL GR07
15-30 ASRS NON-AARP GR08
15-30/100A ASRS GR07
ATW-STD SH-WL07
ATW ENHANCED SH08
ATW-PLUS WL-SH08
9 of 640
Plan Benefit - AZ
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
ATV
BDA
BDL
BOQ
BPT
BVH
BVZ
BWG
C11
C27
C7A
C7E
C7F
C7G
C7H
C7J
C7K
C7L
C7M
C7P
C7S
C7U
C7W
C7Y
CAA
CAB
CAC
CAD
CAE
CFP
CFV
CG2
CGG
CGI
CGL
CGR
CGS
CGU
CGV
CGX
CHU
CHW
COT
CPA
CRR
CT6
CTU
CZA
CZB
CZC
Plan / Benefit Description
ATW-STD WL-SH08
0/250A BOEING IAM725 GR 06
0 BO IAM 725 NO-AARP GR08
15 BO 148 NO-AARP GR08
20/100% BP AMOCO GR06
15 BO-VEBA NON-AARP GR08
15/100A BOEING VEBA GR07
20 BP AMOCO NON-AARP GR08
CONTACT BEHAVIORAL HEALTH
SC 90 ELIGIBILITY ONLY
5/12V 1YR GR-CH07
10/12V 1YR GR-CH07
10/20V 1YR GR-CH07
10/30V 1YR GR-CH07
15/12V 1YR GR-CH07
15/20V 1YR GR-CH07
0/20V 1YR GR-CH07
15/30V 1YR GR-CH07
20/12V 1YR GR-CH07
5/10V 1YR GR-CH07
30/12V 1YR GR-CH07
5/20V 1YR GR-CH07
5/30V 1YR GR-CH07
5/40 1YR GR-CH07
5/12V TRIO SH-CH05
5/12V GR-CH05
15/12V GR-CH05
20/12V GR-CH05
10/12V GR-CH05
10 CFI-VEBA NON-AARP GR08
10/100% CFI VEBA GR07
CAREGIVER ENHANCED SH05
CAREGIVER - GOLD SH05
CAREGIVER SH05
CAREGIVER LITE SH06
CAREGIVER - RESPITE SH05
CAREGIVER GR05
CAREGIVER-RESPITE CG-SH08
CAREGIVER CG-GR08
CAREGIVER ENHANCED
10/12V 1YR SH-CH07
10/12V 1YR CH-SH08
10-20/350A C TUCSON GR07
RESERVED PFFS
10/12V GR-CH07
30/12V GR-CH06
10-20 TUCSON NON-AARP GR08
10/12V GR-CH05
15/12V BO-148 GR-CH05
10/12V BO-HRLY GR-CH05
10 of 640
Plan Benefit - AZ
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
CZD
CZE
D4R
D4U
D4V
D4W
D4X
D6V
D8A
D8E
D8G
D8H
D8W
D8Y
DA6
DAA
DAB
DB6
DBA
DJ6
DMA
DMB
DN2
DN3
DNE
DNY
DP6
DQ6
DRR
EAE
EC4
ERO
F4T
FSL
FTL
H4J
H4L
H4U
H4X
H6P
H8B
H8D
H8J
H8K
HAA
HAB
HAC
HAD
HAG
HAK
Plan / Benefit Description
15/12V BO-HRLY-F GR-CH05
10/12V BO-837 GR-CH05
$0 466 GR-DN07
$20 469 GR-DN07
SILVER GR-DN07
GOLD GR-DN07
DELUXE OPTION GR-DN07
DENTAL - VISION GR06
DELUXE OPTION DN-SH08
$20 469 DN-SH08
GOLD DN-SH08
SILVER DN-SH08
$0 466 DN-SH08
EC P&C 200 1YR DN-SH08
SILVER SH-DN06
15 SILVER SH-DN05
25 GOLD SH-DN05
GOLD SH-DN06
100%/70% DISCOUNT GR-DN07
$0 466 SH-DN06
20% SH-DM05
0 SH-DM05
SO 460 GRP BILLED - GR
SO 462 INDIV BILLED - GR
EVERCARE $5 SH-DN07
DELUXE OPTION SH-DN07
$5 PREVENTIVE SH-DN06
$20 469 SH-DN06
10-20/200A DERP GR07
EVERCARE DH SH08
EVERCARE DH SH07
EVERCARE DH-D SH08
THIS CODE CANCELLED
SILVER SNEAKER SH/GR-WL07
SILVER SNEAKER SH/GR-WL08
0/500A 3YRS GR-HA07
0/400A 3YRS GR-HA07
0/1300A 3YRS DX GR-HA07
0/1200A 3YRS DX GR-HA07
15-25/100A GR06
0/1300A 3YRS DX HA-SH08
0/800A 3YRS DX HA-SH08
5/400A 3YRS HA-SH08
0/600A 2YRS DX HA-SH08
0/400A 3YR SH-HA05
0/300A 2YR GR-HA05
0/500A 2YR GR-HA05
0/500A 3YR GR-HA05
0/400A 3YR SH-HA05 NP
0/0A 3YR GR-HA05
11 of 640
Plan Benefit - AZ
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
HAM
HAN
HBJ
HD6
HDE
HF6
HHE
HJC
HL8
HOA
HOE
HOI
HPE
HRB
HRD
HRE
HRR
HRY
HTC
HWC
LAD
LAL
LCE
LCN
LCP
LCU
LCW
LCX
LCY
LDD
LDE
LDN
LDP
LEE
LEN
LEP
LGD
LGE
LGN
LGP
LJ8
LND
LNE
LNN
LNP
LOK
LOL
LRI
MBG
MBS
Plan / Benefit Description
1000A PER YR GR-HA05
300A/24M GR-HA07
HEARING AID $500 EVERY 3YR
5/400A 3 YRS SH-HA06
300A 2YRS HA-GR08
25/400A 3 YRS SH-HA06
500A 3YRS HA-GR08
0/0A 3YR HA-GR08
400A 3YRS 0PREM HA-GR08
RESERVED HEARING PFFS
RESERVED HEARING PFFS
RESERVED HEARING PFFS
RESERVED PFFS
0/500A 3YRS SH-HA07
0/800A 3YRS DX SH-HA07
5/400A 3YRS SH-HA07
300A GR-HA07
0/1300A 3YRS DX SH-HA07
500A 2YRS HA-GR08
1000A PER YR HA-GR08
20-30/250A LOKHEED GR06
15/100% LACERS GR07
10/30 PINAL C SH06 EPO
10/30 PINAL C SH06
10/30 PINAL C SH06 ODP
ARP MCC 1 PINAL PP SH08
ARP MCC 1 PINAL SH08
ARP MCC 1 PINAL DLX SH08
ARP MCC 1 PINAL EP SH08
MCC 1 PINAL DELUXE SH07
MCC 1 PINAL EP SH07
MC COMP 1 PINAL SH07
MCC 1 PINAL PP SH07
5/10 PINAL CE SH06 EPO
5/10 PINAL CE SH06
5/10 PINAL CE SH06 ODP
MCC 2 PINAL DELUXE SH07
MCC 2 PINAL EP SH07
MC COMP 2 PINAL SH07
MCC 2 PINAL PP SH07
15 LACERS NON-AARP GR08
MCC ESS PINAL DELUXE SH07
MCC ESS PINAL EP SH07
MC COMP ESS PINAL SH07
MCC ESS PINAL PP SH07
20-30/250A LOKHEED GR07
20-30 LOKHEED NON-AARP GR8
LIABILITY/RECOVERY INFO
ARP MCC 1 MCOPA GLD SH08
ARP MCC 1 MCOPA SLVR SH08
12 of 640
Plan Benefit - AZ
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
MBW
MBX
MCE
MCG
MCN
MCS
MEE
MEG
MEN
MES
MGN
MJD
MJG
MJN
MJS
MLD
MLG
MLN
MLS
MQD
MQG
MQN
MQS
MRD
MRG
MRN
MRS
MTK
MTM
MVG
MVS
MVW
MVX
MXG
MXS
MXW
MXX
NL8
NTB
NTL
O1Q
O1R
O1W
O2A
O2K
O2M
O2Q
O2R
O2S
O2T
Plan / Benefit Description
ARP MCC 1 MCOPA SH08
ARP MCC 1 MCOPA DLX SH08
10/30 MARICOPA C SH06 EPO
10/30 MARICOPA C SH06 GOLD
10/30 MARICOPA C SH06
10/30 MARICOPA C SH06 SLVR
5/10 MARICOPA CE SH06 EPO
5/10 MARICOPA CE SH06 GOLD
5/10 MARICOPA CE SH06
5/10 MARICOPA CE SH06 SLVR
0/0 SECURE GOLD SH06
MCC 3 MARCOPA DELUXE SH07
MCC 3 MARCOPA GOLD SH07
MC COMP 3 MARCOPA SH07
MCC 3 MARCOPA SILVER SH07
MCC ESS MARCOPA DELUX SH07
MCC ESS MARCOPA GOLD SH07
MC COMP ESS MARCOPA SH07
MCC ESS MARCOPA SLVER SH07
MCC 1 MARCOPA DELUXE SH07
MCC 1 MARCOPA GOLD SH07
MC COMP 1 MARCOPA SH07
MCC 1 MARCOPA SILVER SH07
MCC 2 MARCOPA DELUXE SH07
MCC 2 MARCOPA GOLD SH07
MC COMP 2 MARCOPA SH07
MCC 2 MARCOPA SILVER SH07
10/5V 1YR MSG THRPY SH07
10/5V 1YR MSG THRPY SH08
ARP MCC 3 MCOPA GLD SH08
ARP MCC 3 MCOPA SLVR SH08
ARP MCC 3 MCOPA SH08
ARP MCC 3 MCOPA DLX SH08
ARP MCC ES MCOPA GLD SH08
ARP MCC ES MCOPA SLVR SH08
ARP MCC ES MCOPA SH08
ARP MCC ES MCOPA DLX SH08
24HR NURSLINE WL-SH/GR08
0/24-1W NON-ER TRANS SH07
0/24-1W NON-ER TRANS SH08
10-20/750A T2A GR07
15-25/200D T3A GR07
10-15/50A T1A GR07
0/100% BOEING-GR05
10/100% BOEING HRLY-GR05
15/100% BOEING HRLY-F-GR05
10-20/750A T2A GR07
15-25/200D T3A GR07
15/200A BOEING 148-GR05
10-20/100% ASRS-GR05
13 of 640
Plan Benefit - AZ
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
O2W
O33
O3D
O3Q
O3R
O3W
O4Q
O4R
O4W
O5Q
O5R
O5W
O6Q
O6R
O6W
O7Q
O7R
O7W
O8K
O8Q
O8R
O8W
O9Q
O9R
O9W
OBC
OBL
OC1
OC3
OC5
OD3
ODE
ODF
ODG
ODK
OE1
OE3
OEB
OEC
OEE
OF1
OF3
OF5
OG1
OG3
OG5
OH1
OH3
OH5
OJ8
Plan / Benefit Description
10-15/50A T1A GR07
10/100% NAT'L-GR06
10/100% NAT'L-GR06
10-20/750A T2A GR07
15-25/200D T3A GR07
10-15/50A T1A GR07
15-25/130D T2B GR07
15-30/220D T3B GR07
5-20/100A T1B GR07
15-25/130D T2B GR07
15-30/220D T3B GR07
5-20/100A T1B GR07
15-25/130D T2B GR07
15-30/220D T3B GR07
5-20/100A T1B GR07
10-25/150D T2C GR07
20-35/250D T3C GR07
10-20/200A T1C GR07
10 BO HRLY NO-AARP GR08
10-25/150D T2C GR07
20-35/250D T3C GR07
10-20/200A T1C GR07
10-25/150D T2C GR07
20-35/250D T3C GR07
10-20/200A T1C GR07
10/100% NON-AARP GR08
10 SDCERA NON-AARP GR08
5/100% NAT'L GR 06
5/100% NAT'L GR 06
5/100% NAT'L GR 06
10/100% NAT'L GR 06
5/100% AARP GR08
10/100% AARP GR08
15/250A AARP GR08
20/100% NON-AARP GR08
10-20/250A NAT'L GR 06
10-20/250A NAT'L GR 06
15 BO HRLY-F NO-AARP GR08
15 BO SCPEA NO-AARP GR08
10-20/250A NAT'L-GR06
10-20/500A NAT'L GR 06
10-20/500A NAT'L GR 06
10-20/500A NAT'L GR 06
15/250A NAT'L GR 06
15/250A NAT'L GR 06
15/250A NAT'L GR 06
15-25/500A NAT'L GR 06
15-25/500A NAT'L GR 06
15-25/500A NAT'L GR 06
10-20/250A NON-AARP GR08
14 of 640
Plan Benefit - AZ
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
OLV
OP3
OP4
OP5
OR1
OR3
OR5
ORX
OTZ
OVW
OY8
OYY
PAA
PAB
PAD
PAE
PAF
PAG
PAH
PAK
PCE
PCG
PCN
PCS
PDE
PDS
PEE
PEG
PEN
PES
PIE
PIF
PIG
PIH
PII
PIK
PIL
PIN
PIO
PLP
PTD
PTG
PTM
PTS
PXY
PYD
PYG
PYI
PYN
PYS
Plan / Benefit Description
5/100% NON-AARP GR08
20-40/250A NAT'L GR 06
20-40/250A NAT'L GR 06
20-40/250A NAT'L GR 06
20/100% NAT'L GR 06
20/100% NAT'L GR 06
20/100% NAT'L GR 06
OTHR RX-NOT PS GR06
20-40/250A AARP GR08
10/100% NON-AARP GR08
10-20/250A NON-AARP GR08
15/250A NON-AARP GR08
PPO - PFFS
PPO - PFFS
PPO - PFFS
PPO - PFFS
RESERVED PFFS
RESERVED PFFS
RESERVED PFFS
RESERVED PFFS
10/30 PIMA C SH06 EPO
10/30 PIMA C SH06 GOLD
10/30 PIMA C SH06
10/30 PIMA C SH06 SLVR
O/3V 1YR POD SH07
O/3V 1YR POD SH07
5/10 PIMA CE SH06 EPO
5/10 PIMA CE SH06 GOLD
5/10 PIMA CE SH06
5/10 PIMA CE SH06 SLVR
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
PAYMENT LAG PREMIUM ALLOC
MCC 2 PIMA DELUXE SH07
MCC 2 PIMA GOLD SH07
MC COMP 2 PIMA SH07
MCC 2 PIMA SILVER SH07
$30/Q PHB CREDIT SH08
MCC 1 PIMA DELUXE SH07
MCC 1 PIMA GOLD SH07
RESERVED PFFS
MC COMP 1 PIMA SH07
MCC 1 PIMA SILVER SH07
15 of 640
Plan Benefit - AZ
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
RE1
RPE
RPX
S25
S2A
S2B
S2C
S2D
S2E
S2F
S2G
S2H
S2J
S2K
S2M
S2N
S2P
S2R
S2S
S2T
S34
S3B
S3C
S3D
S3E
S3F
S3G
S3H
S3P
S3R
S3W
S8B
SA2
SA3
SAA
SBA
SGA
SNA
SP2
SP3
SPA
SSP
SSR
TA6
TAA
TAX
TPH
TPJ
TPL
TPT
Plan / Benefit Description
OP REHAB SH-05
RESPITE/PERS CARE SH07
RESPITE/PERS CARE WL-SH08
10-20/250A NON-AARP GR08
0/100% BOEING-GR05
10/100% ADOA-GR05
5/100% NAT'L-GR05
10/100% NAT'L-GR05
10-20/250A NAT'L-GR05
10-20/500A NAT'L-GR05
15/250A NAT'L-GR05
15-25/500A NAT'L-GR05
15-20/100A TOWERS PER-GR05
10/100% BOEING HRLY-GR05
15/100% BOEING HRLY-F-GR05
0/100% BOEING IAM-GR05
20-40/250A NAT'L-GR05
20/100% NAT'L-GR05
15/200A BOEING 148-GR05
10-20/100% ASRS-GR05
10-20/250A AARP GR08
10/100% ADOA-GR06
5/100% NAT'L-GR06
10/100% NAT'L-GR06
10-20/250A NAT'L-GR06
10-20/500A NAT'L-GR06
15/250A NAT'L-GR06
15-25/500A NAT'L-GR06
20-40/250A NAT'L-GR06
20/100% NAT'L-GR06
15-25/500A AARP GR08
10/100% ADOA NON-AARP GR08
10-30/300A MAR-W/DS-SH05
10-30/300A MAR-W/DG-SH05
10-30/300A MAR-AJ-SH05
20-30 PART B-SH05
2-5/50A SECURE GOLD-SH05
10-30/300A PINAL-SH05
10-30/300A PIMAW/DS-SH05
10-30/300A PIMAW/DG-SH05
10-30/300A PIMA-SH05
SILVER SNEAKERS SH05
SLV SNEAK/FITNESS BEN GR06
0/24T NON-ER TRANS SH-06
NON-EMERGENCY TRANS SH05
PCAZ PREMIUM TAX
5-10/100% GR06
15-20/100A AARP GR08
15-20/100A GR06
15-20/100A NON-AARP GR08
16 of 640
Plan Benefit - AZ
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
TRD
TRW
V27
V2A
V2B
V2C
V2D
V2E
V2F
V2G
V2L
V8P
V8Q
V8R
V8S
V8T
V8U
V8V
V8W
V8X
VA4
VA6
VA7
VAA
VAB
VAC
VAD
VAZ
VB6
VC8
VDA
VDF
VDK
VFP
VFQ
VG6
VG8
VGP
VGQ
VJQ
VK8
VKP
VMQ
VN2
VNQ
VP6
VPE
VPP
VQC
VQD
Plan / Benefit Description
20-30/250A TRW NO-AARP GR8
20-30/250A TRW GR06
SC 20 ELIGIBILITY ONLY
0/75A BOHRLY GR-VN05 ESA
0/250A BO 837 GR-VN05 ESA
0/0 BO 148 GR-VN05 ESA
0/250A GR-VN05 ESA
10/50A ADOA GR-VN05 ESA
0/70A TOWERS GR-VN05 ESA
0/25%D GR-VN05
0/75A BOHRLY-F GR-VN05 ESA
0 REFRAC 1/V YR VN-GR08
5 REFRAC 1/V YR VN-GR08
10 REFRAC 1/V YR VN-GR08
15 REFRAC 1/V YR VN-GR08
20 REFRAC 1/V YR VN-GR08
25 REFRAC 1/V YR VN-GR08
30 REFRAC 1/V YR VN-GR08
35 REFRAC 1/V YR VN-GR08
40 REFRAC 1/V YR VN-GR08
30/70A 2YRS GR-VN07
5/100A 2 YRS SH-VN06
20/130A 1 YR GR-VN07
0/150A SH-VN05 ESA
5/100A SH-VN05 ESA
0/125A GR-VN05 ESA
0/75A GR-VN05 ESA
20/130A 1YR ASRS GR-VN07
25/150A 2 YRS SH-VN06
20/50A ADOA VN-GR08
15/70A GR-VN07
15/125A 2YRS GR-VN07
20/50A ADOA GR-VN07 ESA
0/75A 2YRS VN-GR08
0/125A 2YRS VN-GR08
25/75A VN-GR06
10/50A ADOA VN-GR08
5/75A 2YRS VN-GR08
5/125A 2YRS VN-GR08
10/75A 2YRS VN-GR08
20/130A 1YR ASRS VN-GR08
10/125A 2YRS VN-GR08
15/125A 2YRS VN-GR08
10/75A 2YRS GR-VN07
20/75A 2YRS VN-GR08
ADVANCE WELLNESS SH-WL06
RESERVED PFFS
20/125A 2YRS VN-GR08
15/130A 1YR DLX VN-SH08
30/70A 2YRS VN-SH08
17 of 640
Plan Benefit - AZ
State
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
Plan / Benefit
VQJ
VQM
VQP
VRR
VSK
VSQ
VSX
VU4
VVP
VVQ
VWP
VWQ
VXX
VZB
VZH
WAA
WB6
WPR
WPS
WPT
WQR
WQS
WQT
WRR
WRS
WRT
XAA
Z2P
Z2T
Z5R
Z8P
Plan / Benefit Description
5/100A 2YRS VN-SH08
0/100A 2YRS VN-SH08
25/70A 2YRS VN-GR08
10/75A GR-VN07
5/100A 2YRS SH-VN07
30/70A 2YRS SH-VN07
15/130A 1YR DLX SH-VN07
15/130A 1YR DLX GR-VN07
15/75A 2YRS VN-GR08
25/75A 2YRS VN-GR08
25/125A 2YRS VN-GR08
25/70 2YRS VN-GR08
INFO ONLY
0/250A VN GR08
0/0 BO 148 VN-GR08
EDUC-NUTRITION SH05
HLTH EDUC SH-WL06
10-15/50A T1A GR07
5-20/100A T1B GR07
10-20/200A T1C GR07
10-20/750A T2A GR07
15-25/130D T2B GR07
10-25/150D T2C GR07
15-25/200D T3A GR07
15-30/220D T3B GR07
20-35/250D T3C GR07
NO RX GR05
10-15/50A T1A NON-AARP GR8
15-25/200D T3A NO-AARP GR8
15-25/130D T2B N0-AARP GR8
10-20/200A T1C NO-AARP GR8
18 of 640
Plan Benefit - CA
Cap/Eligibility CP7810
Assigned Plan Benefit Codes & Descriptions
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
001
002
003
004
005
006
007
009
010
012
013
018
022
026
027
028
030
031
035
036
037
038
040
041
042
043
044
045
046
053
064
071
073
0AD
0C1
0C2
0D3
0D4
0D5
0D6
0D7
0DM
Plan / Benefit Description
HPA - PLAN A
HPA - PLAN B
HPA - PLAN C
HPA - PLAN D
HPA - PLAN E
HPA - PLAN F
HPA - PLAN G
HPA - PLAN I
HPA - PLAN I2 EFF 1.1.92
HPA - PLAN L
HPA - PLAN M
HPA - A1
HPA-VISION ONLY
HPA - PLAN Z
HPA - PLAN Z1
HPA - PLAN Z2
HPA - PLAN L1
HPA - PLAN LB
$3G/$5B
HPA - PLAN A2/11.1.91-MH
HPA - PLAN A3/11.1.91 NOMH
HPA - PLAN C1
HPA-PLAN B (PM DUAL OPT.)
HPA - PLAN LJ
HPA-PLAN D (PM DUAL OPT.)
HPA - PLAN SD (SAME AS L)
HPA - PLAN BB
HPA - PLAN BK
HPA - PLAN L
$5G/30%B
$4G/$6B
HPA-PHARMACY ONLY
HPA-PHARMACY ONLY
HPA ADMINISTRATION FEE
HPA COMM RATED UNDER 50
HPA-COMM RATED 50+ CONTRAT
HPA-DENTAL PLAN III
HPA-DENTAL PLAN IV
HPA-DENTAL BLUE SHIELD
HPA-PACIFIC UN DENT /D794F
HPA-SIERRA DENTAL/D794F
HPA-DURABLE MEDICAL EQUIP
19 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
0EM
0F1
0F3
0F4
0F6
0F7
0FP
0HO
0LA
0LL
0P0
0P1
0P2
0P3
0P4
0P5
0P6
0P7
0P8
0P9
0PC
0PE
0PR
0R1
0RX
0S1
0V1
0V2
103
123
150
15Z
1AA
1AB
1AD
1AE
1AL
1BA
1BR
1C1
1C2
1C3
1C4
1C5
1C6
1CC
1CL
1CN
1CR
1CS
Plan / Benefit Description
HPA-EXTENDED MENTAL HEALTH
HPA-FP STANDARD/WITH RX
HPA-FP STANDARD/NO RX
HPA-FP-NO COPAY/NO RX
HPA-FP-RELIGIOUS WAVIER
HPA-FP-DUAL OPTION/RX ONLY
HPA-FAMILY PLANNING
HPA-HOSPICE
HPA-LIFE & ADM/D-794F
HPA-LIFELINK COVERAGE
HPA-$0
HPA-$1
HPA-$2
HPA-$3
HPA-$4
HPA-$5
HPA-$5G/$10B
HPA-$5G/30%B
HPA-$3G/$5B
HPA-$4G/$6B
HPA-PCS (OLD PHARMACY)
HPA-EXCOBAR PHARMACY (OLD)
HPA-PROSTHETICS($2000)
HPA-DRUG REHABILITATION
O/P PRESCRIP DRUG $0 COPAY
HPA-SUB ABUSE DETOX & REHA
HPA-MEDICAL EYE SERVICE
HPA-MEDICAL EY SERVICE C1
PPO RESERVED FOR PPO RX
DUMMY
1500 PLAN
1500 PLAN (COBRA)
7/7 RX 06
10/10 RX 06
ALAMEDA I STANDARD PLAN
ALAMEDA I STANDARD PLAN
SH ALAMEDA BASIC W/ NO DEN
SANTA BARBARA STANDARD PLN
SANTA BARBARA STANDARD PLN
$5
$5
$5
$5
$5G/$5B CUSTOM RX
$2 COAST CMNTY
SH C COSTA BASIC W/ NO DEN
SANTA CLARA STANDARD PLAN
CONTRA COSTA STANDARD PLAN
CONTRA COSTA I STD PLAN
CONTRA COSTA I STD PLAN
20 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
1DE
1DG
1DN
1DO
1DS
1DV
1EG
1EO
1EV
1FC
1FE
1FN
1FP
1FR
1FS
1GE
1GG
1GL
1GM
1GO
1JH
1KA
1KE
1KK
1KN
1LA
1LC
1LD
1LE
1LG
1LN
1LO
1LU
1MA
1MC
1MD
1ME
1MG
1MO
1MR
1MT
1NA
1ND
1NE
1NM
1NR
1NV
1OC
1OE
1OG
Plan / Benefit Description
RIVERSIDE STANDARD PLAN
SAN DIEGO I STANDARD PLAN
SAN BERNARDINO STD PLAN
SAN BERNARDINO STD PLAN
RIVERSIDE STANDARD PLAN
SAN DIEGO VALUE STD PLAN
SAN DIEGO I STANDARD PLAN
SAN MATEO STANDARD PLAN
VENTURA STANDARD PLAN
SAN FRANCISCO CLASSIC I
S FRANCSCO CLSC I W/EPODDS
FRESNO STANDARD PLAN
S FRANCSCO CLSC I W/ODPDDS
FRESNO STANDARD PLAN
FRESNO STANDARD PLAN
ORANGE I STANDARD PLAN
10/20 RX06
LOS ANGELES I STD PLAN
5/5 RX 06
SAN DIEGO I STANDARD PLAN
10/10 RX 06
KERN STANDARD PLAN
KERN STANDARD PLAN
KERN STANDARD PLAN
SH KERN BASIC W/ NO DENTAL
SH LA BASIC W/ NO DENTAL
7 LACERA RX05
LOS ANGELES CLASSIC I
LOS ANGELES I STD PLAN
LOS ANGELES I STD PLAN
LOS ANGELES I STD PLAN
SAN LUIS OBISPO STANDARD
SAN LUIS OBISPO STANDARD
MADERA STANDARD PLAN
MMC TPA SV $10 PLAN
MADERA STANDARD PLAN
ALAMEDA I STANDARD PLAN
$5G/$5B
SAN MATEO STANDARD PLAN
MADERA STANDARD PLAN
SACRAMENTO I STANDARD PLAN
SAN FRANCISCO STANDARD PLN
SAN BERNARDINO STD PLAN
NEVADA STANDARD PLAN
SONOMA STANDARD PLAN
SAN BERNARDINO STD PLAN
NEVADA STANDARD PLAN
SH ORANGE BASIC W/ NO DENT
ORANGE I STANDARD PLAN
ORANGE STANDARD PLAN
21 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
1PA
1PB
1PL
1PO
1PR
1RA
1RB
1RC
1RD
1RE
1RF
1RG
1RI
1RN
1RR
1RS
1RV
1S1
1SA
1SB
1SC
1SD
1SE
1SF
1SH
1SJ
1SK
1SL
1SM
1SN
1SP
1SS
1SU
1SZ
1TA
1TC
1TO
1TU
1U5
1U7
1UA
1UD
1US
1UZ
1VE
1VR
1VT
1YC
1ZU
200
Plan / Benefit Description
PLACER I STANDARD PLAN
$5 FLAT PBGH
PLACER STANDARD PLAN
SAN LUIS OBISPO STANDARD
PLACER I STANDARD PLAN
$5G/5B
$5G/5B 50I
$5G/5B HI
$5G/5B
$5G/5B 50I
$5G/5B HI
ORANGE STANDARD PLAN
RIVERSIDE STANDARD PLAN
KERN STANDARD PLAN
SANTA BARBARA STANDARD PLN
SH RIVERSIDE BAS W/ NO DEN
RIVERSIDE STANDARD PLAN
$5
SH SACRAM BASIC W/ NO DENT
SANTA BARBARA STANDARD
SH S CLARA BAS W/ NO DENTA
SH S DIEGO BAS W/ NO DENTA
SH S BERNARD BAS W/ NO DEN
SH S FRAN BASIC W/ NO DENT
SACRAMENTO STANDARD PLAN
SAN BERNARDINO STANDARD
SANTA CLARA STANDARD PLAN
SAN LUIS OBISPO STANDARD
SAN MATEO STANDARD PLAN
STANISLAUS STANDARD PLAN
SAN DIEGO STANDARD I PLAN
STANISLAUS STANDARD PLAN
SANTA CRUZ STANDARD PLAN
NOT USED
SANTA CLARA STANDARD PLAN
5/5 RX 06
SACRAMENTO I STANDARD PLAN
VENTURA STANDARD PLAN
$5
RX CODE RESRVD INACTIVATED
$10
$10
STANISLAUS STANDARD PLAN
SANTA CRUZ STANDARD PLAN
VENTURA STANDARD PLAN
VENTURA STANDARD PLAN
SH VENTURA BAS W/ NO DENTA
YOLO STANDARD PLAN
SANTA CRUZ STANDARD PLAN
MANDATED OFFER RIDERS
22 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
201
202
203
204
205
206
207
208
209
20C
20S
210
211
212
213
214
215
216
217
218
219
21C
21S
220
221
222
223
224
225
226
227
228
229
22C
22D
22R
22S
230
23C
24C
25F
26S
2A2
2A3
2A7
2AA
2AC
2AD
2AF
2AL
Plan / Benefit Description
ICUPUNCTURE PPO
SPECIALIZED FOOTWEAR PPO
INFERTILITY PPO
ORTHOTIC PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDERS PPO
MANDATED OFFER RIDERS PPO
MANDATED OFFER RIDERS PPO
MANDATED OFFER RIDERS PPO
$5G/$10B HERSHEY
$10G/$35B
MANDATED OFFER RIDERS PPO
MANDATED OFFER RIDERS PPO
MANDATED OFFER RIDERS PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
$5G/$5B + DIFF
$20/$35 $100 DED
MANDATED OFFER RIDERS PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
$5G/$10B
$5G/$10B MGM
10/20 RX06
$10G/$35B 100I
MANDATED OFFER RIDER PPO
$15G/$30B/$50NF
$5/$15/$35 PBGH
5/5 RX06
15/30 RX 05
ALAMEDA II STANDARD PLAN
10/35 ARADIANT
5/10 RX05
5/5 GGUSD RX05
$10G/$20B FEDS
$2G/$2B
$15G/$35B/$50NF
2/2 CCC RX05
23 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
2AM
2AN
2AP
2AR
2AS
2AT
2AW
2AY
2B2
2B3
2BA
2BB
2BC
2BE
2BF
2BJ
2BL
2BR
2C0
2C1
2C2
2C3
2C4
2C5
2C6
2C7
2C8
2C9
2CA
2CB
2CC
2CD
2CE
2CF
2CG
2CH
2CI
2CJ
2CK
2CL
2CM
2CN
2CO
2CP
2CQ
2CR
2CS
2CT
2CU
2CV
Plan / Benefit Description
SH ALAMEDA STANDARD PLAN
4/20/40 LO GR-RX07
$10G/$30B
$20G/35B D-I
OK TO USE
$5G/$15B AT&T
$10G/$20B
4/25/50 HI GR-RX07
$5G/$5B
$5G/$15B
10/20 RX 06
5/5 RX06
$7G/$7B
SH BUTTE STANDARD MED PLAN
7/7 RX07
$5G/$10B
10/25/50 RX-GR08
$20G/35B DHI
$10G/$20B CSTM RX
$10G/$20B
$5G/$10B
$10G/$15B
$10G/$15B
$5G/$15B
$10G/$15B
$10G/$20B
$4G/$7B
$7G/$9B
$5G/$10B
$5G/$10B
$5G/$10B
$5G/$10B
$3G/$5B
$10G/$20B
$5 CALPERS 2000
$7.50G/$15B
$10G/$20B
$5G/$15B+DIFF FEDS RX 2001
$5G/$10B
$5G/$5B
$3G/$5B MO X'S 2
$5G/$10B CUSTOM RX
$10G/$15B CUSTOM RX
$5G/$15B-$10G/$30B M/O
$10G/$15B-$20G/$30B M/O
$7G/$7B
$5G/$15B
SH CONTRA COSTA STANDARD
$10G/$20B
$5G/$5B
24 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
2CW
2CX
2CY
2CZ
2D2
2DA
2DB
2DC
2DE
2DF
2DL
2DR
2E2
2EA
2EC
2ED
2EP
2ER
2EW
2FC
2FH
2FI
2FL
2FN
2FR
2G1
2G2
2G3
2GA
2GC
2GF
2GG
2GH
2GL
2GM
2GN
2GR
2GX
2HA
2HC
2HD
2HE
2HH
2HM
2HR
2IM
2JD
2JH
2KB
2KH
Plan / Benefit Description
$7G/$15B
$5G/$15B
$10G/$15B
$5G/$20B
ALAMEDA II STANDARD PLAN
7/15 RX 06
5/5 RX 06
$10G/$20B
5/10 RX 06
$10/$30 SDUF
$5G/$10B
$10G/10B 50I
LOS ANGELES II STD PLAN
10/25 RX06
5/15 RX06
SH EL DORADO STANDARD PLAN
L. ANGLES CLSCII W/EPO DDS
$10G/10B 100I
10/20 RX 06
10/20 SKYWEST
4/15/30 RX-GR08
10/30 FARMERS INS
5/20/45 RX-GR08
SH FRESNO STANDARD PLAN
$20G/30B 50I
RESERVED INACTIVATED
RESERVED INACTIVATED
RESERVED INACTIVATED
10/20 RX06
$10G/$20B
5/10 RX 07
5/5 RX06
4/20/40 RX-GR08
7/20 RX 06
$5G/$10B
5/10 RX 06
$20G/30B 100I
7/20 GM
5/10 RX 08
15/30 SARES-REGIS
L. ANGELES CLSC II W/HIDDS
$15G/$30B
4/15/30 RX-GR08
10/20 RX06
$10G/20B 50I
SH IMPERIAL STANDARD PLAN
5/5 RX06
4/20/40 RX-GR08
10/10 RX 07
4/25/50 RX-GR08
25 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
2KR
2KU
2L2
2L6
2L7
2LA
2LC
2LD
2LG
2LH
2LO
2LR
2LS
2LT
2LU
2M2
2MA
2MB
2MC
2MD
2MF
2MH
2MN
2MW
2N2
2NA
2NB
2NH
2ON
2OR
2P2
2PA
2PB
2PG
2PH
2PL
2PR
2PW
2PX
2PY
2PZ
2QA
2QB
2QD
2QH
2R1
2R2
2RA
2RB
2RC
Plan / Benefit Description
SH KERN STANDARD MED PLAN
10/20 RX06
LOS ANGELES STD. II PLAN
5/5 RX06
5/10 RX06
5/10 CNTY LA
10/30 LA MACHINI
L. ANGLES CLSC II W/OP DDS
LOS ANGELES CLASSIC II
2/2 RX07
RESERVED
$15G/30B 50I
SH LOS ANGELES STANDARD
7/9 RX05
3/3 RX06
SACRAMENTO II STD PLAN
SH MADERA STANDARD PLAN
10/20 RX 08
MMC TPA SV $15 PLAN
10/25 RX06
5/5 RX07
4/25/45 RX-GR08
SH MARIN STANDARD MED PLAN
15/35 RX06
ORANGE II STANDARD PLAN
SH NAPA STANDARD MED PLAN
15/35 RX 07
4/28/55 RX-GR08
OUT-OF-NETWORK SB1221
SH ORANGE STANDARD PLAN
PLACER II STANDARD PLAN
5/10 RX 08
PBGH $20 GRP RET PLAN
10/30 RX07
4/28/58 RX-GR08
SH PLACER STANDARD MED
5/10 SP-RX05
10/30 APW
10/35 SP-RX05
10/10 RX05
10/20 RX05
15/30 RX 08
10/35 RX 08
10/25 RX 07
4/25/50 RX-GR08
$10G/$35B
CONTRA COSTA II STD PLAN
$5G/10B
$5G/$10B 50I
$5G/10B HI
26 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
2RD
2RE
2RF
2RG
2RH
2RI
2RJ
2RK
2RL
2RM
2RN
2RO
2RP
2RQ
2RR
2RS
2RT
2RU
2RV
2RW
2RX
2RY
2RZ
2S0
2S1
2S2
2S3
2S4
2S5
2S6
2S7
2S8
2S9
2SA
2SB
2SC
2SD
2SE
2SF
2SG
2SH
2SI
2SJ
2SL
2SM
2SN
2SO
2SQ
2SR
2SS
Plan / Benefit Description
$5G/15B
$5G/15B 50I
$5G/15B HI
$10G/15B
$10G/15B 50I
$10G/15B HI
$10G/20B
$10G/20B 50I
$10G/20B HI
$10G/25B
$10G/25B 50I
$10G/25B HI
$10G/35B
$10G/35B 50I
SH RIVERSIDE STANDARD PLAN
$10G/35B HI
$15G/25B
$15G/25B 50I
$15G/25B HI
$15G/35B
$15G/35B 50I
$15G/35B HI
$20G/35B D
$7G/$9B
$10G/$15B
$10G/$30B
$10G/$15B
$10G/$15B
$10G/$25B
$5G/$10B
$4(FLAT)
$10G/$30B PPO MID/LARGE
$10G/$25B
$20G/$35B
SH SAN BERNARDINO STANDARD
$10G/$30B
$10G/$25B
$20G/$35B
$10G/$30B
SH SAN DIEGO STANDARD PLAN
$10G/$10B
RESERVED
$10G/$10B
SH SAN LUIS OBISPO STD MED
SH SACRAMENTO STANDARD MED
SH SAN FRANCISCO STD MED
RESERVED
SH SAN JOAQUIN STANADARD
SH SANTA BARBARA STD MED
SH STANISLAUS STANDARD MED
27 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
2ST
2SV
2SW
2SX
2SY
2SZ
2T2
2TA
2TC
2TE
2TH
2U1
2U2
2U3
2U4
2U5
2U6
2UA
2UB
2UC
2UD
2UE
2UF
2UG
2UH
2UK
2VB
2VH
2VN
2WD
2WH
2WP
2XA
2XH
2YH
2ZA
2ZB
2ZC
2ZD
2ZE
2ZF
2ZG
30C
30N
313
31S
32C
32S
33C
33R
Plan / Benefit Description
SH SAN MATEO STANDARD MED
5/10 RX06
SH SONOMA STANDARD MED
SH SANTA CLARA STANDARD
SH SOLANO STANDARD MEDICAL
SH SANTA CRUZ STANDARD MED
CONTRA COSTA II STD PLAN
5/20 RX 08
5/5/25 RX07
SH TULARE STANDARD MEDICAL
20/35 100D RX 06
$5G/$10B
$5G/$15B
$5G/$20B
RX CODE RESRVD INACTIVATED
$10G/$20B
$10G/$25B
$5G/$10B
$5G/$15B
RX CODE RESERVED INACTIVAT
RX CODE RERRVD INACTIVATED
$10G/$20B
RX CODE RESRVD INACTIVATED
20/40 RX06
10/25/50 RX-GR08
10/20 RX06
0/5 RX 07
10/25/50 RX-GR08
SH VENTURA STD-I LOW PLAN
L. ANGELES CLSC I W/OP DDS
5/20/45 RX-GR08
5/5 RX06
7/7 RX07
5/20/45 RX-GR08
4/10/20 RX-GR08
0/0 GR-RX07
2/40 GR-RX07
5/25 GR-RX07
5/65 GR-RX07
5/10 GR-RX07
10/20 GR-RX07
10/20 RX06
10/20/35 HCA LP
OUT-OF-NETWORK SB1221 IND
RESERVED FOR PREMIER PASS
$10G/$25B/$50NF
$10G/$20B/$30NF
10G/25B/35NF 150I
$10/15/25 BURNHAM
5/10/20 SSCA RX05
28 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
33S
33T
34S
35S
36C
39C
3A3
3A6
3AA
3AC
3AL
3AM
3AP
3AR
3AS
3AU
3AV
3B2
3B3
3B4
3B6
3BA
3BB
3BC
3BD
3BE
3BF
3BH
3BL
3BN
3BO
3BP
3BR
3BS
3BT
3BU
3BV
3C0
3C1
3C2
3C3
3C4
3C5
3C6
3C7
3C8
3C9
3CA
3CB
3CC
Plan / Benefit Description
10G/25B/50NF 0I
5/10/20 RX06
15G/35B/50NF 150I
15/35/50 RX05
5/15/30 RX06
5/15/30 RX06
LOS ANGELES VALUE STD PLAN
20/30/50 RX06
10/20/35 RX06
10/20/35 RX06
ALAM PT B BASIC W/ NO DENT
SH ALAMEDA BASIC MED PLAN
10/20/25 AMYLIN
$10G/25B/50NF
10/20/35 C SCHWAB
5/20/35 RX 06
10/20/50 AVON
$5G/$15B/$30NF
5/15/30 SNBRD RX05
5G/15B/30NF GRP RT
5/15/25 RX06
20/35/50 RX 07
5/10/15 RX 07
$10G/$20B/$35NF
10/20/30 ABCW RX05
SH BUTTE BASIC MED PLAN
10/20/40 RX07
$15G/$30B
$5G/$15B/$30NF
$5G/$15B/$30NF
$5G/$15B/$30NF
$5G/$15B/$35NF
$10G/25B/50NF 50I
$20G/$35B/$50NF
$10G/$20B/$35NF
10/20/45 RX 05
$10G/$20B/$35NF
$10/$25/$50 ADMINSTAFF
$5/$10/$25
$8/$8/$20
$10G/$15B/$25NF
$10G/$15B/$25NF
$5G/$10B/$20NF
$7G/$15B/$35NF
$7G/$15B/$35NF
$7G/$15B/$35NF
$10G/$20B/$40NF
$5/$10/$25 500 SERIES
$5G/$15B/$30NF
C COSTA PT B BAS W/ NO DEN
29 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
3CD
3CE
3CF
3CG
3CH
3CI
3CJ
3CK
3CL
3CM
3CN
3CO
3CQ
3CR
3CS
3CT
3CU
3CV
3CW
3CX
3CY
3D3
3DA
3DB
3DC
3DD
3DF
3DI
3DQ
3DR
3DU
3DZ
3E4
3E5
3E6
3E7
3E9
3EA
3EC
3ED
3EG
3EL
3ER
3ES
3ET
3EU
3FB
3FC
3FD
3FH
Plan / Benefit Description
$5G/$5B/$20NF
$10G/$15B/$30NF CUSTOM RX
$10G/$15B/$25NF
$10G/$20B/$35NF
$5G/$15B/$30NF
$10G/$20B/$25NF
$10G/$10B/$20NF
$10G/$25B/$50NF
10/20/25 AM RED CS
10/20/35 GR-RX05
$5G/$10B/$15NF
$10G/$20B/$35NF
5/15/25 CRC RX05
$10G/25B/50NF HI
$5G/$20B/$35NF
SH CONTRA COSTA BASIC MED
$5G/$5B/$20NF
$5G/$10B/$20NF
$15G/$30B/$50NF
10G/20B/40NF PEPSI
10G/20B/35NF VEBA
SAN DIEGO III STD PLAN
10/25/35 RX 05
15/35/50 RX 05
10/20/40 DUDEK
5/20/40 RX 08
5/10/20 RX 07
SAN DIEGO III STD PLAN
5/15/35 RX 08
$15G/25B/40NF
5/20/50 RX 06
5/10/25 RX 06
10/25/35 RX06
10/25/35 RX06
10/25/35 RX06
10/25/35 RX06
10/25/35 RX06
3 VISIT EAP /INCIDENT
10/20/35 GOODRICH
SH EL DORADO BASIC MEDICAL
SAN DIEGO CLASSIC III
$10G/$20B/$35NF
$15G/25B/40NF 50I
10/15/25 SEMPRA
5/15/30 L3ET RX05
5/15/30 RX06
10/20/40 RX 07
10/30/50 RX05
15/30/60 RX06
10/20/25 CFHC RX05
30 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
3FL
3FN
3FR
3FS
3G1
3G2
3G3
3G4
3G5
3GA
3GB
3GC
3GD
3GE
3GS
3GU
3GV
3HA
3HB
3HC
3HD
3HE
3HP
3HS
3HU
3IC
3IM
3JA
3JG
3JP
3JU
3KA
3KC
3KG
3KN
3KR
3KV
3L0
3L1
3L2
3L3
3L4
3L5
3L6
3L7
3L8
3L9
3LA
3LB
3LC
Plan / Benefit Description
15/30/45 RX 06
SH FRESNO BASIC MED PLAN
$15G/25B/40NF HI
10/30/40 5STR RX05
INACTIVATED
RESERVED INACTIVATED
RESERVED INACTIVATED
$5G/$10B/$25NF
$10G/$20B/$35NF
$15G/$25B/$40NF
15G/25B/40NF W/INJ
$10G/$20B/$35NF
15/25/40 GOODRICH
10/25/35 RX06
7/20/30 GM SAL
5/15/30 RX06
15/35/50 RX06
5/30/45 RX 06
5/10/15 RX 07
$5G/$25B/$40NF HP
L.ANGLES CLSC I W/HIOP DDS
5/10/25 RX 07
5/30/45 GRRX07
5/10/25 RX 07
$10G/$20B/$35NF 06
10/25/35 FOLEY
SH IMPERIAL BASIC MED PLAN
10/20/35 RX 07
5/5/20 RX06
10G/25B/40NF JPM
$5G/$10B/$35NF 06
5/15/25 RX 07
10/20/25 SCC RX05
5/10/25 RX 07
SH KERN PT B BAS W/ NO DEN
SH KERN BASIC MEDICAL PLAN
5/20/40 RX 08
E $15G/30B/50NF D
10/20/45E
10G/20B/45NF 50I E
10G/20B/45N 100I E
10/30/50E
10G/30B/50NF 50I E
10G/30B/50N 100I E
15/25/50E
15G/25B/50NF 50I E
15G/25B/50N 100I E
SH LA PT B BASIC W/ NO DEN
15/30/50 D 50I E
15/30/50 D 100I E
31 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
3LD
3LE
3LF
3LL
3LO
3LS
3LU
3LV
3M2
3M3
3M4
3M5
3M6
3M7
3M8
3M9
3MA
3MB
3MC
3ME
3MG
3MI
3ML
3MN
3MP
3MS
3N3
3NA
3NC
3ND
3OC
3OE
3OK
3ON
3OR
3P2
3PA
3PC
3PF
3PG
3PH
3PL
3PP
3PQ
3PR
3PS
3PT
3PV
3PW
3PX
Plan / Benefit Description
5/10/20 RX06
5/15/30 RX06
10/20/35 RX06
10/20/50 GR-RX07
RESERVED
SH LOS ANGELES BASIC MED
5/10/35 RX 06
LOS ANGELES VALUE STD PLAN
$5G/15B/30NF 50I
$20G/30B/50NF 50I
$15G/30B/45NF 50I
$20G/30B/50NF 100I
$5G/15B/30NF 100I
$15G/30B/45NF 100I
$20G/35B/50NF D-I
$20G/35B/50NF DHI
SH MADERA BASIC MED PLAN
10/20/45 RX07
MMC TPA SV $35 PLAN
15/30/55 RX07
5/10/25 RX 07
10/20/35 MARRIOTT
10/20/35 MER LYN
SH MARIN BASIC MED PLAN
5/10/20 MPAN RX05
20/35/50 MSSY RX05
SAN DIEGO STD. III PLAN
SH NAPA BASIC MED PLAN
10/20/35 RX06
10/20/25 SND RX05
ORANGE PT B BASIC W/ NO DE
10/20/35 OPER ENG
5/15/25/25 GR-RX07
INDIVIDUAL POS OON-SB1221
SH ORANGE BASIC MED PLAN
10/20/25 PERKOWITZ
$10G/$25B/$50NF E
$10G/$30B/$40NF E
10/25/40 RX06
10/25/45 RX 06
10/30/50 RX06
SH PLACER BASIC MED PLAN
5/15/40 RX05
10/20/35 RX 06
10/20/35 PEARSON INC
$5G/$15B/$30NF GRP RET
RESERVED 3TIER RX06
5/15/45 RX05
10/20/30 RX05
10/30/50 1SDS RX05
32 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
3PY
3PZ
3QB
3QD
3QE
3R1
3R5
3R6
3RA
3RB
3RC
3RD
3RE
3RF
3RG
3RH
3RI
3RJ
3RK
3RL
3RM
3RN
3RO
3RP
3RQ
3RR
3RS
3RT
3RU
3RV
3RW
3RX
3RY
3RZ
3S1
3S2
3S3
3S4
3S5
3S6
3S7
3S8
3S9
3SA
3SB
3SC
3SD
3SE
3SF
3SG
Plan / Benefit Description
10/20/25 SP-RX05
10/25/35 SP-RX05
5/15/25 RX 07
10/25/35 QUIDEL
10/20/40 RX07
$10G/$25B/$35NF
10/20/30 RIVERSIDE
10/30/50 RX06
$5G/10B/20NF
$5G/10B/20NF 50I
$5G/10B/20NF HI
$5G/10B/25NF
$5G/10B/25NF 50I
$5G/10B/25NF HI
$5G/15B/25NF
$5G/15B/25NF 50I
$5G/15B/25NF HI
$10G/20B/25NF
$10G/20B/25NF 50I
$10G/20B/25NF HI
$10G/20B/30NF
$10G/20B/30NF 50I
$10G/20B/30NF HI
$10G/20B/40NF
$10G/20B/40NF 50I
SH RIVERSIDE BASIC MED PLN
SH RIVER PT B BAS W/ NO DE
$10G/20B/40NF HI
$10G/25B/35NF
$10G/25B/35NF 50I
$10G/25B/35NF HI
$10G/25B/40NF
$10G/25B/40NF 50I
$10G/25B/40NF HI
$5/$5/$20
$10/$10/$20
$5/$15/$25
$5/$10/$20
$10/$10/$20
$10G/$20B/$25NF
EL $10G/20B/25NF
PR $10G/25B/35NF
$15G/$35B/$50NF
SACRAM PT B BAS W/ NO DENT
SH SAN BERNARDINO BASIC
S CLARA PT B BAS W/ NO DEN
S DIEGO PT B BAS W/ NO DEN
S BERNARD PT B BAS W/ NO D
S FRAN PT B BAS W/ NO DENT
SH SAN DIEGO BASIC MED
33 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
3SH
3SI
3SJ
3SK
3SL
3SM
3SN
3SO
3SQ
3SR
3SS
3ST
3SW
3SX
3SY
3SZ
3T6
3TA
3TE
3TG
3TM
3TT
3TU
3U1
3U2
3U3
3U4
3U6
3U7
3U8
3U9
3UA
3UB
3UC
3UD
3UE
3UF
3UG
3UH
3UI
3UJ
3UK
3UL
3UN
3UP
3UV
3V3
3V4
3V5
3V6
Plan / Benefit Description
10/20/35 RX06
RESERVED
10/20/35 RX06
10/20/35 RX 06
SH SAN LUIS OBISPO BASIC
SH SACRAMENTO BASIC MED
SH SAN FRANCISCO BASIC MED
RESERVED
SH SAN JOAQUIN BASIC MED
SH SAN BARBARA BASIC MED
SH STANISLAUS BASIC MED
SH SAN MATEO BASIC MED
SH SONOMA BASIC MED PLAN
SH SANTA CLARA BASIC MED
SH SOLANO BASIC MED PLAN
SH SANTA CRUZ BASIC MED
10/20/35 RX06
10/30/50 RX-06
SH TULARE BASIC MED PLAN
10/20/35 RX 06
$5G/$10B/$35NF
5/10/35 RX 05
$10G/$25B/$35NF 06
$5/$10/$20
$10/$10/$25
RX CODE RESERVED INACTIV
RX CODE RESRVD INACTIVATED
RX CODE RESRVED INACTIVATE
RX CODE RESRVD INACTIVATED
RX CODE RESRVD INACTIVATED
RX CODE RESRVD INACTIVATED
$5/$10/$20
RX CODE RESRVD INACTIVATED
10/20/35 UC RX05
RX CODE RESRVD INACTIVATED
RX CODE RESRVD INACTIVATED
RX CODE RESRVD INACTIVATED
$5/$15/$30
RX CODE RESRVD INACTIVATED
$10/$20/$35
$10G/$15B/$25NF
$5/$15/$30 PUB SEC
$5/$15/$45 PUB SEC
10/20/35 RX 06
10/20/30 RX 06
RESERVED 3TIER RX
LOS ANGELES VALUE STD PLAN
15/35/50 RX06
15/35/50 RX06
15/35/50 RX06
34 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
3V7
3V9
3VA
3VB
3VC
3VF
3VN
3VT
3WA
3WD
3WE
3WG
3WH
3XH
3XK
3YB
3YF
3ZA
3ZB
3ZC
3ZD
3ZE
3ZF
3ZG
3ZH
3ZJ
3ZK
3ZL
3ZM
3ZR
3ZT
40A
40B
40C
40D
40E
40F
40G
40H
40I
40J
40K
40L
40M
40N
40O
40P
40Q
40R
40S
Plan / Benefit Description
15/35/50 RX06
15/35/50 RX06
CODE IS FOR OR RX BENEFIT
10/20/35 RX 08
5/10/20 RX 07
10/20/35 RX 08
SH VENTURA BASIC MED PLAN
VENT PT B BASIC W/ NO DENT
10/20/35 RX 05
S DIEGO CLSC III W/OP DDS
S DIEGO CLSC III W/EPO DDS
5/10/25 RX 07
S DIEGO CLSC III W/HI DDS
5/10/25 RX 07
10/25/35 RX06
10/30/45 RX 07
5/15/30 RX 08
5/15/30 SCEET RX05
5/10/35 SCEET RX05
5/10/25 RX05
10/20/25 RX05
5/10/20 GR-RX07
10/20/35 GR-RX07
10/20/35 GR-RX07
10/25/55 GR-RX07
10/40/75 GR-RX07
7/20/50% GR-RX07
2/30/60 GR-RX07
10/25/50 GR-RX07
20/35/50 RX06
10/25/50 RX06
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
35 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
40T
40U
40V
40W
40X
40Y
40Z
41A
41B
41C
41D
41E
41F
41G
41H
41I
41J
41K
41L
41M
41N
41O
41P
41Q
41R
41S
41T
41U
41V
41W
41X
41Y
41Z
42I
43A
43I
43J
43K
440
44A
44I
44N
44P
45I
45J
45K
46I
46J
46K
47I
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
MCC 1 S DIEGO GR08
RESERVED RX PPO
MCC 1 S BERDO GR08
MCC 1 S BERDO DLX GR08
RESERVED RX PPO
MCC S FRAN GR08
RESERVED RX PPO
MCC 1 FRSNO GR08
MCC 1 MADRA GR08
RESERVED RX PPO
MCC S JOAQUIN GR08
MCC S JOAQUIN DLX GR08
RESERVED RX PPO
MCC KERN GR08
MCC KERN DLX GR08
RESERVED RX PPO
36 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
47J
47K
48I
48R
48S
49I
49R
49S
4A0
4A1
4A2
4A3
4AA
4AD
4AE
4AI
4AM
4AO
4B0
4B1
4BE
4BH
4BI
4BL
4BO
4BW
4C0
4C1
4C2
4C3
4C4
4CF
4CI
4CL
4CO
4CT
4D0
4D1
4D2
4D3
4DE
4DG
4DI
4DN
4DO
4DS
4DV
4E0
4E1
4E2
Plan / Benefit Description
MCC 1 RVSIDE GR08
MCC 1 RVSIDE DLX GR08
RESERVED RX PPO
MCC 1 LA GR08
MCC 1 LA DLX GR08
RESERVED RX PPO
MCC 1 OR GR08
MCC 1 OR DLX GR08
RESERVED RX PPO
RESERVED RX PPO
ALAMEDA II PLUS PLAN
LOS ANGLES VALUE PLUS PLAN
MEDCO CARVE OUT A RX05
ALAMEDA I PLUS PLAN
ALAMEDA I PLUS PLAN
RESERVED RX PPO
RESERVED
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED
ARP MCC 1 ALMDA HI SH08
RESERVED RX PPO
ARP MCC 1 ALMDA LO SH08
RESERVED RX PPO
ARP MCC 1 ALMDA SH08
RESERVED RX PPO
RESERVED RX PPO
$7G/$15B/$35NF
$5G/$10B/$25NF DCHS
$5G/$10B/$25NF CHW
$5G/$10B
RESERVED RX PPO
SANTA CLARA PLUS PLAN
RESERVED RX PPO
RESERVED
RESERVED RX PPO
RESERVED RX PPO
ALAMEDA II PLUS PLAN
SAN DIEGO III PLUS PLAN
RIVERSIDE PLUS PLAN
SAN DIEGO I PLUS PLAN
SAN DIEGO III PLUS PLAN
SAN BERNARDINO PLUS PLAN
SAN BERNARDINO PLUS PLAN
RIVERSIDE PLUS PLAN
SAN DIEGO VALUE PLUS PLAN
RESERVED RX PPO
RESERVED RX PPO
LOS ANGELES II PLUS PLAN
37 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
4ED
4EG
4EI
4EO
4EP
4F0
4F1
4FI
4FN
4FO
4G0
4G1
4GE
4GI
4GL
4GO
4H0
4H1
4HD
4HI
4HO
4I0
4I1
4IA
4IB
4IC
4ID
4IE
4IF
4IG
4IH
4II
4IJ
4IK
4IL
4IM
4IN
4IO
4IP
4IQ
4IR
4IS
4IT
4IU
4IV
4IW
4IX
4IY
4IZ
4J0
Plan / Benefit Description
RESERVED
SAN DIEGO I PLUS PLAN
RESERVED RX PPO
RESERVED RX PPO
L.ANGLES CLSC I W/EPO DDS
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
ORANGE I PLUS PLAN
RESERVED RX PPO
LOS ANGELES I PLUS PLAN
SAN DIEGO I PLUS PLAN
RESERVED RX PPO
RESERVED RX PPO
S MATEO CLSC I W/HI DDS
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
38 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
4J1
4JI
4JO
4K0
4K1
4KI
4KN
4KO
4KR
4L0
4L1
4L2
4LE
4LG
4LI
4LN
4LO
4LV
4M0
4M1
4M2
4MA
4MC
4ME
4MI
4MN
4MO
4MT
4N0
4N1
4N2
4N3
4NA
4ND
4NI
4NO
4NR
4O0
4O1
4OA
4OB
4OC
4OD
4OE
4OF
4OG
4OH
4OI
4OJ
4OK
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
SH KERN STD - PART B ONLY
RESERVED RX PPO
RESERVED
RESERVED RX PPO
RESERVED RX PPO
LOS ANGELES II PLUS PLAN
LOS ANGELES I PLUS PLAN
LOS ANGELES I PLUS PLAN
RESERVED RX PPO
LOS ANGELES I PLUS PLAN
RESERVED
LOS ANGLES VALUE PLUS PLAN
RESERVED RX PPO
RESERVED RX PPO
SACRAMENTO II PLUS PLAN
RESERVED
MMC TPA SV $35 PLAN HIPPA
ALAMEDA I PLUS PLAN
RESERVED RX PPO
RESERVED
RESERVED RX PPO
SACRAMENTO I PLUS PLAN
RESERVED RX PPO
RESERVED RX PPO
ORANGE II PLUS PLAN
SAN DIEGO III PLUS PLAN
RESERVED
SAN BERNARDINO PLUS PLAN
RESERVED RX PPO
RESERVED RX PPO
SAN BERNARDINO PLUS PLAN
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
ORANGE I PLUS PLAN
RESERVED RX PPO
ORANGE PLUS PLAN
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
39 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
4OL
4OM
4ON
4OO
4OP
4OQ
4OR
4OS
4OT
4OU
4OV
4OW
4OX
4OY
4OZ
4P0
4P1
4PI
4PL
4PO
4Q0
4Q1
4QI
4QO
4R0
4R1
4RG
4RI
4RO
4RR
4RV
4S0
4S1
4SA
4SB
4SC
4SD
4SE
4SG
4SH
4SI
4SJ
4SK
4SL
4SM
4SN
4SO
4SP
4SQ
4SR
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
NATIONAL POS OON SB1221
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
ORANGE PLUS PLAN
RIVERSIDE PLUS PLAN
RESERVED RX PPO
RESERVED
RIVERSIDE PLUS PLAN
RESERVED RX PPO
RESERVED RX PPO
KEENAN COMP S CLARA GR07
RESERVED
SAN MATEO CLASSIC I
S MATEO CLSC I W/OP DDS
S MATEO CLSC I W/EPO DDS
SH SAN DIEGO STD-II ($0)
SACRAMENTO PLUS PLAN
RESERVED
SAN BERNARDINO PLUS PLAN
SANTA CLARA PLUS PLAN
RESERVED
RESERVED
RESERVED
RESERVED
SAN DIEGO I PLUS PLAN
RESERVED
RESERVED
40 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
4SS
4ST
4SX
4SY
4SZ
4T0
4T1
4TA
4TE
4TI
4TO
4U0
4U1
4UI
4UO
4V0
4V1
4V3
4VI
4VN
4VO
4W0
4W1
4WI
4WO
4X0
4X1
4X5
4XI
4XO
4XP
4XQ
4XR
4Y0
4Y1
4YI
4YO
4Z0
4Z1
4ZI
4ZO
50A
50B
50C
50D
50E
50F
50G
50H
50I
Plan / Benefit Description
RESERVED
SH SAN MATEO STD/ENDORSED
RESERVED
RESERVED
RESERVED
RESERVED RX PPO
RESERVED RX PPO
SANTA CLARA PLUS PLAN
RESERVED
RESERVED RX PPO
SACRAMENTO I PLUS PLAN
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
LOS ANGLES VALUE PLUS PLAN
RESERVED RX PPO
RESERVED
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
KEC S CLARA CG GR07
RESERVED RX PPO
RESERVED RX PPO
5/29/60 N/G GR-RX7
5/29/60 W/G GR-RX7
5/29/60 N/G 3 GRX7
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
41 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
50J
50K
50L
50M
50N
50O
50P
50Q
50R
50S
50T
50U
50V
50W
50X
50Y
50Z
51A
51B
51C
51D
51E
51F
51G
51H
51I
51J
51K
51L
51M
51N
51O
51P
51Q
51R
51S
51T
51U
51V
51W
51X
51Y
51Z
52I
535
536
537
538
539
53I
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
42 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
540
541
542
543
544
545
546
547
548
549
54I
550
551
552
553
554
555
556
557
558
559
55I
560
561
562
563
564
565
566
567
568
569
56I
570
571
572
573
574
575
576
577
578
579
57I
580
581
582
583
584
585
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
43 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
586
587
588
589
58I
590
591
592
593
594
59I
5A0
5A1
5A2
5A3
5AC
5AD
5AE
5AI
5AL
5AM
5AO
5B0
5B1
5B2
5BB
5BE
5BI
5BO
5C0
5C1
5CC
5CD
5CI
5CL
5CN
5CO
5CR
5CS
5CT
5D0
5D1
5D2
5D3
5DD
5DE
5DG
5DI
5DN
5DO
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
ALAMEDA II STD W/OPT DDS
L.A. VALUE STD W/OPT DDS
PPO ACUPUNTURE TRMNT RIDER
ALAMEDA I STD W/OPT DDS
ALAMEDA I STD W/OPT DDS
RESERVED BENEFIT PPO
SH ALAMEDA PLUS W/ NO DENT
RESERVED
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
SH PART B STD W/NO PREMIUM
SH PART B STANDARD W/$50
SH PART B - SD, IMP. & VNT
RESERVED
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
CONTRA COSTA PLS W/ NO DEN
KEENAN COMP S CRUZ GR07
RESERVED BENEFIT PPO
SANTA CLARA STD W/OPT DDS
CONTRA COSTA STD W/OP DDS
RESERVED BENEFIT PPO
CNTRA COSTA I STD W/OP DDS
CNTRA COSTA I STD W/OP.DDS
RESERVED
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
ALAMEDA II STD W/OPT DDS
S.DIEGO III STD W/OP DDS
SAN MATEO MEDICAL W/OP DDS
RIVERSIDE STD W/OPT DDS
SAN DIEGO I STD W/OP DDS
S.DIEGO III STD W/OP DDS
S.BERNARDINO STD W/OP DDS
S.BERNARDINO STD W/OP DDS
44 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
5DP
5DS
5DV
5E0
5E1
5E2
5ED
5EG
5EI
5EO
5EP
5EV
5F0
5F1
5FI
5FN
5FO
5FP
5FT
5G0
5G1
5GE
5GI
5GL
5GO
5H0
5H1
5HA
5HD
5HI
5HO
5I0
5I1
5IA
5IB
5IC
5ID
5IE
5IF
5IG
5IH
5II
5IJ
5IK
5IL
5IM
5IN
5IO
5IP
5IQ
Plan / Benefit Description
PPO DOMESTIC PARTNER RIDER
RIVERSIDE STD W/OPT DDS
S.DIEGO VALUE STD W/OP DDS
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
LOS ANGLES II STD W/OP DDS
RESERVED
SAN DIEGO I STD W/OP DDS
RESERVED BENEFIT PPO
SAN MATEO STD W/OPT DDS
SAN MATEO MEDICL W/EPO DDS
VENTURA STANDARD W/OPT DDS
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED
RESERVED BENEFIT PPO
PPO FAMILY PLANNING RIDER
PPO FOOTWEAR RIDER
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
ORANGE I STD W/OPT DDS
RESERVED BENEFIT PPO
LOS ANGELES I STD W/OP DDS
SAN DIEGO I STD W/OP DDS
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
PPO HEARING AID RIDER
SAN MATEO MEDICL W/HI DDS
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
45 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
5IR
5IS
5IT
5IU
5IV
5IW
5IX
5IY
5IZ
5J0
5J1
5JI
5JO
5K0
5K1
5KA
5KE
5KI
5KK
5KN
5KO
5KR
5L0
5L1
5L2
5LA
5LE
5LG
5LI
5LN
5LO
5LV
5M0
5M1
5M2
5MA
5MB
5MC
5ME
5MI
5MM
5MN
5MO
5MT
5N0
5N1
5N2
5N3
5NA
5ND
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
PPO INFERTILITY RIDER
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
KERN STANDARD W/OPT DDS
KERN STANDARD W/OPT DDS
RESERVED BENEFIT PPO
KERN STANDARD W/OPT DDS
SH KERN PLUS W/ NO DENTAL
RESERVED BENEFIT PPO
RESERVED
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
LOS ANGLES II STD W/OP.DDS
SH LA PLUS MED W/ NO DENTA
LOS ANGELES I STD W/OP.DDS
LOS ANGELES I STD W/OP DDS
RESERVED BENEFIT PPO
LOS ANGELES I STD W/OP DDS
RESERVED
L.A. VALUE STD W/OPT DDS
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
SACRAMENTO II STD W/OP DDS
RESERVED
KEENAN COMP S MATEO GR07
MMC TPA SV $10 PLAN HIPPA
ALAMEDA I STD W/OPT DDS
RESERVED BENEFIT PPO
SAN MATEO STD. W/OPT. DDS
RESERVED
SAN MATEO STD W/OPT DDS
SACRAMENTO I STD W/OP DDS
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
ORANGE II STD W/OPT DDS
S. DIEGO III STD. W/OP.DDS
RESERVED
S.BERNARDINO STD W/OP DDS
46 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
5NI
5NO
5NR
5O0
5O1
5O2
5O3
5O4
5O5
5O6
5O7
5O8
5O9
5OA
5OB
5OC
5OD
5OE
5OF
5OG
5OH
5OI
5OJ
5OK
5OL
5OM
5ON
5OO
5OP
5OQ
5OR
5OS
5OT
5OU
5OV
5OW
5OX
5OY
5OZ
5P0
5P1
5PI
5PL
5PO
5Q0
5Q1
5QI
5QO
5R0
5R2
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
S.BERNARDINO STD W/OP DDS
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
SH ORANGE PLUS W/ NO DENTA
RESERVED BENEFIT PPO
ORANGE I STD W/OPT DDS
RESERVED BENEFIT PPO
ORANGE STANDARD W/OPT. DDS
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
PPO ORTHO/PROSTHETIC RIDER
RESERVED BENEFIT PPO
RESERVED
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
CNTRA CSTA II STD W/OP DDS
47 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
5RG
5RI
5RN
5RO
5RR
5RS
5RV
5S0
5S5
5SA
5SB
5SC
5SD
5SE
5SF
5SG
5SH
5SI
5SJ
5SK
5SL
5SM
5SN
5SO
5SP
5SQ
5SR
5SS
5ST
5SX
5SY
5SZ
5T0
5T1
5T2
5TA
5TE
5TI
5TM
5TO
5TU
5U0
5U1
5UI
5UO
5V0
5V1
5V3
5VE
5VI
Plan / Benefit Description
ORANGE STD W/OPT DDS
RIVERSIDE STD W/OPT DDS
KERN STANDARD W/OPT DDS
RESERVED BENEFIT PPO
RESERVED
SH RIVERSIDE PLS W/ NO DEN
RIVERSIDE STD. W/OPT. DDS
RESERVED BENEFIT PPO
SACRAMENTO STD. W/OPT. DDS
SH SACRAM PLUS W/ NO DENTA
RESERVED
SH S CLARA PLUS W/ NO DENT
SH S DIEGO PLUS W/ NO DENT
SH S BERNARD PLS W/ NO DEN
SH S FRAN PLUS W/ NO DENTA
SAN DIEGO-II STD. W/HI DNT
PPO SPEECH & HEARING RIDER
RESERVED
S. BERNARDINO STD W/OP.DDS
SANTA CLARA STD W/OPT. DDS
RESERVED
RESERVED
RESERVED
RESERVED
SAN DIEGO I STD. W/OPT DDS
RESERVED
RESERVED
RESERVED
RESERVED
RESERVED
RESERVED
RESERVED
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
CNTRA CSTA II STD W/OP.DDS
SANTA CLARA STD W/OPT DDS
RESERVED
RESERVED BENEFIT PPO
SAN MATEO MEDICAL
SACRAMENTO I STD W/OP DDS
VENTURA STANDARD W/OPT DDS
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
L.A. VALUE STD W/OPT DDS
VENTURA STANDARD W/OPT DDS
RESERVED BENEFIT PPO
48 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
5VN
5VO
5VR
5VT
5W0
5W1
5WI
5WO
5X0
5X1
5XI
5XO
5Y0
5Y1
5YI
5YO
5Z0
5Z1
5ZI
5ZO
635
636
637
638
639
640
641
642
643
644
645
646
647
648
649
650
651
652
653
654
655
656
657
658
659
660
661
662
663
664
Plan / Benefit Description
RESERVED
RESERVED BENEFIT PPO
PPO 500 SERIES VISION RDR
VENTURA STANDARD W/OPT DDS
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
49 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
665
666
667
668
669
670
671
672
673
674
675
676
677
678
679
680
681
682
683
684
685
686
687
688
689
690
691
692
693
694
6A2
6A3
6AA
6AD
6AE
6AH
6AJ
6AL
6AM
6AP
6AY
6BG
6BH
6BL
6BR
6CD
6CH
6CI
6CJ
6CL
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
ALAMEDA II STD W/HI DDS
L.A. VALUE STD W/HI OP DDS
SV 25-35/300A+75% 06
ALAMEDA I STD W/HI DDS
ALAMEDA I STD W/HI OPT DDS
0/0 HI GR-RX07
SV 25-35/300A+75% 06 AB
0/0 LO GR-RX07
SH ALAMEDA PLUS PLAN
8.50/25.90/50% SH6
SV 25-35/300A+75% 06 CB
SAN BERNARDINO SECURE GOLD
2/30/60 HI GR-RX07
2/30/60 LO GR-RX07
0/0 FLAT GR-RX06
7/14 GR-RX06
SP 10/100% SD CHRGRS 06
7/14 I GR-RX06
SP 10/100% SD CHRGRS 06 AB
SANTA CLARA STD W/HI DDS
50 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
6CN
6CP
6CR
6CS
6CT
6CY
6D2
6D3
6DD
6DE
6DG
6DH
6DI
6DL
6DN
6DO
6DR
6DS
6DV
6E2
6EG
6EH
6EL
6EO
6EV
6FA
6FD
6FH
6FJ
6FL
6FY
6GD
6GE
6GG
6GL
6GO
6GP
6GR
6HH
6HI
6HL
6HP
6HR
6JH
6JL
6JM
6JP
6JR
6KA
6KE
Plan / Benefit Description
CONTRA COSTA STD W/HI DDS
8.50/26.15/50% SH6
CNTRA COSTA I STD W/HI DDS
CNTRA COSTA I STD W/HI DDS
SH CONTRA COSTA PLUS PLAN
SP 10/100% SD CHRGRS 06 CB
ALAMEDA II STD W/HI OP DDS
SAN DIEGO III STD W/HI DDS
7/20/30 GR-RX06
RIVERSIDE STD W/HI OP DDS
SAN DIEGO I STD W/HI DDS
2/40 HI GR-RX07
SAN DIEGO III STD W/HI DDS
2/40 LO GR-RX07
S.BERNARDINO STD W/HI DDS
S.BERNARDINO STD W/HI DDS
10/10 FLAT GR-RX06
RIVERSIDE STD W/HI OP DDS
S.D. VALUE STD W/HI OP DDS
LOS ANGLES II STD W/HI DDS
SAN DIEGO I STD W/HI DDS
5/25 HI GR-RX07
5/25 LO GR-RX07
SAN MATEO STD W/HI OP DDS
VENTURA STANDARD W/HI DDS
SV 30-40/350A+70% 06
7/7 GR-RX06
5/65 HI GR-RX07
SV 30-40/350A+70% 06 AB
5/65 LO GR-RX07
SV 30-40/350A+70% 06 CB
10/20/30 GR-RX06
ORANGE I STD W/ HI OP DDS
ORANGE SECURE GOLD
LOS ANGELES I STD W/HI DDS
SAN DIEGO I STD W/HI DDS
8.50/26.45/50% SH6
10/20/35 GR-RX06
5/10 HI GR-RX07
10/20 I GR-RX06
5/10 LO GR-RX07
8.50/26.45/50% SH6
10/20 GR-RX06
5/10/20 HI GR-RX07
5/10/20 LO GR-RX07
5/10 GR-RX06
8.50/26.70/50% SH6
10/10 GR-RX06
KERN STANDARD W/HI OPT DDS
KERN STANDARD W/HI DDS
51 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
6KH
6KK
6KL
6KM
6KN
6KP
6KR
6L2
6LA
6LE
6LG
6LH
6LL
6LM
6LN
6LO
6LP
6LS
6LV
6MA
6ME
6MH
6ML
6MM
6MO
6MP
6N2
6N3
6ND
6NH
6NL
6NP
6NR
6OE
6OG
6OR
6PH
6PL
6PP
6QH
6QL
6QM
6R2
6RG
6RH
6RI
6RL
6RM
6RN
6RR
Plan / Benefit Description
7/14 HI GR-RX07
KERN STANDARD W/HI OPT DDS
7/14 LO GR-RX07
5/10/20 GR-RX06
SH KERN STD - ENDORSED GRP
8.50/26.70/50% SH6
10/20/35 GR-RX06
LOS ANGLES II STD W/HI DDS
LOS ANGELES SECURE GOLD
LOS ANGELES I STD W/HI DDS
LOS ANGELES I STD W/HI DDS
7/20/50% HI GR-RX7
7/20/50% LO GR-RX7
5/15 GR-RX06
LOS ANGELES I STD W/HI DDS
RESERVED
8.50/26.70/50% SH6
SH LOS ANGELES PLUS PLAN
L.A. VALUE STD W/HI OP DDS
10/25%/40% RX-GR06
ALAMEDA I STD W/HI OPT DDS
10/20 HI GR-RX07
10/20 LO GR-RX07
SAN MATEO STD. W/HI DDS
SAN MATEO STD W/HI OP DDS
8.50/26.75/50% SH6
ORANGE II STD W/HI OP DDS
SAN DIEGO III STD W/HI DDS
S.BERNARDINO STD W/HI DDS
10/20/40 HI GR-RX7
10/20/40 LO GR-RX7
8.50/26.75/50% SH6
S.BERNARDINO STD W/HI DDS
ORANGE I STD W/ HI OP DDS
ORANGE STANDARD W/HI DDS
SH ORANGE PLUS PLAN
10/20 HI GR-RX07
10/20 LO GR-RX07
8.50/26.85/50% SH6
10/20/35 HI GR-RX7
10/20/35 LO GR-RX7
5/15/30 GR-RX06
CNTRA CSTA II STD W/HI DDS
ORANGE STD W/HI OP DDS
10/20/35 HI GR-RX7
RIVERSIDE STD W/HI OP DDS
10/20/35 LO GR-RX7
5/15/30 GR-RX06
KERN STANDARD W/HI OPT DDS
SH RIVERSIDE PLUS PLAN
52 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
6RS
6RV
6SB
6SG
6SH
6SI
6SJ
6SK
6SL
6SM
6SN
6SO
6SP
6SR
6SX
6T2
6TA
6TH
6TL
6TM
6TP
6TU
6UC
6UH
6UL
6UP
6V3
6VE
6VM
6VP
6VR
6WH
6WI
6WM
6WP
6WR
710
711
712
713
714
715
716
717
718
719
71A
71B
71C
71D
Plan / Benefit Description
RIVERSIDE SECURE GOLD
RIVERSIDE STD. W/HI DDS
SH SAN BERNARDINO PLUS PLN
SH SAN DIEGO PLUS PLAN
10/25/55 HI GR-RX7
10/20/40 I GR-RX06
S. BERNARDINO STD W/HI DDS
SANTA CLARA STD. W/HI DDS
10/25/55 LO GR-RX7
SH SACRAMENTO PLUS PLAN
SH SAN FRANCISCO PLUS PLAN
RESERVED
SAN DIEGO I STD. W/HI DDS
10/20/40 GR-RX06
SH SANTA CLARA PLUS PLAN
CNTRA CSTA II STD W/HI DDS
SANTA CLARA STD W/HI DDS
10/40/75 HI GR-RX7
10/40/75 LO GR-RX7
5/5 GR-RX06
4.50/14.50/50% SH6
VENTURA STANDARD W/HI DDS
10/20/35 GR-RX06
15/25/40 HI GR-RX7
15/25/40 LO GR-RX7
25%/25%/25% SH6
L.A. VALUE STD W/HI OP DDS
VENTURA STANDARD W/HI DDS
5/5 GR-RX06
25%/25%/25% SH6
VENTURA STANDARD W/HI DDS
10/25/50 HI GR-RX7
15/25/40 I GR-RX06
5/7.50 GR-RX06
8.50/26.45/50% SH6
15/25/40 GR-RX06
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
53 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
71E
71F
71G
71H
71I
71J
71K
71L
71M
71N
71O
71P
71Q
71R
71S
71T
71U
71V
71W
71X
71Y
71Z
720
721
722
723
724
725
726
727
728
729
72A
72B
72C
72D
72E
72F
72G
72H
72I
72J
72K
72L
72M
72N
72O
72P
72Q
72R
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
54 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
72S
72T
72U
72V
72W
72X
730
731
732
733
734
735
736
737
738
739
73A
73B
73C
73D
73E
73F
73G
73H
73I
73J
73K
73L
73M
73N
73O
73P
73Q
73R
73S
73T
73U
73V
73W
73X
73Y
73Z
740
741
742
743
744
745
746
747
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
55 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
748
749
74A
74B
74C
74D
74E
74F
74G
74H
74I
74J
74K
74L
74M
74N
74O
74P
74Q
74R
74S
74T
74U
74V
74W
74X
74Y
74Z
750
751
752
753
754
755
756
757
758
759
75A
75B
75C
75D
75E
75F
75G
75H
75I
75J
75K
75L
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
56 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
75M
75N
75O
75P
75Q
75R
75S
75T
75U
75V
75W
75X
75Y
75Z
760
761
762
763
764
765
766
767
768
769
76A
76B
76C
76D
76E
76F
76G
76H
76I
76J
76K
76L
76M
76N
76O
76P
76Q
76R
76S
76T
76U
76V
7A2
7A3
7AD
7AE
Plan / Benefit Description
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPOO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
ALAMDA II PLS PLN W/OP DDS
L.A. VALUE PLS PLN W/DDS
ALAMEDA I PLS PLN W/OP DDS
ALAMEDA I PLS PLN W/OP DDS
57 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
7AL
7AQ
7AR
7B1
7B2
7BB
7BD
7BH
7BI
7BL
7BR
7CC
7CD
7CI
7CL
7CM
7CQ
7D2
7D3
7DD
7DE
7DG
7DH
7DI
7DL
7DM
7DN
7DO
7DR
7DS
7DV
7E2
7ED
7EG
7EH
7EL
7EM
7ER
7FA
7FD
7FH
7FL
7FM
7FR
7GD
7GE
7GL
7GM
7GO
7GR
Plan / Benefit Description
ALMAMEDA PT B PL W/ NO DEN
7/20 GR-RX07
0/0 GR-RX07
SH PART B PLUS MED W/$12
SH PART B PLUS W/$62 PREM.
SH PART B PLS: SD, IM & VT
7/14 GR-RX07
4/10/20 T1A H GRX7
7/14 I GR-RX07
4/10/20 T1A L GRX7
0/0 FLAT GR-RX07
CONTRA COSTA B PL W/ NO DE
7/14 GR-RX07
7/14 I GR-RX07
S.CLARA PLS PLN W/OPT DDS
15/25/40 GR-RX07
5/29/60 W/G SH-RX7
ALAMDA II PLS PLN W/OP DDS
S.DIEGO III PLUS W/OP DDS
7/20/30 GR-RX07
RIVERSIDE PLS PLN W/OP DDS
S.DIEGO I PLS PLN W/OP DDS
4/15/30 T1B H GRX7
S.DIEGO III PLUS W/OP DDS
4/15/30 T1B L GRX7
15/25/40 GR-RX07
S. BERDO PLS PLN W/OP DDS
S. BERDO PLS PLN W/OP DDS
10/10 FLAT GR-RX07
RIVERSIDE PLS PLN W/OP DDS
S.D. VALU PLS PLN W/OP DDS
L.A. II PLUS PLAN W/OP DDS
7/7 GR-RX07
S.DIEGO I PLS PLN W/OP DDS
4/20/40 T1C H GRX7
4/20/40 T1C L GRX7
3/3 FLAT GR-RX07
10/20 GR-RX07
25% PART D GR-RX07
7/7 C GR-RX07
4/25/50 T1D H GRX7
4/25/50 T1D L GRX7
3/3/3 GR-RX07
10/20 GR-RX07
10/20/30 GR-RX07
ORANGE I PLS PLN W/OP DDS
L.A. I PLUS PLAN W/OPT DDS
5/10 GR-RX07
S.DIEGO I PLS PLN W/OP DDS
10/20 GR-RX07
58 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
7HH
7HI
7HL
7HR
7JH
7JL
7JM
7JR
7KH
7KI
7KL
7KM
7KR
7L2
7LA
7LE
7LG
7LH
7LL
7LM
7LN
7LR
7LV
7M2
7MA
7ME
7MH
7MI
7ML
7MR
7MT
7N2
7N3
7ND
7NH
7NL
7NM
7NR
7OC
7OE
7OG
7PH
7PI
7PL
7PM
7PR
7Q5
7Q6
7Q7
7QH
Plan / Benefit Description
4/15/30 T2A H GRX7
10/20 I GR-RX07
4/15/30 T2A L GRX7
10/20 GR-RX07
4/28/58 T3C H GRX7
4/28/58 T3C L GRX7
5/10 GR-RX07
10/10 GR-RX07
4/28/55 T3B H GRX7
10/20/35 I GR-RX07
4/28/55 T3B L GRX7
5/10/20 GR-RX07
10/20/35 GR-RX07
L.A. II PLUS PLAN W/OP.DDS
SH LA PT B PL W/ NO DENTAL
L.A. I PLUS PLAN W/OPT DDS
L.A. I PLUS PLAN W/OPT DDS
4/25/45 T3A H GRX7
4/25/45 T3A L GRX7
5/15 GR-RX07
L.A. I PLUS PLAN W/OPT DDS
15/25/40 GR-RX07
L.A. VALUE PLS PLN W/DDS
SACTO II PLS PLN W/OP DDS
10/25%/40% GR-RX07
ALAMEDA I PLS PLN W/OP DDS
4/20/40 T2B H GRX7
10/20/40 I GR-RX07
4/20/40 T2B L GRX7
10/20/40 GR-RX07
SACTO I PLS PLN W/OP DDS
ORANGE II PLS PLN W/OP DDS
S.DIEGO III PLUS W/OPT DDS
S. BERDO PLS PLN W/OP DDS
4/25/50 T2C H GRX7
4/25/50 T2C L GRX7
5/15/30 GR-RX07
S. BERDO PLS PLN W/OP DDS
SH ORANGE PT B PL W/ NO DE
ORANGE I PLS PLN W/OP DDS
ORANGE PLUS PLAN W/ OP.DDS
4/25/50 T2C H GRX7
10/20/40 I GR-RX07
4/25/50 T2C L GRX7
5/15/30 GR-RX07
10/20/40 GR-RX07
5/29/57.20W/G SHX7
5/29/57.95W/G SHX7
5/29/58 W/G SH-RX7
4/20/40 T2B H GRX7
59 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
7QI
7QL
7QM
7QR
7RA
7RB
7RC
7RD
7RG
7RH
7RI
7RL
7RM
7RS
7RV
7SA
7SB
7SC
7SD
7SE
7SF
7SH
7SI
7SJ
7SK
7SM
7SP
7SR
7TA
7TH
7TL
7TM
7TO
7TR
7UC
7UH
7UL
7UM
7UR
7V3
7VH
7VL
7VM
7WE
7WH
7WI
7WL
7WM
7WP
7WR
Plan / Benefit Description
10/20/40 I GR-RX07
4/20/40 T2B L GRX7
5/15/30 GR-RX07
10/20/40 GR-RX07
10/20/35 RDS GRX7
10/20 RDS GR-RX07
10/20/35 RDS GRX7
10/20 RDS GR-RX07
ORANGE PLUS PLN W/OP DDS
4/15/30 T2A H GRX7
RIVERSIDE PLS PLN W/OP DDS
4/15/30 T2A L GRX7
5/15/30 GR-RX07
RIVERSIDE PT B PL W/ NO DE
RIVERSIDE PLS PLN W/OP.DDS
SH SACRAM PT B PL W/ NO DE
10/25%/40% GR-RX07
S CLARA PT B PL W/ NO DENT
S DIEGO PT B PL W/ NO DENT
S BERNARD PT B PL W/ NO DE
SH S FRAN PT B PL W/ NO DE
SACRMNTO PLS PLN W/OPT.DDS
10/20/40 I GR-RX07
SAN BERDO PLS PLN W/OP.DDS
S.CLARA PLS PLN W/OPT. DDS
S0NOMA CLASSIC I
S.DIEGO I PLS PLN W/OP.DDS
10/20/40 GR-RX07
S.CLARA PLS PLN W/OPT DDS
4/28/55 T3B H GRX7
4/28/55 T3B L GRX7
5/5 GR-RX07
SACTO I PLS PLN W/OP DDS
10/25/40 GR-RX07
10/20/35 GR-RX07
4/28/58 T3C H GRX7
4/28/58 T3C L GRX7
5/5 GR-RX07
15/25/40 GR-RX07
L.A. VALUE PLS PLN W/DDS
4/25/50 T1D H GRX7
4/25/50 T1D L GRX7
5/5 GR-RX07
SONOMA CLASSIC I W/EPO DDS
4/20/40 T1C H GRX7
15/25/40 I GR-RX07
4/20/40 T1C L GRX7
5/7.50 GR-RX07
SONOMA CLASSIC I W/ODP DDS
15/25/40 GR-RX07
60 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
7XA
7XB
7XC
7XD
7XE
7XF
7XG
7XH
7XJ
7XL
7XM
7XP
7XQ
7XR
7XS
7XT
7XU
7XY
7XZ
7YH
7YI
7YL
7YM
7YR
7ZH
7ZL
7ZM
7ZR
810
811
812
813
814
815
816
817
818
819
820
821
822
823
824
825
826
827
828
829
82A
82B
Plan / Benefit Description
4/10/20 RDS GR-RX7
4/15/30 RDS GR-RX7
4/20/40 RDS GR-RX7
4/25/50 RDS GR-RX7
4/10/20 RDS GR-RX7
4/15/30 RDS GR-RX7
4/20/40 RDS GR-RX7
4/15/30 T1B H GRX7
4/25/50 RDS GR-RX7
4/15/30 T1B L GRX7
7/14 GR-RX07
5/29/60 N/G SH-RX7
5/29/60 W/G SH-RX7
5/29/60 N/G 3 SHX7
5/29/60 5G SH-RX7
5/29/60 10G SH-RX7
5/28/64 N/G SH-RX7
25% N/G SH-RX7
5/35/65 NGE SH-RX7
4/10/20 T1A H GRX7
15/25/40 I GR-RX07
4/10/20 T1A L GRX7
7/14 GR-RX07
15/25/40 GR-RX07
4/25/45 T3A H GRX7
4/25/45 T3A L GRX7
7/14 GR-RX07
15/25/40 GR-RX07
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED OOI
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
61 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
82C
82D
82E
82F
82G
82H
82J
82K
82L
82M
82N
82P
82Q
82R
82S
82T
82U
82V
82W
82X
82Y
82Z
830
831
832
833
834
835
836
837
838
839
83A
83B
83C
83D
83E
83F
83G
83H
83J
83K
83L
83M
840
841
842
843
844
845
Plan / Benefit Description
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
62 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
846
847
848
849
850
851
852
853
854
855
856
857
858
859
860
861
862
863
864
865
866
867
868
869
880
881
8A2
8A3
8AD
8AE
8AH
8AM
8AR
8B3
8B5
8B8
8B9
8BH
8BL
8BN
8BW
8C8
8CH
8CL
8CT
8D2
8D3
8DD
8DE
8DG
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX OOI
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
880 PLAN INACTIVE
880 PLAN
ALAMDA II PLS PLN W/HI DDS
L.A.VALUE PLS PLN W/HI DDS
ALAMEDA I PLS PLN W/HI DDS
ALAMEDA I PLS PLN W/HI DDS
0/0 HI C GR-RX07
SH ALAMEDA STD W/OPT DNTL
0/0 C GR-RX07
MCC VENTURA LO-PL SH07
MCC VENTURA HI-PL SH07
5/29/60NG RX-SH08
MCC VENTURA PLUS SH07
MCC VENTURA HIGH SH07
MCC VENTURA LOW SH07
MC COMP VENTURA SH07
OK TO USE
5/29/60NG RX-SH08
2/30/60 HI C GRX07
S.CLARA PLS PLN W/HI DDS
SH CONTRA COSTA STD-LO DNT
ALAMDA II PLS PLN W/HI DDS
S.DIEGO III PLUS W/HI DDS
7/20/30 C GR-RX07
RIVERSIDE PLS PLN W/HI DDS
S.DIEGO I PLS PLN W/HI DDS
63 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
8DH
8DI
8DN
8DO
8DR
8DS
8DV
8E2
8E8
8ED
8EG
8EH
8EM
8ER
8F8
8FD
8FH
8G8
8GE
8GH
8GL
8GM
8GO
8H3
8H5
8H9
8HD
8HH
8HL
8HN
8J8
8JH
8JL
8JW
8JX
8K3
8K5
8KH
8KL
8KM
8KN
8KO
8KR
8KV
8KW
8KX
8L2
8LE
8LG
8LH
Plan / Benefit Description
2/40 HI C GR-RX07
S.DIEGO III PLUS W/HI DDS
S. BERDO PLS PLN W/HI DDS
S. BERDO PLS PLN W/HI DDS
10/10 FLAT C GRX07
RIVERSIDE PLS PLN W/HI DDS
S.D. VALU PLS PLN W/HI DDS
L.A. II PLUS PLAN W/HI DDS
6/40/80NG RX-SH08
7/7 C GR-RX07
S.DIEGO I PLS PLN W/HI DDS
5/25 HI C GR-RX07
3/3 FLAT C GR-RX07
10/20 C GR-RX07
6/41/80NG RX-SH08
7/7 C GR-RX07
5/65 HI C GR-RX07
6/42/85NG RX-SH08
ORANGE I PLS PLN W/HI DDS
5/10 HI C GR-RX07
L.A. I PLUS PLAN W/HI DDS
5/10 C GR-RX07
S.DIEGO I PLS PLN W/HI DDS
MCC ESS VENTURA LO-PL SH07
MCC ESS VENTURA HI-PL SH07
MCC ESS VENTURA PLUS SH07
10/20/30 C GR-RX07
MCC ESS VENTURA HIGH SH07
MCC ESS VENTURA LOW SH07
MC COMP ESS VENTURA SH07
5/34/79NG RX-SH08
ARP MCC 1 S BERDO HI SH08
ARP MCC 1 S BERDO LO SH08
ARP MCC 1 S BERDO SH08
ARP MCC 1 S BERDO DLX SH08
ARP MCC 1 LA LO-PL SH08
ARP MCC 1 LA HI-PL SH08
ARP MCC 1 LA HI SH08
ARP MCC 1 LA LO SH08
5/10/20 C GR-RX07
RESERVED
ARP MCC 1 LA PL-DLX SH08
SH KERN STANDARD W/LO DNTL
ARP MCC 1 LA PLUS SH08
ARP MCC 1 LA SH08
ARP MCC 1 LA DLX SH08
L.A. II PLUS PLAN W/HI DDS
L.A. I PLUS PLAN W/HI DDS
L.A. I PLUS PLAN W/HI DDS
7/20/50% HI C GRX7
64 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
8LM
8LN
8LV
8M3
8M5
8M8
8MA
8ME
8MH
8ML
8MO
8MV
8MW
8MX
8N2
8N3
8N8
8ND
8NH
8NL
8NM
8NR
8NW
8NX
8OE
8OG
8P8
8PH
8PM
8Q8
8R8
8RG
8RH
8RI
8RM
8RR
8RU
8RV
8S8
8SB
8SC
8SE
8SG
8SH
8SI
8SJ
8SK
8SM
8SN
8SO
Plan / Benefit Description
5/15 C GR-RX07
L.A. I PLUS PLAN W/HI DDS
L.A.VALUE PLS PLN W/HI DDS
ARP MCC 2 LA LO-PL SH08
ARP MCC 2 LA HI-PL SH08
5/36/82NG RX-SH08
10/25%/40% C GRX07
ALAMEDA I PLS PLN W/HI DDS
ARP MCC 2 LA HI SH08
ARP MCC 2 LA LO SH08
ARP MCC 2 LA PL-DLX SH08
ARP MCC 2 LA PLUS SH08
ARP MCC 2 LA SH08
ARP MCC 2 LA DLX SH08
ORANGE II PLS PLN W/HI DDS
S.DIEGO III PLUS W/HI DDS
5/29/60G RX-SH08
S. BERDO PLS PLN W/HI DDS
ARP MCC 3 S BERDO HI SH08
ARP MCC 3 S BERDO LO SH08
5/15/30 C GR-RX07
S. BERDO PLS PLN W/HI DDS
ARP MCC 3 S BERDO SH08
ARP MCC 3 S BERDO DLX SH08
ORANGE I PLS PLN W/HI DDS
ORANGE PLUS PLAN W/HI DDS
5/29/60G RX-SH08
10/20 HI C GR-RX07
5/15/30 C GR-RX07
5/37/71G RX-SH08
5/37/71G RX-SH08
ORANGE PLS PLN W/HI OP DDS
10/20/35 HI C GRX7
RIVERSIDE PLS PLN W/HI DDS
5/15/30 C GR-RX07
SH RIVERSIDE STD W/OPT DNT
15/25/40 C GR-RX07
RIVERSIDE PLS PLN W/HI DDS
5/29/60G RX-SH08
SH SAN BERN STD W/OPT DNTL
STANISLAUS CLASSIC I
STANISLAUS CLSC I W/EPODDS
SH SAN DIEGO STD W/OP DNTL
10/25/55 HI C GRX7
RESERVED
SAN BERDO PLS PLN W/HI DDS
S.CLARA PLS PLN W/HI DDS
SH SACRAMENTO STD W/OP DNT
SH SAN FRAN STD W/OPT DNTL
RESERVED
65 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
8SP
8SU
8SW
8SX
8SY
8T8
8TA
8TH
8TM
8TR
8TU
8TW
8TY
8U3
8U5
8UH
8UL
8UM
8UO
8UR
8UV
8UW
8UX
8V3
8VJ
8VM
8VN
8WH
8WP
8Y3
8Y5
8YH
8YL
8YO
8YV
8YW
8YX
8Z1
8ZU
8ZW
8ZY
910
911
912
913
914
915
916
917
918
Plan / Benefit Description
S.DIEGO I PLS PLN W/HI DDS
ARP MCC SONOMA PP SH08
ARP MCC SONOMA SH08
SH SANTA CLARA STD-OP DNTL
ARP MCC SONOMA EP SH08
5/29/60G RX-SH08
S.CLARA PLS PLN W/HI DDS
10/40/75 HI C GRX7
5/5 C GR-RX07
10/25/40 C GR-RX07
NOT USED
ARP MCC ES NO SH08
NOT USED
ARP MCC 3 LA LO-PL SH08
ARP MCC 3 LA HI-PL SH08
ARP MCC 3 LA HI SH08
ARP MCC 3 LA LO SH08
5/5 C GR-RX07
ARP MCC 3 LA PL-DLX SH08
15/25/40 C GR-RX07
ARP MCC 3 LA PLUS SH08
ARP MCC 3 LA SH08
ARP MCC 3 LA DLX SH08
L.A.VALUE PLS PLN W/HI DDS
VEBA B15 $15/$100/$500 AB
5/7.50 C GR-RX07
SH VENTURA STD-I W/OP DNTL
10/25/50 HI C GRX7
STANISLAUS CLSC I W/ODPDDS
ARP MCC VA LA LO-PL SH08
ARP MCC VA LA HI-PL SH08
ARP MCC VA LA HI SH08
ARP MCC VA LA LO SH08
ARP MCC VA LA PL-DLX SH08
ARP MCC VA LA PLUS SH08
ARP MCC VA LA SH08
ARP MCC VA LA DLX SH08
880 PLAN (COBRA)
ARP MCC STANLUS PP SH08
ARP MCC STANLUS SH08
ARP MCC STANLUS EP SH08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
66 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
919
91H
920
921
922
923
924
925
926
927
928
929
92H
930
931
932
933
934
935
936
937
938
939
93H
940
941
942
943
944
945
946
947
948
949
94H
950
951
952
953
954
955
956
957
958
959
95E
95H
95N
95P
960
Plan / Benefit Description
RESERVED PPO
15/25/40 HI GR-RX8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/25/50 HI GR-RX8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/20/40 HI GR-RX8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/20 HI GR-RX08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
MCC SAN FRAN EP SH07
10/40/75 HI C GRX8
MC COMP SAN FRAN SH07
MCC SAN FRAN PP SH07
RESERVED RX PPO
67 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
961
962
963
964
965
966
967
968
969
96D
96E
96N
96P
970
971
972
973
974
975
976
977
978
979
97E
97M
97N
97P
980
981
982
983
984
985
986
987
988
989
98E
98N
98P
990
991
992
993
994
99E
99N
99P
9AM
9AN
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
MCC SAN JOAQUN DELUXE SH07
MCC SAN JOAQUN EP SH07
MC COMP SAN JOAQUN SH07
MCC SAN JOAQUN PP SH07
BENEFIT RESERVED PPO
BENEFIT RESERVED PPO
BENEFIT RESERVED PPO
BENEFIT RESERVED PPO
BENEFIT RESERVED PPO
BENEFIT RESERVED PPO
BENEFIT RESERVED PPO
BENEFIT RESERVED PPO
BENEFIT RESERVED PPO
BENEFIT RESERVED PPO
MCC SON0MA EP SH07
DO NOT USE
MC COMP S0NOMA SH07
MCC SON0MA PP SH07
BENEFIT RESERVED PPO
BENEFIT RESERVED PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
MCC STANISLAUS EP SH07
MC COMP STANISLAUS SH07
MCC STANISLAUS PP SH07
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
MCC ESS STANLAUS EP SH07
MC COMP ESS STANLAUS SH07
MCC ESS STANLAUS PP SH07
SH ALAMEDA STD W/ HI DNTL
4/20/40 LO GR-RX08
68 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
9AQ
9AR
9AY
9BE
9BH
9BL
9BR
9CM
9CT
9DF
9DH
9DL
9DR
9EH
9EL
9ER
9FD
9FH
9FL
9GE
9GM
9HD
9HH
9HK
9HL
9HN
9HP
9HQ
9HR
9HS
9HT
9HU
9HV
9HW
9HX
9HY
9HZ
9JH
9JL
9KH
9KL
9KN
9KR
9KS
9KU
9LA
9LG
9LH
9LL
9LM
Plan / Benefit Description
7/20 GR-RX08
0/0 GR-RX08
4/25/50 HI GR-RX08
7/14 GR-RX08
4/10/20 T1A H GRX8
4/10/20 T1A L GRX8
S. BERDO CNTY SECURE GOLD
15/25/40 GR-RX08
SH CONTRA COSTA STD-HI DNT
10/10 FLAT GR-RX08
4/15/30 T1B H GRX8
4/15/30 T1B L GRX8
10/10 FLAT C GRX08
4/20/40 T1C H GRX8
4/20/40 T1C L GRX8
10/20 GR-RX08
7/7 C GR-RX08
4/25/50 T1D H GRX8
4/25/50 T1D L GRX8
10/20/30 GR-RX08
5/10 GR-RX08
10/20/30 C GR-RX08
4/15/30 T2A H GRX8
4/10/20 RX-GR08
4/15/30 T2A L GRX8
4/15/30 RX-GR08
5/30/45 GRRX08
4/20/40 RX-GR08
4/25/50 RX-GR08
10/25/50 RX-GR08
4/15/30 RX-GR08
4/20/40 RX-GR08
4/25/50 RX-GR08
5/20/45 RX-GR08
4/25/45 RX-GR08
4/28/55 RX-GR08
4/28/58 RX-GR08
4/28/58 T3C H GRX8
4/28/58 T3C L GRX8
4/28/55 T3B H GRX8
4/28/55 T3B L GRX8
RESERVED
SH KERN STD W/HI OPT DENTL
10/20/35 GR-RX08
10/20/40 RX-GR08
L.A. COUNTY SECURE GOLD
L.A. COUNTY SECURE GOLD
4/25/45 T3A H GRX8
4/25/45 T3A L GRX8
5/15 C GR-RX08
69 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
9LO
9LP
9LR
9LS
9LV
9LX
9MA
9MH
9MI
9ML
9MR
9NH
9NL
9NM
9OC
9OG
9OK
9OR
9PH
9PI
9PL
9PW
9PX
9PY
9QH
9QL
9RD
9RH
9RI
9RL
9RP
9RR
9RX
9SA
9SB
9SD
9SG
9SI
9SL
9SN
9SO
9SX
9TE
9TH
9TL
9TN
9TP
9UC
9UH
9UL
Plan / Benefit Description
RESERVED
5/15 GR-RX08
10/20/50 GR-RX08
SH LA STD W/HI OPT DENTAL
10/20/35 RX-GR08
10/20/35 RX-GR08
10/25%/40% GR-RX08
4/20/40 T2B H GRX8
10/20/40 I GR-RX08
4/20/40 T2B L GRX8
10/20/40 GR-RX08
4/25/50 T2C H GRX8
4/25/50 T2C L GRX8
5/15/30 GR-RX08
ORANGE COUNTY SECURE GOLD
ORANGE COUNTY SECURE GOLD
5/15/25/25 GR-RX08
SH ORANGE STD W/HI OP DNTL
4/25/50 T2C H GRX8
RX RETIREE TPIG $5G/10B UN
4/25/50 T2C L GRX8
5/29/60 P RX-GR08
5/29/60 P RX-GR08
5/29/60 P RX-GR08
4/20/40 T2B H GRX8
4/20/40 T2B L GRX8
RIVERSIDE CNTY SECURE GOLD
4/15/30 T2A H GRX8
RIVERSIDE CNTY SECURE GOLD
4/15/30 T2A L GRX8
5/15/30 GR-RX08
SH RIVERSIDE STD W/HI DNTL
NO RX
S. BERDO CNTY SECURE GOLD
SH SAN BERN STD W/HI DENTL
S. DIEGO CNTY SECURE GOLD
SH SAN DIEGO STD W/HI DNTL
RESERVED
SH LOS ANGELES STD -HI DNT
SH SAN FRAN STD W/HI DENTL
RESERVED
SH SANTA CLARA STD-HI DNTL
STANISLAUS MEDCL W/EPO DDS
4/28/55 T3B H GRX8
4/28/55 T3B L GRX8
STANISLAUS MEDICAL
STANISLAUS MEDCL W/ODP
10/20/35 GR-RX08
4/28/58 T3C H GRX8
4/28/58 T3C L GRX8
70 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
9VH
9VJ
9VL
9VM
9VN
9WH
9WI
9WL
9WM
9XH
9XL
9YH
9YL
9ZH
9ZL
A
A01
A02
A03
A04
A05
A06
A07
A08
A09
A10
A11
A12
A13
A14
A15
A16
A17
A18
A19
A1C
A1G
A1I
A1J
A1L
A1Y
A1Z
A20
A21
A22
A23
A24
A25
A26
A27
Plan / Benefit Description
4/25/50 T1D H GRX8
SV 10/80% PVH 05 AB
4/25/50 T1D L GRX8
5/5 GR-RX08
SH VENTURA STD-I W/HI DNTL
4/20/40 T1C H GRX8
15/25/40 I GR-RX08
4/20/40 T1C L GRX8
5/7.50 GR-RX08
4/15/30 T1B H GRX8
4/15/30 T1B L GRX8
4/10/20 T1A H GRX8
4/10/20 T1A L GRX8
4/25/45 T3A H GRX8
4/25/45 T3A L GRX8
THIS IS A TEST
PPO SERIES A PLAN 1
PPO SERIES A PLAN 2
PPO SERIES A PLAN 3
PPO SERIES A PLAN 4
PPO SERIES A PLAN 5
PPO SERIES A PLAN 6
PPO SERIES A PLAN 7
PPO SERIES A PLAN 8
PPO SERIES A PLAN 9
PPO SERIES A PLAN 10
SERIES A NATL PLAN 1
SERIES A NATL PLAN 2
SERIES A NATL PLAN 3
SERIES A NATL PLAN 4
SERIES A NATL PLAN 5
SERIES A NATL PLAN 6
SERIES A NATL PLAN 7
SERIES A NATL PLAN 8
SERIES A NATL PLAN 9
PREFERRED PLAN
II
GM HRLY HMO 2001
PASTEUR INDIVIDUAL CONV PL
SV ABC APPRN TRST-HIGH AB
ALAMEDA STANDARD PLAN
GM HRLY HMO 2001 COBRA
PREFERRED PLAN COBRA II
SERIES A NATL PLAN 10
PPO SERIES A PLAN 1-COBRA
PPO SERIES A PLAN 2-COBRA
PPO SERIES A PLAN 3-COBRA
PPO SERIES A PLAN 4-COBRA
PPO SERIES A PLAN 5-COBRA
PPO SERIES A PLAN 6-COBRA
PPO SERIES A PLAN 7-COBRA
71 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
A28
A29
A2A
A2D
A2E
A2H
A2J
A2P
A2S
A30
A31
A32
A33
A34
A35
A36
A37
A38
A39
A3C
A3D
A3E
A3J
A3L
A3M
A3S
A3Z
A40
A42
A4A
A4J
A4L
A4T
A4W
A5J
A5L
A63
A64
A65
A6C
A6D
A6J
A6L
A73
A74
A75
A7F
A7J
A7L
A7Z
Plan / Benefit Description
23O SERIES A PLAN 8-COBRA
PPO SERIES A PLAN 9-COBRA
NON STANDARD $10/$250
ALAMEDA CLSC II W/OPT DDS
ALAMEDA CLSC II W/EPO DDS
ALAMEDA CLSC II W/HI DDS
SV 10/100% CTYANHM 06 AB
SV 10/100% CTYANHM 06 CB
ALAMEDA CLASSIC II
PPO SERIES A PLAN 10-COBRA
SERIES A NATL PLAN 1-COBRA
SERIES A NATL PLAN 2-COBRA
SERIES A NATL PLAN 3-COBRA
SERIES A NATL PLAN 4-COBRA
SERIES A NATL PLAN 5-COBRA
SERIES A NATL PLAN 6-COBRA
SERIES A NATL PLAN 7-COBRA
SERIES A NATL PLAN 8-COBRA
SERIES A NATL PLAN 9-COBRA
PRFD PLAN FHP FAMILY SEC
ALAMEDA MEDICAL W/OPT DDS
ALAMEDA MEDICAL W/EPO DDS
SV ABC APPRN TRST-APPRN AB
ALAMEDA PLUS PLAN
ALAMEDA MEDICAL
ALAMEDA MEDICAL W/HIOP DDS
PRFD PLAN FHP FAM SEC COBR
SERIES A NATL PLAN 10-COBR
10/12V 1YR ACU GR07
FOOTWARE FOR DISFIGUREMENT
AMR UNION $5/$350A AB
ALAMEDA STAND. W/OPT. DDS
ATW-STD GR-WL07
ATW-PLUS GR-WL07
SV ABC APPRN TRST-LOW AB
ALAMEDA STANDARD W/HI DENT
KEC 1 AMEDA CG GR07
KEC 1 AMEDA LO CG GR07
KEC 1 AMEDA HI CG GR07
$5/6VSTS/YR ACUPUNCTURE 06
SV 15-25/200A ADP 06
AMR UNION $10/350A AB
ALAMEDA PLUS PLN W/OPT DDS
KEC 1 AMEDA CGII GR07
KEC 1 AMEDA LO CGII GR07
KEC 1 AMEDA HI CGII GR07
SV 5/100% AFSCME 05
SV 5/100% AFSCME 05 AB
ALAMEDA PLUS PLAN W/HI DNT
SV 5/100% AFSCME 05 CB
72 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
A83
A84
A85
A8J
A9J
AAA
AAB
AAC
AAF
AAG
AAH
AAJ
AAM
AAN
AAR
AAT
AAV
AAX
AAY
AAZ
AB2
ABA
ABC
ABH
ABJ
ABP
ABT
ABZ
AC1
AC2
AC3
AC4
AC5
AC6
AC7
AC8
AC9
ACA
ACB
ACC
ACD
ACE
ACF
ACH
ACI
ACJ
ACK
ACL
ACP
ACQ
Plan / Benefit Description
KEC 1 AMEDA CGEH GR07
KEC 1 AMEDA LO CGEH GR07
KEC 1 AMEDA HI CGEH GR07
AMR UNION $20/$350A AB
SP $10/100 AZUSA PU AB
SV 15/250A SNTAROSA 05
SV 10-20/100D AIW SEL05
SV 15/250A ABC APRNT 05 CB
SV 15/250A ADMSTFF 06
SV 20/250A ASCENT 07
SV 10/100% ABC APPREN 05CB
SP 15/100% ALDILA AB
15/20V ACU/CHIRO 07
SV 10/100% ABC 06
SV 20/100% AIR-C&R 06
SV 15/250A ABC APRNTC 05
SV 20-40/80% AI 07
SV 15/250A ADMSTFF 06 AB
SV 10-20/100D AIW SEL05 CB
SV 15/250A ADMSTFF 06 CB
SP 20/100A AGC 05 CB
SV 15/250A SNTAROSA 05 CB
US BORAX-PC
US BEHAVIORAL HEALTH CARE
SP 20/100A AGC 05 AB
SV 15/250A ABC 06
SP 20/100A AGC 05
US BORAX-PC
$5/$5/40V ACU/CHIRO/HERBAL
$5/$5/20V ACU/CHIRO/HERBAL
$10/$5/30V ACU/CHIRO/HERBA
$10/$5/40V ACU/CHIRO/HERBA
$15/$5/20V ACU/CHIRO/HERBA
$5/$5/40V ACU/CHIRO/HERBAL
$10/$5/30V ACU/CHIRO/HERBA
$10/30V ACU/CHIRO
$5/$5/40V ACU/CHIRO
$5/$5/20V ACU/CHIRO
$10/$10/30V ACU/CHIRO
SCRIPPS CUSTOM HMO
$10/$10 40V ACU/CHIRO
$15/$15/20V ACU/CHIRO
ADMINS/CONSULTANTS FEE
$10/$10/40V ACU/CHIRO
ACCUPUNCTURE - PLHIC
SV 15/250A ABC APRNT 05 AB
15/20V ACU/CH06
10/30V ACU/CHIRO 07
SCRIPPS CUSTOM POS
5/40V ACU/CHIRO 07
73 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
ACR
ACS
ACT
ACW
ACY
ACZ
AD3
AD6
ADA
ADC
ADE
ADG
ADH
ADJ
ADL
ADM
ADP
ADR
ADS
ADU
ADV
ADX
ADY
ADZ
AEC
AED
AEF
AEJ
AEP
AET
AEU
AEX
AEZ
AF2
AF3
AFA
AFC
AFH
AFJ
AFK
AFM
AFN
AFS
AFX
AFZ
AG2
AG3
AGA
AGB
AGC
Plan / Benefit Description
PPO ACCUPUNTURE RIDER
HOSPITAL CAP SUPPRESSION
SV 20/250A + 20% ABC 06
5/20V ACU/CHIRO 07
SCRIPPS CUSTOM POS COBRA
SCRIPPS CUSTOM HMO COBRA
ADMINISTAFF $15/$250A
SV 15/250A ADMIN
ADMINISTAFF HMO $10/$250
SV 20/350A HTAU 06
ENDORS ALAM BASIC W/ NO DE
SV 20/250A ASCENT 07 CB
ALCOHOL/DRUG REHAB-HIGH
ADMINISTAFF $15/$250A AB
ALCOHOL/DRUG REHAB-LOW
SV 15/100% AGCHWT 06
SV 15-25/200A ADP
SV 20/100% AIR-C&R 06 CB
SV 15-25/200A ADP 06
SV 15-25/200A ADP 06 CB
SV 15-25/200A ADP 06 AB
SV 15-25/200A ADP 06 AB
SV 15-25/200A ADP 06 CB
ADMINISTAFF COBRA $10/$250
SV 15-30/250A ADP 05
SV 15-25/200A ADP 07
EXECUFIT WELLNESS PROGRAM
SV 10-20/100D AIW SEL05 AB
ALAMEDA CLSC I W/EPO DDS
10/30V ACU/CHIRO 07
15/20V ACU/CHIRO 07
SV 15-30/250A ADP 05 AB
SV 15-30/250A ADP 05 CB
ST. ANTHONY $10/100 MFP
ST. ANTHONY $10/100 MFP CB
SV 15/100% AME HONDA 06
CTY FRESNO DRCT PAY ADM
RETENTION FEE
SV 15/250A SNTAROSA 05 AB
15/20V ACU/CHIRO 07
SV 15/100% AGCHWT 06 CB
SV 10/100% ABC 06 CB
ADMINISTRATIVE SERVICE FEE
SV 15/100% AME HONDA 06 AB
SV 15/100% AME HONDA 06 CB
AGILENT $20/$100A
AGILENT $20/$100A COBRA
SP 15/100% ALDILA
SP 15/100% ALDILA CB
CUSTOM PREFERRED PLAN/GM
74 of 640
Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
AGD
AGE
AGF
AGH
AGI
AGJ
AGP
AGR
AGV
AGZ
AHA
AHC
AHD
AHG
AHH
AHJ
AHL
AHN
AHT
AHX
AHZ
AI1
AI2
AIC
AIJ
AIW
AIZ
AJA
AJJ
AJN
AJS
AJT
AJU
AJZ
AKA
AKF
AKH
AKJ
AKK
AKL
AKV
AKX
AKZ
AL1
AL2
AL3
AL4
AL5
AL6
AL7
Plan / Benefit Description
SV 10/100% AMGEN 07
SV 15/250A ADMSTFF 07
SV 10/100% AMGEN 07 CB
SV 10/100% AMGEN 07 AB
AGILENT $20 GRP RET PLAN
AGILENT $20/$100A AB
SV 15/250A ABC 06 CB
10/20V ACU/CHIRO 07
10/40V ACU/CHIRO 07
CUSTOM PREFERRED/GM/COBRA
SV 20-40/500D ADP 05
BEAVERTON HOSPITAL CAP
ALAMEDA CLSC I W/HI OP DDS
SV 20/250A ASCENT 07 AB
MCC 1 ALAMEDA HIGH SH07
SV 10/100% ABC APPREN 05AB
MCC 1 ALAMEDA LOW SH07
MC COMP 1 ALAMEDA SH07
SV 10/100% ABC APPREN 05
SV 20-40/500D ADP 05 AB
SV 20-40/500D ADP 05 CB
ISUPPLI
ISUPPLI
BIOLA UNIV. PLAN
SV 10-20/100% AIWF SEL AB
SV 10-20/100% AIWF SEL
BIOLA PLAN
COBRA
SV 10/100% TENET 06
SV 10/100% TENET 06 AB
SV 10/100% ABC 06 AB
SP 15/100% ALDILA 06
SP 15/100% ALDILA 06 CB
SP 15/100% ALDILA 06 AB
SV 10/100% TENET 06 CB
SV 10/100% LCKMARTIN 06
SV 10/100% CTY ANHM 07
SV 10/100% C ALAMEDA 06
SV 10/100% LCKMARTIN 06 AB
DUMMY
SV 10/100% C ALAMEDA 06 CB
DUMMY
SV 10/100% C ALAMEDA 06 AB
SV 10/100% LCKMARTIN 06 CB
SH ALAMEDA STD MED
SH ALAMEDA STD W/ HI DEN
SH ALAMEDA PART B ONLY MED
SH ALAMEDA PART B W/ HI DE
SH ALAMEDA PLUS PLAN MED
SH ALAMEDA PLUS W/ HI DEN
SH ALAMEDA PART B PLUS MED
75 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
AL8
ALA
ALB
ALC
ALD
ALE
ALF
ALG
ALH
ALJ
ALK
ALM
ALP
ALT
ALW
ALX
ALY
ALZ
AM2
AM3
AM4
AM5
AM6
AM7
AM8
AM9
AMA
AMB
AMC
AMD
AME
AMF
AMG
AMH
AMJ
AML
AMR
AMS
AMT
AMV
AMX
AMY
AMZ
AN2
ANA
ANB
ANC
ANH
ANJ
ANL
Plan / Benefit Description
SH ALAMEDA B PLUS & HI DEN
ASIAN-L.A./ORANGE BASIC
ASIAN-L.A./ORANGE NO PRT A
LOCKHEED-HOURLY
ALAMEDA CLASSIC I W/OP DDS
SP 15/100% ALDILA 05
*** OK TO USE ***
KEENAN COMP 1 AMEDA GR07
SV 10/350A HTAU 06
SV 20/250A+20%ABC APP 05AB
KEC 1 AMEDA HI GR07
KEC 1 AMEDA LO GR07
SV 15/250A ABC 06 AB
SV 20/250A+20%ABC APP 05
SV 20/250A+20%ABC APP 05CB
SP 15/100% ALDILA 05 AB
SP 15/100% ALDILA 05 CB
LOCKHEED-HOURLY
COBRA
AMGEN $10/100%
AMGEN $10/100% COBRA
DMR UNION $5/$350A
AMR UNION $5/$350A COBRA
AMR UNION $10/350A
AMR UNION $10/350A COBRA
AMR UNION $20/$350A
AMR UNION $20/$350A COBRA
SH BASIC PLAN ALAMEDA CO.
SH BASIC-SAN FRANCI B ONLY
MARTIN MARIETTA PLAN
SV 5/350A HTAU 06
SV 15/100% C ALAMEDA 06
SV 5/350A HTAU 06 CB
SV 10/100% AMGEN
ADM CDE-OVR 20 OPMH VISITS
SV 10/100% AMGEN AB
SV 5/350A HTAU 06 AB
AMER MED RESPONSE
SV 15/100% C ALAMEDA 06 CB
SV 20/250A + 20% ABC 06 CB
SV 20-40/80% AI 07 CB
SV 15/100% C ALAMEDA 06 AB
SV 5/100% AME MED 07
MARTIN MARIETTA PLAN
SV 10/100% CTYANHM 06
ASIAN-NO.CAL.BASIC PLAN
ASIAN-NO.CAL.NO PART A
SV 20/350A HTAU 06 CB
SV 10/350A HTAU 06 CB
SV 10/100% CTY OF ANAHM AB
SV 10/100% AMGEN 06
76 of 640
Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
ANN
ANP
ANX
ANZ
AOB
AOC
AOK
AOZ
AP2
AP3
AP4
AP5
AP6
AP7
APB
APD
APE
APF
APG
APJ
APK
APN
APQ
APR
APS
APU
APV
APW
APX
APY
APZ
AQA
AQD
AQG
AQH
AQJ
AQK
AQQ
AQT
AQV
AQX
AQY
ARB
ARC
ARH
ARJ
ARL
ARN
ARQ
ART
Plan / Benefit Description
SV 10/100% CTY OF ANAHM
SV 10/100% CTY OF ANAHM CB
SV 10/100% AMGEN 06 AB
SV 10/100% AMGEN 06 CB
ADM CODE-PAC BELL/OB/GYN
ROCKWELL-HOURLY
10/30V 1YR GR-CH07
ROCKWELL-HOURLY
COBRA
CALPERS MED SH 2002
APW LTD $15/$500A
APW LTD $15/$500A COBRA
SVA 15/500A APW
SVA 15/500A APW CB
SVA 15/500A APW 06 AB
SP 10/100% AZUSA PU 06
SP 10/100% AZUSA PU 06 CB
5/6V 1YR ACU SH07
10/12V 1YR ACU SH07
5/6V 1YR ACU SH08
SV 15-25/200A ADP AB
DUMMY
10/12V 1YR ACU SH08
SP 10/100% AZUSA PAC 07
ADMIN/PREMIUM REVERSAL
SPLIT PREMIUM - DUMMY
SP $10/100 AZUSA PU
DUMMY
SVA 15/500A APW 06
SP 10/100% AZUSA PU 06 AB
SVA 15/500A APW 06 CB
SV 15-25/200A ADP CB
SV 10/100% OAKDALE ID 05
SV 10/100% OAKDLE ID 05 CB
SV 5/100% AME MED 07 CB
SV 20-40/500D ADP 07
SV 10/100% OAKDLE ID 05 AB
SP 20/100A AGC 06
SP 10/100% AZUSA PAC 07 CB
SV 20/250A + 20% ABC 06 AB
SP 20/100A AGC 06 CB
SP 20/100A AGC 06 AB
SV 5/100% AME MED 07 AB
SV 20-30/250A IKON 06
RETAIL CLERK PLAN
MCC 2 ALAMEDA HIGH SH07
SV 20-30/250A IKON 06 AB
MCC 2 ALAMEDA LOW SH07
MC COMP 2 ALAMEDA SH07
SP 10/100% AZUSA PAC 07 AB
ADVANCED REPRODUCTIVE THER
77 of 640
Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
ARU
ARW
ARX
ARY
ARZ
AS1
AS2
ASA
ASC
ASE
ASF
ASG
ASH
ASJ
ASL
ASM
ASP
ASQ
AST
ASU
ASX
ASZ
AT1
AT2
AT3
AT4
AT5
AT6
AT7
ATA
ATB
ATC
ATD
ATH
ATJ
ATK
ATL
ATM
ATP
ATQ
ATT
ATU
ATV
ATX
ATZ
AU2
AU3
AU5
AUA
AUJ
Plan / Benefit Description
SV 15-30/250A ADP 07
SV 15-30/250A ADP 07 CB
SV 15-30/250A ADP 07 AB
SV 20-30/250A IKON 06 CB
RETAIL CLERK PLAN COBRA
ALLERGY SERUM (SPECIAL)
SMALL GROUP ALLERGY SERUM
1996 SUB AGRMT ALL CHANGES
PERS-MED. SH BENEFIT
ALLERGY SERUM DCHS $10/P
ALLERGY SERUM DCHS $5/NC
ALLERGY SERUM DCHS $10/SC
SV 10/350A HTAU 06 AB
SV 15/250A ADMIN AB
SV 5/100% C ALAMEDA 06
ALAMEDA CLASSIC I
PERS-MED. SH BENEFIT
SH AREA REDUCTION PLAN
SV 5/100% C ALAMEDA 06 CB
SP $10/100 AZUSA PU CB
SV 5/100% C ALAMEDA 06 AB
PERS-MED. SH BENEFIT COBRA
SV ABC APPRN TRST-HIGH
SV ABC APPRN TRST-HIGH CB
SV ABC APPRN TRST-APPRN
SV ABC APPRN TRST-APPRN CB
SV ABC APPRN TRST-LOW
SV ABC APPRN TRST-LOW CB
ATW-STD SH-WL07
SVA AT&T $10-$15/$100A
SVA AT&T $10-$15/$100A CB
PREFERRED PLAN SCE RET
10/20V ACU/CH06
SVA 10-15/100A AT&T 06
SVA AT&T $10-$15/$100A AB
15/20V ACU/CH06
SVA 10-15/100A AT&T 06 CB
SV 15/100% AGCHWT 06 AB
ATW-PLUS SH-WL07
ATW ENHANCED SH08
AT&T
ATW-PLUS WL-SH08
ATW-STD WL-SH08
SVA 10-15/100A AT&T 06 AB
PREFERRED PLAN SCE RET
$20-$25/100%
$20-$25/100% COBRA
SV $20-$25/100% ARAMARK CB
SV 25-30/250A ARAMARK 06
SV $20-$25/100% ARAMARK AB
78 of 640
Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
AUR
AUS
AUT
AUX
AUZ
AV1
AV6
AVB
AVD
AVE
AVF
AVH
AVJ
AVL
AVN
AVV
AVX
AVY
AVZ
AWB
AWC
AWG
AWH
AWJ
AWK
AWM
AXA
AXB
AXD
AXE
AXF
AXH
AXJ
AXR
AXW
AXZ
AYA
AYJ
AYW
AYZ
AZ2
AZ3
AZ6
AZA
AZC
AZG
AZJ
AZM
AZR
AZT
Plan / Benefit Description
U/R MGMT. FEE - ARMSTRONG
SV $20-$25/100% ARAMARK
SV 10-20/100% AIWF SEL CB
SV 25-30/250A ARAMARK 6 AB
SV 25-30/250A ARAMARK 6 CB
SV 15-20/100A AVON
SV 15-20/100A AVON 06
SV 20-30/250A AVAD 08
SV 15-25/200A ADP 07 CB
SV 15/250A ADMSTFF 07 CB
SV 10/100% CTY ANHM 07 CB
MCC ESS ALAMEDA HIGH SH07
SV 15-20/100A AVON AB
MCC ESS ALAMEDA LOW SH07
MC COMP ESS ALAMEDA SH07
SV 20-40/80% AI 07 AB
SV 15-20/100A AVON 06 AB
SV 15-20/100A AVON 06 CB
SV 15-20/100A AVON CB
SV 20-30/250A AVAD 08 CB
SV 20/350A HTAU 06 AB
SV 10-20/100D AIW SEL06
SV 20-40/500D ADP 07 CB
SVA 15/500A APW AB
SV 10-20/100D AIW SEL06 CB
SV 10-20/100D AIW SEL06 AB
SV 15-25/90% TENET 06
SV 20-30/250A AVAD 08 AB
SV 15-25/200A ADP 07 AB
SV 15/250A ADMSTFF 07 AB
SV 10/100% CTY ANHM 07 AB
SV 20-40/500D ADP 07 AB
SV 15-25/90% TENET 06 AB
SV 20/100% AIR-C&R 06 AB
SV 20-40/500A+10% ATT07
SV 15-25/90% TENET 06 CB
SV 20-30/100A LHMRTN 06
SV 20-30/100A LHMRTN 06 AB
SV 20-40/500A+10% ATT07 CB
SV 20-30/100A LHMRTN 06 CB
CALPERS MED SH 2002 COBRA
ADMINISTAFF $15/$250A CBRA
SV 15/250A ADMIN CB
NON STD $10/$250 COBRA
SV 10-15/150A AMR 06
SV 10/100% AMGEN CB
PREFERRED PLAN II AB
AMER MED RESPONSE COBRA
SV 10-15/150A AMR 06 CB
AT&T COBRA
79 of 640
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
AZW
AZX
B0D
B0H
B0L
B0N
B1C
B1D
B1H
B1J
B1L
B1N
B1T
B1X
B1Z
B25
B2A
B2B
B2C
B2D
B2E
B2F
B2G
B2H
B2J
B2P
B2R
B2X
B3A
B3B
B3C
B3D
B3E
B3F
B3G
B3H
B3J
B3P
B3R
B4A
B4B
B4C
B4D
B4E
B4F
B4G
B4H
B4J
B4P
B4R
Plan / Benefit Description
SV 20-40/500A+10% ATT07 AB
SV 10-15/150A AMR 06 AB
MCC 3 S BERDO DELUXE SH07
MCC 3 S BERDO HIGH SH07
MCC 3 S BERDO LOW SH07
MC COMP 3 S BERDO SH07
NON-STANDARD $2 PLAN
MCC ESS S BERDO DELUX SH07
MCC ESS S BERDO HIGH SH07
SP 20/500D BEAUDRY AB
MCC ESS S BERDO LOW SH07
MC COMP ESS S BERDO SH07
BUTTE STANDARD PLAN
BOEING REP PLAN I COBRA
NON-STANDARD $2 PLAN COBRA
BEHAVORIAL HEALTH
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
BOEING REP PLAN II COBRA
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
80 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
B50
B5A
B5B
B5C
B5D
B5E
B5F
B5G
B5H
B5J
B5P
B5R
B6A
B6B
B6C
B6D
B6E
B6F
B6G
B6H
B6J
B6R
B7A
B7B
B7C
B7D
B7E
B7F
B7G
B7H
B7J
B7P
B7R
B8A
B8B
B8C
B8D
B8E
B8F
B8G
B8H
B8J
B8P
B8R
B9A
B9B
B9C
B9D
B9E
B9F
Plan / Benefit Description
BASIC 5 PLAN
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
81 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
B9G
B9H
B9J
B9P
B9R
BA0
BA1
BAA
BAB
BAD
BAJ
BAX
BAY
BAZ
BBA
BBB
BBC
BBD
BBE
BBF
BBG
BBJ
BBK
BBP
BBZ
BCA
BCB
BCC
BCD
BCJ
BCK
BCT
BCX
BCY
BCZ
BDA
BDC
BDD
BDE
BDH
BDJ
BDL
BDP
BDR
BDS
BDZ
BEA
BEB
BED
BEJ
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
BASIC PLAN INACTIVE
BASIC PLAN
SV 20/250A PBGH BCTL 06
SV 10/100% BOEING 06
SV 10/100% BOEING 06 CB
SV 15/150A BAYER AB
SV 10/100% BOEING 06 AB
SV 15/150A BAYER
SV 15/150A BAYER CB
SV 20/250A PBGH BCTL 06
SV 15/250A BOEING 06
SANTA BARBARA CLASSIC I
SV 15/250A BOEING 07
S BARBARA CLSC I W/EPO DDS
SV 15/250A BOEING 06 CB
SV 20-30/250A BP 07
SV 20/250A PBGH BCTL 06 AB
SV 15/250A BOEING 06 AB
S BARBARA CLSC I W/ODP
SV 20/250A PBGH BCTL 06 CB
SV 15/150A BAYRCRP 06
SV 10/100% BOEING 06
NOT USED
SV 10/100% BOEING 06 CB
SV 15/150A BAYRCRP 06 AB
$15/$250 BECKMAN
CONTRA COSTA - PART B ONLY
SV 10/100% BOEING 06 AB
SV 15/150A BAYRCRP 06 CB
$15/$250 BECKMAN COBRA
0/250A BOEING IAM725 GR 06
SAN BERNARDINO CLASSIC I
S BERDO CLSC I W/OP DDS
S BERDO CLSC I W/EPO DDS
S BERDO CLSC I W/HI OP DDS
SP $10 BD BIO PHARMAGIN AB
0 BO IAM 725 NO-AARP GR08
SP $10 BD BIO PHARMAGIN
SV 20-40/250A BAC 07
OTHER SO. CA - OPTION DNTL
SP $10 BD BIO PHARMAGIN CB
SV 15-20/250A BECKMN 06
SV 15/100% BOEING 06
SV 15/100% BOEING 06 CB
SV 15-20/250A BECKMN 06 AB
82 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
BER
BES
BEX
BEZ
BFA
BFB
BFE
BFG
BFH
BFJ
BFN
BFP
BFR
BFZ
BGA
BGC
BGD
BGE
BGG
BGH
BGJ
BGP
BH2
BH4
BHA
BHJ
BHZ
BJA
BJD
BJF
BJG
BJH
BJJ
BJL
BJN
BJZ
BK1
BK2
BK3
BK4
BK5
BK6
BK7
BKD
BKE
BKF
BKJ
BKM
BKN
BKU
Plan / Benefit Description
SV 20-40/250A BAC 07 CB
S BERDO CLSC ENHANCED
SV 15/100% BOEING 06 AB
SV 15-20/250A BECKMN 06 CB
SV 15/100% BOEING 06
SPA 30/500A BARNEY 06
MCC SAN BARBARA EP SH07
SPA 30/500A BARNEY 06 CB
SPA 30/500A BARNEY 06 AB
SV 15/100% BOEING 06 AB
MC COMP SAN BARBARA SH07
MCC SAN BARBARA PP SH07
SV 20-40/250A BAC 07 AB
SV 15/100% BOEING 06 CB
SV 25/250A 07
SV 25/250A 07 CB
SV 15/250A BOEING 07 CB
SV 25/250A 07 AB
SV 20-30/250A BP 07 CB
SV PBGH $20/$250A
SV PBGH $20/$250A AB
SV PBGH $20/$250A CB
BOEING NA-HRLY $10 GRP RET
BOEING HOURLY $15 GRP RET
SP 20/250A BARNEY 06
SP 20/250A BARNEY 06 AB
SP 20/250A BARNEY 06 CB
SV 10/100% BOEING 06
MCC 1 S BERDO DELUXE SH07
SP 30/500A BARNEY 07
SV 20-30/250A BP 07 AB
MCC 1 S BERDO HIGH SH07
SV 10/100% BOEING 06 AB
MCC 1 S BERDO LOW SH07
MC COMP 1 S BERDO SH07
SV 10/100% BOEING 06 CB
SV $30-$40/70%
SV $30-$40/70% CB
SV $30-$40/70% CAL CB
SV $30-$40/70% FED CB DIS
SV $30-$40/70% FED CB EXT
SV $30-$40/70% CAL CB EXT
SV $30-$40/70% CAL CB DIS
SV 15/250A BOEING 07 AB
SV 15/250A BOEING 07 CB
SP 30/500A BARNEY 07 CB
SV $30-$40/70% AB
SV 15-20/250A BECKMAN
KERN - PART B ONLY
SV $30-$40/70% USERRA
83 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
BLA
BLB
BLD
BLF
BLG
BLH
BLJ
BLL
BLN
BLZ
BM1
BM2
BMA
BMB
BMC
BMD
BME
BMG
BMH
BMJ
BMR
BMS
BMX
BMY
BMZ
BNB
BNC
BNJ
BNZ
BO1
BO2
BOC
BON
BP2
BP3
BP4
BP5
BP6
BP7
BP8
BP9
BPA
BPC
BPD
BPE
BPF
BPG
BPH
BPJ
BPK
Plan / Benefit Description
LOS ANGELES - PART B ONLY
SV 15/100% BOEING 06
MCC 2 S BERDO DELUXE SH07
SP 30/500A BARNEY 07 AB
SV 15-20/250A BECKMN 07
MCC 2 S BERDO HIGH SH07
SV 15/100% BOEING 06 AB
MCC 2 S BERDO LOW SH07
MC COMP 2 S BERDO SH07
SV 15/100% BOEING 06 CB
SP 20/500D BEAUDRY
SP 20/500D BEAUDRY CB
SV 20-30/250A IBM 06
SV 20-40/500D BEAU 06
SV 15-20/250A BECKMAN CB
S BERDO MEDICAL W/OP DDS
S BERDO MEDICAL W/EPO DDS
SV 15/250A BOEING 07 AB
S BERDO MEDICAL W/HI DDS
SV 15-20/250A BECKMAN AB
SV 20-40/500D BEAU 06 CB
SAN BERNARDINO MEDICAL
SV 20-30/250A IBM 06 AB
SV 20-40/500D BEAU 06 AB
SV 20-30/250A IBM 06 CB
SP $20 BARNEY & BARNEY
SV 15/250A BOEING 07
SP $20 BARNEY & BARNEY AB
SP $20 BARNEY & BARNEY CB
BOEING REP PLAN I
BOEING REP PLAN II
ORANGE - PART B ONLY
2006 PART B ONLY PLAN
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
84 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
BPL
BPM
BPN
BPP
BPQ
BPR
BPS
BPT
BPU
BPV
BPW
BPX
BPY
BPZ
BR2
BR3
BR4
BR5
BR6
BR7
BR8
BR9
BRC
BRG
BRH
BRJ
BRS
BRZ
BS1
BS7
BSA
BSC
BSD
BSE
BSG
BSL
BSM
BSR
BST
BSX
BSZ
BT1
BT2
BT3
BT4
BT5
BT6
BT7
BT8
BTA
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
2004 PART B ONLY PLAN
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
SV 15/100% BOEING 06
SV 15-20/250A BECKMN 07 CB
15/250A BH 08 DONOT USE
SV 15/100% BOEING 06 AB
RIVERSIDE - PART B ONLY
SV 15/100% BOEING 06 CB
$20/$250 BECHTEL GR
BARIATRIC SURGERY 06
1996 SUB AGRMT-LEGAL ONLY
SOUTH CAL EDISON PLAN
SAN DIEGO-I : PART B ONLY
SAN BERNARDINO - PART B
SAN DIEGO-II : PART B ONLY
SAN LUIS OBISPO - PART B
SACRAMENTO - PART B ONLY
SANTA BARBARA -PART B ONLY
SAN MATEO - PART B ONLY
SANTA CLARA - PART B ONLY
SOUTH CAL EDISON COBRA
SH BUTTE STD MED
SH BUTTE STD W/ HI DEN
SH BUTTE PART B STD MED
SH BUTTE PART B W/ HI DEN
SH BUTTE PLUS PLAN MED
SH BUTTE PLUS W/ HI DEN
SH BUTTE PART B PLUS MED
SH BUTTE B PLUS W/ HI DEN
RESERVED TENET BH 06
85 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
BTD
BTG
BTH
BU1
BU2
BU3
BU4
BU5
BU6
BU7
BU8
BU9
BUA
BUB
BUC
BUD
BUE
BUF
BUG
BUH
BUI
BUJ
BUK
BUL
BUM
BUN
BVA
BVB
BVC
BVD
BVE
BVJ
BVL
BVX
BWA
BWD
BWE
BWH
BX1
BX2
BX3
BX4
BX5
BX6
BX7
BX8
BX9
BXA
BXB
BXC
Plan / Benefit Description
RESERVED TENET BH 06
SV 15-20/250A BECKMN 07 AB
NOT IN USE
PREFERRED PLAN (BIOLA)
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
SH BUTTE PART B PLUS MED
RESERVED FOR RX PPO
RESERVED FOR RX PPO
BUTTE COUNTY-BASIC PLAN
BUTTE COUNTY-PART B ONLY
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
SV $15-$25/$250A BOEING
SV $15-$25/$250A BOEING CB
SV 15-25/250A BOEI 06
SV 15-25/250A BOEI 06 CB
15/100A BOEING VEBA GR07
SV $15-$25/$250A BOEING AB
15 BO-VEBA NON-AARP GR08
SV 15-25/250A BOEI 06 AB
*** OK TO USE ***
S BRDO CLSC ENHNCD W/OPDDS
S BRDO CLSC ENHNCD W/EPDDS
S BRDO CLSC ENHNCD W/HIDDS
BAXTER PLAN
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
86 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
BXD
BXE
BXF
BXG
BXH
BXJ
BXK
BXL
BXM
BXN
BXP
BXR
BXS
BXT
BXU
BXV
BXW
BXX
BXY
BXZ
BYA
BYB
BYC
BYD
BYE
BYF
BYG
BYH
BYJ
BYK
BYL
BYM
BYN
BYP
BYR
BYS
BYU
BYW
BYY
BZ0
BZ1
BZ3
BZ4
BZ5
BZ6
BZ7
BZ8
BZ9
BZA
BZB
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
ARP MCC S BRBRA PP SH08
ARP MCC S BRBRA SH08
ARP MCC S BRBRA EP SH08
BASIC 5 PLAN COBRA
BASIC PLAN (COBRA)
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
87 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
BZC
BZD
BZE
BZG
BZH
BZJ
BZK
BZL
BZM
BZN
BZP
BZR
BZS
BZT
BZU
BZV
BZW
BZX
BZY
BZZ
C10
C11
C1C
C1G
C1J
C1N
C1T
C1Y
C1Z
C20
C22
C27
C2B
C2C
C2E
C2H
C2J
C2M
C2V
C2Z
C3C
C3G
C3J
C3T
C3U
C3V
C3W
C3Z
C40
C4C
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
PREFERRED PLAN (BIOLA)
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RG CHIRO CUSTOM
CHIRO - RETIREE GOLD CUST
STANDARD 3 PLAN
II
GM SLRY HMO 2001$3
STANDARD 3 PLAN II AB
$10G/$25B
CONTRA COSTA STANDARD PLAN
GM SLRY HMO 2001$3 COBRA
STANDARD 3 PLAN COBRA II
RETIREE GOLD 200 DENTAL
SP 25/250A CREST 06 AB
SC 90 ELIGIBILITY ONLY
SP 25/250A CREST 06 CB
MFP STANDARD 3 PLAN II
15/30V GR-CH06
SV 10/100% CHLDRNS HOSP
SV 10/100% CHLDRNS HOSP AB
15/20V ACU/CH07
SV 5/100% SCSVEBA 06
MFP STAND 3 PLAN COBRA II
$3 GENERAL MOTORS
SV 10/100% CA FLD IRN 06
VEBA $5/100%
AB
CONTRA COSTA PLUS PLAN
SV 10/100% CA FLD IRN 06AB
SV 5/100% SCSVEBA 06
SV 10/100% CA FLD IRN 06AB
$3 GENERAL MOTORS
RG CENTURY DENTAL 400 N CA
NOT USED
88 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
C4H
C4J
C4P
C4Q
C4R
C4T
C4U
C4Z
C50
C5C
C5F
C5G
C5H
C5J
C5L
C5T
C5V
C5W
C5X
C63
C64
C65
C6A
C6H
C6J
C6L
C6T
C6W
C6X
C6Z
C73
C74
C75
C7A
C7C
C7E
C7F
C7G
C7H
C7J
C7K
C7L
C7M
C7N
C7P
C7S
C7T
C7U
C7W
C7Y
Plan / Benefit Description
SV 5/100% CHLDHSP 05
SV 5/100% CHLDHSP 05 AB
SV 15/100% CAMINO MG 07
SV 15/100% CAMINO MG 07 CB
SV 15/100% CAMINO MG 07 AB
AUNTRA COSTA STD W/OPT DDS
10/12V 1YR GR-CH07
SV 5/100% CHLDHSP 05 CB
RETIREE GOLD 550 DENTAL
NOT USED
10/30V ACU/30V CHIRO 07
CAREGIVER ENHANCED GR-CG07
ARP MCC S CLARA HI SH08
VEBA $10/100% AB
ARP MCC S CLARA LO SH08
CONTRA COSTA STD. W/HI DNT
SV 10/100% SCSVEBA 06
ARP MCC S CLARA SH08
ARP MCC S CLARA DLX SH08
KEC C COSTA CG GR07
KEC C COSTA LO CG GR07
KEC C COSTA HI CG GR07
SV 20-40/400D CKE 06
ARP MCC C CSTA HI SH08
CHWSC SIGPOS 100/80/50 AB
ARP MCC C CSTA LO SH08
CONTRA COSTA PLUS W/ DENTL
ARP MCC C CSTA SH08
SV 20-40/400D CKE 06 AB
SV 20-40/400D CKE 06 CB
KEC C COSTA CGII GR07
KEC C COSTA LO CGII GR07
KEC C COSTA HI CGII GR07
5/12V 1YR GR-CH07
COLA 2001 HMO $3/100
10/12V 1YR GR-CH07
10/20V 1YR GR-CH07
10/30V 1YR GR-CH07
15/12V 1YR GR-CH07
15/20V 1YR GR-CH07
0/20V 1YR GR-CH07
15/30V 1YR GR-CH07
20/12V 1YR GR-CH07
25/12V 1YR GR-CH07
5/10V 1YR GR-CH07
30/12V 1YR GR-CH07
CONTRA COSTA PLUS W/HI DEN
5/20V 1YR GR-CH07
5/30V 1YR GR-CH07
5/40 1YR GR-CH07
89 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
C7Z
C80
C83
C84
C85
CA0
CA1
CA2
CA3
CA4
CA5
CA6
CA7
CA8
CA9
CAA
CAB
CAC
CAD
CAE
CAF
CAG
CAH
CAI
CAJ
CAK
CAL
CAM
CAN
CAO
CAP
CAQ
CAR
CAS
CAU
CAW
CAZ
CB0
CB1
CB2
CB3
CB4
CB5
CB6
CB7
CB8
CB9
CBA
CBB
CBC
Plan / Benefit Description
COLA 2001 HMO$3/100 COBRA
RETIREE GOLD 800 DENTAL
KEC C COSTA CGEH GR07
KEC C COSTA LO CGEH GR07
KEC C COSTA HI CGEH GR07
$0
CARPENTERS PLAN
$2
$3
$4
$5
$6
$7
$8
$9
$10
$5G/$10B
LA MACHINISTS
$1
$5G/$5+30%B
$5G/10B/OON
$10G/$15B
$5
$5G/$10B
$7
$5
$10
$5
$10
$0
$5G/$10B
$10G/$15B
$5G/$25B
$10G/$30B
$10
$10G/$30B
LA MACHINISTS
COBRA
$0
$1
$2
$3
$4
$5
$6
$7
$8
$9
$10
$5G/$10B
$5G/$5+30%B
90 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
CBD
CBE
CBF
CBG
CBH
CBI
CBJ
CBK
CBL
CBM
CBN
CBP
CBR
CBS
CBT
CBV
CBW
CBZ
CC1
CC2
CC3
CC4
CC5
CC6
CC7
CC8
CCA
CCB
CCC
CCD
CCE
CCF
CCG
CCI
CCJ
CCK
CCL
CCM
CCW
CCY
CCZ
CD0
CD1
CD2
CD3
CD4
CD5
CD6
CD7
CD8
Plan / Benefit Description
$6G/$12B
SV 15/250A CCEB 05
$5G/$15B
SP 25/250A CREST 06
MCC C COSTA HIGH SH07
$5G/$7B
SV 15/250A CCEB 05 AB
SP 10/100% CBM 07
MCC C COSTA LOW SH07
$3 FLAT
MC COMP C COSTA SH07
$10G/$20B
$5G/$25B
$10G/$30B
SP 25/250A CREST BEV 07
COBRA VENDOR PREM ALLOCATE
SP 10/100% CHW-B 07
SV 15/250A CCEB 05 CB
SH CONTRA COSTA STD MED
CONTRA COSTA MED W/ HI DEN
SH CONTRA COSTA PART B MED
CONTRA COSTA B W/ HI DEN
SH CONTRA COSTA PLUS MED
CONTRA COSTA PLUS & HI DEN
CONTRA COSTA B W/ HI DEN
CONTRA COSTA B PL & HI DEN
CAL COBRA 10% ADMIN FEE
CAL COBRA RETENTION
SV $3/$35 COAST CMNTY CB
$6G/$12B
END C COSTA BASIC W/ NO DE
KEENAN COMP C COSTA GR07
0/20V ACU/20V CHIRO 07
SH CONTRA COSTA STD MED
SV $3/$35 COAST CMNTY AB
KEC C COSTA HI GR07
KEC C COSTA LO GR07
SV 10/100% CHW-A 07
SV 10/100% CCCYO 06
SV 10/100% CCCYO 06 CB
SV 10/100% CCCYO 06 AB
LIFELINK CD100 1995
LIFELINK-CHEM DEP 100%
LIFELINK CD80
SV 10/100% OCEANSD 06 AB
SV 10/100% CHW 06 AB
SP 10/100% CHW 06 AB
SP 10/100% CHW 06 AB
SP 10/100% CHW 06 AB
LIFELINK-CHEM DEP 80%
91 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
CD9
CDA
CDB
CDC
CDD
CDE
CDF
CDG
CDH
CDJ
CDK
CDL
CDM
CDN
CDP
CDQ
CDR
CDS
CDT
CDU
CDV
CDX
CDZ
CE2
CE4
CE6
CE8
CE9
CEA
CEB
CEC
CED
CEE
CEF
CEG
CEH
CEJ
CEM
CEO
CEP
CEQ
CES
CET
CEU
CEY
CEZ
CF0
CF1
CF2
CF3
Plan / Benefit Description
10/40V CH 07
SV 15/250A SCHWAB 06
RET.GOLD DENTAL BASIC
SV 10/100% CHBRSCHL 05
SV 10/100% CHW 06
SV 10/100% CHBRSCHL 05 CB
SP 10/100% CHW 06
SP 10/100% CHW 06
SP 10/100% CHW 06
SV 15/250A SCHWAB 06 AB
SP 10/100% CBM 07 CB
$5G/$5B
SV 10/100% CHW-A 07 CB
SV 10/100% OCEANSD 06
CENTRAL CAL DENTAL PLAN
SV 10/100% CHW 06 CB
SP 10/100% CHW 06 CB
STANDARD 10 PLAN (NO FP)
SP 10/100% CHW 06 CB
SP 10/100% CHW 06 CB
SV 10/100% OCEANSD 06 CB
SV 10/100% CHBRSCHL 05 AB
SV 15/250A SCHWAB 06 CB
5/40V CH 07
5/30V CH 07
5/20V CH 07
10/30V CH 07
14/20V CH 07
SP 10/100% CALLAWAY 05
SVA 20/250A CENTRE 06
SV 15/250A C CONSTN 06
$0G/$0B
SV 15/250A C CONSTN 06 CB
SVA 20/250A CENTRE 06 CB
SV 15/250A C CONSTN 06 AB
SVA 20/250A CENTRE 06 AB
SP 10/100% CALLAWAY 05 AB
SV 10/100% CHW-A 07 AB
15/30V CH 07
C. COSTA CLSC I W/EPO DDS
SV 15-25/100A COMCAST07
SV 15-25/100A COMCAST07 CB
SP 25/250A CREST BEV 07 CB
SV 15-25/100A COMCAST07 AB
SP 10/100% CALLAWAY 05 CB
SV CKE LOW OPTION CB
SR. PLAN SO.CAL CHIRO
SR. PLAN PLUS SO.CAL CHIRO
SR. PLAN/PLUS CHIRO-NO CAL
SR. PLAN PREMIER CHIRO
92 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
CF4
CF5
CF6
CF7
CF8
CF9
CFA
CFB
CFC
CFD
CFE
CFF
CFH
CFJ
CFK
CFN
CFO
CFR
CFS
CFT
CFU
CFZ
CG3
CG4
CG5
CG6
CG7
CG8
CG9
CGC
CGE
CGG
CGI
CGJ
CGK
CGL
CGM
CGP
CGQ
CGR
CGS
CGT
CGU
CGV
CGX
CH0
CH1
CH2
CH3
CH4
Plan / Benefit Description
CHIRO - RETIREE GOLD NO CA
CHIRO RETIREE GOLD CUSTOM
RG PREMIER CUSTOM
CHIRO RETIREE GOLD
RG CHIRO CUSTOM
RG CHIRO CUSTOM
RESERVED FOR RX PPO
BASIC ONLY - CHIRO
CLOSED RX/CENTRAL 1,000
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
CHIRO HI-OPTION SUPP.
SV CKE HIGH OPTION AB
SP 10/100% CBM 07 AB
CLOSED RX/NORTHERN 1,200
RET.GOLD $3 CO-PAY
RT. GOLD CHIRO $0 A-1325
CLOSED RX/SOUTHERN 2,500
RET.GOLD $0 CO-PAY EH790
CLOSED RX/UPR NO.CAL.1,500
SV CKE HIGH OPTION CB
SV 10-15/100% CAPTL GRP
SV 10-15/100% CAPTL GRP CB
0/20V CH 07
SV CAPITAL 25/30/500A
SV CAPITAL 25/30/500A CB
10/20V CH 07
15/20 CH 07
$5G/$5B
CAREGIVER ENHANCED-LACERS
CAREGIVER-SH GOLD
CAREGIVER-SH INDIV
SV 10-15/100% CAPTL GRP AB
SV 20-40/400A CKE 08
CAREGIVER LITE SH06
$5G/$5B
CAREGIVER PROGRAM
SP 15/250A CALLAWAY 07
CAREGIVER- RESPITE SH06
CAREGIVER PROGRAM
CAREGIVER STD CG-SH08
CAREGIVER-RESPITE CG-SH08
CAREGIVER CG-GR08
CAREGIVER ENHANCED
CHIROPRACTIC CARE
CHIROCARE 5/40 PLAN
CHIROCARE 5/30 PLAN
CHIROCARE 5/20 PLAN
CHIROCARE 10/30 PLAN
93 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
CH5
CH6
CH7
CH8
CH9
CHA
CHB
CHC
CHD
CHE
CHF
CHG
CHH
CHI
CHJ
CHM
CHO
CHP
CHQ
CHR
CHS
CHU
CHV
CHW
CHZ
CJA
CJC
CJD
CJJ
CJK
CJL
CJM
CJS
CJV
CJW
CJX
CJY
CK1
CK2
CK3
CK4
CK5
CK6
CK7
CKA
CKB
CKC
CKE
CKF
CKG
Plan / Benefit Description
CHIROCARE 14/20 PLAN
CHIROCARE $5/$1500 PLAN
CHIROCARE 50%/$1500 PLAN
CHIROCARE 10/20 PLAN
CHIROCARE $15/20 VISITS
CHIROCARE $15/30 VISITS
CHIROCARE $15/30 VISITS
CHIROCARE 5/20 PERS
CHIROCARE $10/40 VISITS
CHIROCARE $15/40VISITS POS
SUTTER CHIRO $10/20 VISITS
$15/30 GRP RET
CHW $10/H
CHIROPRACTIC-PLHIC
CHIRO $0/20 VISITS
CHIROCARE 10/30 PLAN
SR PLAN CHIRO
CHW $10/P
FEDS 10/20V ACU/CHIRO 05
CHIRO-RETIREE $10/12
CHIROCARE 10/30 SMALL GRP
10/12V 1YR SH-CH07
FEDS 10/20V ACU/CHIRO 07
10/12V 1YR CH-SH08
SV 10/100% CHLDRNS HOSP CB
SP 10/100% CRYROP 06
SV 10/100% CVSHWT 06
$10G/$15B
SP 10/100% CRYROP 06 AB
SV 20-40/400A CKE 08 CB
SV 10/100% CVSHWT 06 CB
SV 10/100% CVSHWT 06 AB
SP 10/100% CHW-D 07
SP 10/100% CHW-C 07
SP 10/100% CHW-C 07 CB
SP 10/100% CHW-C 07 AB
SP 10/100% CRYROP 06 CB
SV $10-$30/100%
SV $10-$30/100% CB
SV $10-$30/100% CAL CB
SV $10-$30/100% FED CB DIS
SV $10-$30/100% FED CB EXT
SV $10-$30/100% CAL CB EXT
SV $10-$30/100% CAL CB DIS
10/100A CCSF GR07
SV 25-50/400D CKE 08
SV 15-30/400A CKE 06
CKE RESTAURANTS INC
SV CKE HIGH OPTION
SV 10/100% SAN BERDO 07
94 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
CKH
CKJ
CKK
CKL
CKN
CKP
CKS
CKU
CKX
CKY
CKZ
CLA
CLC
CLD
CLE
CLF
CLG
CLH
CLJ
CLK
CLL
CLM
CLN
CLQ
CLS
CLT
CLU
CLW
CLY
CLZ
CM0
CM1
CM2
CM3
CM4
CM5
CM6
CM7
CM8
CM9
CMA
CMB
CMC
CMD
CME
CMI
CMK
CMM
CMP
CMQ
Plan / Benefit Description
SV 10/100% CHILD HOS 08
SV $10-$30/100% AB
SV 20-40/400A CKE 08 AB
SV CKE LOW OPTION
SV 15-30/400A CKE 06 CB
CKE RESTAURANTS INC
SP 10/100% CHW-D 07 CB
SV $10-$30/100% USERRA
SV 15-30/400A CKE 06 AB
CKE RESTAURANTS INC COBRA
CKE RESTAURANTS INC COBRA
SV 5/100% COLA 06
UNIVERSAL 3 PLAN
II
C. COSTA CLSC I W/OP DDS
SV 25-30/500A CGRP 07
SV 25-30/500A CGRP 07 CB
SV 3/100% COAST COMM 06
MCC ESS C COSTA HIGH SH07
SV CKE LOW OPTION AB
SV 10/100% COLA 08
MCC ESS C COSTA LOW SH07
10/100A CCSF GR07
MC COMP ESS C COSTA SH07
SV 10/100% CHW-B 07
SP 10/100% CHW-D 07 AB
SP 25/250A CREST BEV 07 AB
ARP MCC S CRUZ PP SH08
ARP MCC S CRUZ SH08
ARP MCC S CRUZ EP SH08
UNIVERSAL 3 PLAN COBRA II
LIFELINK CM100 1995
LIFELINK - CHEM/MEN 100
LIFELINK CM80 1995
PBGH CD/MH BASE PLAN
PBGH MH/CD PLAN 1A
PBGH MH/CD PLAN 1B
MH/CD IP/100% OP/$5
MH/CD IP/100% OP $10
LIFELINK - CHEM/MEN 80%
MH/CD IP/100% OP $15
$10G/$15B
SV 25-50/400D CKE 08 CB
CRISIS MANAGEMENT PLAN
C.COSTA MEDICAL W/OP DDS
C.COSTA MEDICAL W/EPO DDS
C. COSTA MEDCL W/HIOP DDS
SV 10/100% COLA 08 CB
CUSTOM MATERIALS ALLOCATIO
CONTRA COSTA MEDICAL
SV 10/100% CHW-B 07 CB
95 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
CMT
CNA
CNB
CNC
CND
CNE
CNF
CNG
CNH
CNJ
CNK
CNM
CNQ
CNY
CNZ
COA
COK
CP0
CP1
CP2
CP3
CP4
CP5
CP6
CP7
CP8
CPA
CPB
CPC
CPH
CPJ
CPL
CPN
CPR
CPU
CPX
CPY
CPZ
CQA
CQD
CQE
CQF
CQH
CQL
CQN
CQU
CR0
CR1
CR2
CR3
Plan / Benefit Description
CHIROCARE $15/40 VISITS
SV 25-30/500A CGRP 06
SV 25-50/400D CKE 08 AB
$3 PLAN COUNTY OF LA
SV 10-15/100% CGRP 07
0/20V ACU/20V CHIRO 07
SV 25-30/500A CGRP 07 AB
SV 10/100% SAN BERDO 07 CB
SV 10/100% CHILD HOS 08 CB
SV 25-30/500A CGRP 06 AB
SV 10/100% COLA 08 AB
15 CTY ANHIM NON-AARP GR08
SV 10/100% CHW-B 07 AB
SV 25-30/500A CGRP 06 CB
$3 PLAN COUNTY OF LA COBRA
15/100% CITY ANAHEIM GR07
10/30V 1YR GR-CH07
CALPERS $10/20VISITS
SH PLUS MED CHIRO
CALPERS ACTIVE
CHWSC SIGPOS 100/75/50
CHWSC SIGPOS 100/75/50 CBR
CUSTOM RX TEAMSTERS $5
CHWSC SIGPOS 100/80/50
CUST $7 RX NRTH COAST TRUS
CHWSC SIGPOS 100/80/50 CBR
RESERVED PFFS
SV 10-20/100% CALPAC 06
$3 PLAN COUNTY OF LA
SV 10-15/100% CGRP 07 CB
CHWSC SIGPOS 100/75/50 AB
SP 10/100% CRYROP 07
SV 10/100% CHW-C 07
CAP RESTORE CODE POS
SP 10/100% CHW-A 07
SV 10-20/100% CALPAC 06 AB
SV 10-20/100% CALPAC 06 CB
$3 PLAN COOUNTY OF LA CBRA
SV 20/250A SCHWAB 08
SV 15-25/500A CITIGP 07
SV 10/100% CHW-C 07 AB
SV 15-25/500A CITIGP 07 CB
SV 15-25/500A CITIGP 07 AB
SP 10/100% CRYROP 07 CB
SV 10/100% CHW-C 07 CB
SP 10/100% CHW-A 07 CB
CHIRO $0 OV/20 VISITS P/YR
PREFERRED - $0 ER PLAN
RET.GOLD $5/20 VISITS
GRP RET CHIRO $5/12VISITS
96 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
CR4
CR5
CR6
CRA
CRB
CRC
CRE
CRG
CRJ
CRL
CRN
CRR
CRU
CRX
CRY
CRZ
CS2
CS3
CS4
CS5
CS9
CSA
CSB
CSC
CSD
CSE
CSF
CSJ
CSK
CSL
CSS
CST
CSX
CSZ
CT1
CT2
CT3
CT4
CT5
CT6
CT7
CT8
CTA
CTB
CTC
CTF
CTG
CTH
CTJ
CTK
Plan / Benefit Description
GRP RET CHIRO $10/12VISITS
GRP RET CHIRO $15/12VISITS
GRP RET CHIRO $20/12VISITS
SV 10-15/100% CGRP 06
SV 10/100% CHBRSCHL 06
SV 10/100% CHBRSCHL 06 CB
IN ACTIVE DO NOT USE
CUSTOM PPO
SV 10-15/100% CGRP 06 AB
SP 10/100% CRYROP 07 AB
SV 10/100% CHBRSCHL 06 AB
10/12V GR-CH07
SP 10/100% CHW-A 07 AB
RESERVED FOR RX PPO
RESERVED FOR RX PPO
SV 10-15/100% CGRP 06 CB
CITY OF SAN DIEGO GR 2003
CITY OF SAN DIEGO GR 2004
CHARLES SCHWAB 15/100A
CHARLES SCHWAB 15/100A CBR
SV $15/$100A C SCHWAB CB
SUB AGREEMENT - CUSTOM
SV 10/100% SAN BERDO 06
STANDARD 3 PLAN - CUSTOM
CITY OF SAN DIEGO
SV $15/$100A C SCHWAB
SPT 15/35 C S DIEGO 06
SV $15/$100A C SCHWAB AB
SV 20/250A+80% COLB 07
SV 10/100% SAN BERDO 06 CB
CONTRA COSTA CLASSIC I
SV $3/$35 COAST CMNTY
SV 10/100% SAN BERDO 06 AB
STAND 3 PLAN - CUSTOM
CHIROCARE $10/20 VISITS
CHIROCARE $15/20 VISITS
CHIROCARE $15/30 VISITS
CHIROCARE $5/20 VISITS
CHIROCARE $5/30 VISITS
CHIROCARE $5/40 VISITS
CHIROCARE $10/30 VISITS
CHIROCARE $14/20 VISITS
SH BASIC CONTRA COSTA CO.
SH CONTRA COSTA CO. B ONLY
SV 15-25/500A CITIGP 06
SPT 15/35 C S DIEGO 06 CB
SV 15-25/500A CITIGP 06 CB
SV 10/100% CCCYO 05
SV10/100% CCCYO 05 AB
SV 20/250A+80% COLB 07 CB
97 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
CTT
CTW
CTX
CUA
CUB
CUF
CUG
CUH
CUK
CUW
CV2
CV3
CV4
CV5
CV6
CV7
CV8
CV9
CVA
CVB
CVC
CVE
CVF
CVG
CVH
CVJ
CVK
CVL
CVM
CVN
CVP
CVQ
CVR
CVS
CVU
CVV
CVW
CVX
CVY
CWA
CWB
CWC
CWE
CWF
CWG
CWH
CWQ
CWW
CX7
CX8
Plan / Benefit Description
SV10/100% CCCYO 05 CB
SP 10/100% CHW-B 07 CB
SV 15-25/500A CITIGP 06 AB
$5G/$20B
$10G/$25B
SPT 15/35 C S DIEGO 06 AB
SV 3/100% COAST COMM 06 CB
SV 10-15/100% CGRP 07 AB
SV 20/250A+80% COLB 07 AB
15/20V ACU/CHIRO 07
VEBA $5/100%
VEBA $5/100% COBRA
VEBA $10/100%
VEBA $10/100% COBRA
SV 15/100% VERIZON COMM CB
SV 10/250A VNTRA 06
SV 10/250A VNTRA 06 CB
SV 10/250A VNTRA 06 AB
HI-OPTION VISION $9 COPAY
HI-OPTION VISION $15 COPAY
HI-OPTION VISION $20 COPAY
SV 5/100% SCSVEBA 06 CB
SV 10/100% SCSVEBA 06 CB
SV 5/100% SCSVEBA 06 CB
SV 5/100% SCSVEBA 06 AB
SV 15/100% VERIZON COMM AB
SV 10/100% SCSVEBA 06 AB
SV 5/100% CVSHWT 06
SV 20/100% CVS 06
SV 5/100% CVSHWT 06 CB
SV 5/100% CVSHWT 06 AB
SV 0/100% CVS 06
SV 20/100% CVS 06 CB
SV 0/100% CVS 06 CB
SV 20/100% CVS 06 AB
SV 0/100% CVS 06 AB
SV 15/100% VERIZON COMM
SV 15/100% VERIZON 06
SV 5/100% SCSVEBA 06 AB
SP 15/100% CSM 07
SP 15/100% CSM 07 CB
SP 15/100% CSM 07 AB
SV 10/100% COLB 07
SVA 15/100% CHU VSTA 08
SV 10/100% SAN BERDO 07 AB
C. COSTA CLSC I W/HIOP DDS
SP 15/250A CALLAWAY 07 CB
SP 10/100% CHW-B 07 AB
SV 15/100% VERIZON 06 CB
25/12V UFCW CH-GR08
98 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
CXA
CXB
CXC
CXD
CXE
CXF
CXG
CXH
CXJ
CXX
CXZ
CYA
CYE
CYF
CYG
CYH
CYJ
CYK
CYL
CYM
CYN
CYO
CYQ
CYW
CYX
CYY
CYZ
CZ1
CZ2
CZH
CZJ
CZP
CZS
D00
D01
D02
D0C
D0D
D10
D1C
D1D
D1E
D1F
D1G
D1J
D1P
D1R
D1S
D1W
D1Y
Plan / Benefit Description
SV 20/250A SCHWAB 08 CB
SV 10/250A OCEANSD 07
SV 10/250A OCEANSD 07 CB
SV 10/250A OCEANSD 07 AB
SV 10/100% COLB 07 CB
SVA 15/100% CHU VSTA 08 CB
SV 3/100% COAST COMM 06 AB
20/30V CH 08
SV 15/100% VERIZON 06 AB
SV 20/250A SCS VEBA 06 AB
SV 20/250A SCS VEBA 06 CB
SV 20/250A SCHWAB 08 AB
SV 10/100% COLB 07 AB
SVA 15/100% CHU VSTA 08 AB
SV 10/100% CHW-D 07
SV 10/100% CHILD HOS 08 AB
SV CATH CHARITIES CYO AB
SV 10/100% CHW-D 07 CB
15/40V CH 07
SV 10/100% CHW-D 07 AB
ENTERED IN ERROR - SEE CYH
SV CATH CHARITIES CYO
SP 15/250A CALLAWAY 07 AB
SV 30/500A CCCYO 06
SV 30/500A CCCYO 06 CB
SV 30/500A CCCYO 06 AB
SV CATH CHARITIES CYO CB
04RPENTERS PLAN (COBRA)
CALPERS ACTIVE COBRA
CHW $10/H COBRA
CHW $10/H AB
CHW $10/P COBRA
STAND 10 PLAN COBRA/NO FP
DURABLE MED EQUIP $0
DURABLE MED. EQUIP. (TRW)
DME COUNTY OF LA
FEDERAL EMPLOYEES 1-99
FEHB DOD EMPLOYEES 2000
DME 10%
STANDARD 5 PLAN
II
ELITE 5 FED CBR DISABLED
ELITE 5 FED CBR EXTENDED
ELITE 5 CAL CBR EXTENDED
ELITE 5 CAL CBR DISABLED
STANDARD 5 PLAN II AB
STANDARD 5 PLAN - POS
ELITE 5
CAL COBRA
ELITE 5
ELITE 5
COBRA
STANDARD 5 PLAN - POS CBR
99 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
D1Z
D20
D2C
D2D
D2E
D2F
D2G
D2J
D2P
D2R
D2S
D2W
D2Y
D2Z
D3C
D3P
D3Y
D3Z
D4C
D4E
D4F
D4G
D4H
D4I
D4J
D4K
D4P
D4Q
D4X
D4Y
D4Z
D50
D5C
D5P
D5Y
D5Z
D6A
D6B
D6C
D6D
D6P
D6V
D6Y
D6Z
D7C
D7P
D7Y
D7Z
D8A
D8B
Plan / Benefit Description
STANDARD 5 PLAN COBRA II
DURABLE MED EQUIP 20%
MFP STANDARD 5 PLAN II
PREMIER 5 FED CBR DISABLED
PREMIER 5 FED CBR EXTENDED
PREMIER 5 CAL CBR EXTENDED
PREMIER 5 CAL CBR DISABLED
MFP STANDARD 5 PLAN II AB
MFP STD 5 - POS
PREMIER 5 PLAN CAL CBRA
PREMIER 5 PLAN
PREMIER 5 PLAN CBRA
MFP STD 5 - POS COBRA
MFP STAND 5 PLAN COBRA II
MODIFIED STANDARD 5 PLAN
STANDARD 5-CUSTOM
STANDARD 5-CUSTOM COBRA
MODIFIED STANDARD 5 COBRA
MFP 5/1000-SJHS
469 (EPO) GR-DN07
SOUTHERN BASIC GR-DN07
CENTRAL BASIC GR-DN07
NORTHERN BASIC GR-DN07
SOUTHERN HIGH GR-DN07
CENTRAL HIGH GR-DN07
NORTHERN HIGH GR-DN07
NON-STANDARD $5 POS PLAN
466 (PPO) GR-DN07
DELUXE OPTION GR-DN07
NON-STANDARD $5 POS CBRA
MFP 5/1000-SJHS COBRA
DME $50 / $2500
UNIVERSITY OF CALIFORNIA
BENEFIT ALLIANCE $5POS-A
BENEFIT ALLIANCE $5POS CBR
UNIVERISTY OF CAL. COBRA
HI-OP DNTL SOTHRN CALIF 06
HI-OP DNTL NORTHRN CAL 06
STANDARD 5-CUSTOM
HI-OP DENTAL CENTRAL CA 06
COLA 2001 POS 100/85/60
DENTAL - VISION GR06
COLA 2001POS 100/85/60 CB
STANDARD 5-CUSTOM COBRA
BENEFITS ALLIANCE PLAN A
MFP STD 10 - POS
MFP STD 10 - POS COBRA
BENEFITS ALLIANCE COBRA
DELUXE OPTION DN-SH08
PREVENTIVE DN-SH08
100 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
D8C
D8E
D8N
D8Q
D8R
D8S
D8T
D8U
D8V
D8Y
D8Z
D9C
D9Z
DA1
DA2
DAC
DAZ
DB1
DB2
DBA
DBC
DBE
DBF
DBG
DBJ
DBZ
DC1
DC2
DCC
DCJ
DCN
DCP
DCR
DCS
DCX
DCZ
DD1
DD2
DD3
DD4
DDC
DDD
DDE
DDF
DDH
DDJ
DDK
DDL
DDP
DDY
Plan / Benefit Description
MCDONNELL DOUGLAS
EPO (469) DENTAL DN-SH08
HI-OP CE CAL DN-SH08
CENTRAL CAL DN-SH08
PPO (466) DENTAL DN-SH08
HI-OP SO CAL DN-SH08
SOUTHERN CAL DN-GR08
HI-OP NO CAL DN-SH08
NORTHERN CAL DN-SH08
EC P&C 200 1YR DN-SH08
MCDONNELL DOUGLAS COBRA
PBGH 5
PBGH 5 COBRA
SUTTER HEALTH $5 HMO
SUTTER HEALTH $5 HMO COBRA
AT&T PLAN
AT&T PLAN COBRA
$5 HMO 2000 SER
$5 HMO 2000 SER CBRA
100%/70% DISCOUNT GR-DN07
US BORAX-HPA
SV 25/100% DUCOMMUN 07
SVA 15-30/250A DELUX 07
SV 10/100% DCHS 07
$5 HMO 2000 SER AB
US BORAX-HPA
NON-STD HMO $5
NON-STD HMO $5 COBRA
STANDARD $5/$25 PLAN
DCHS SOUTHERN CALIF AB
DCHS NORTHERN CALIF
DCHS POS SO CAL
POS DEDUCTIBLE CREDIT
DCHS SOUTHERN CALIF
DCHS POS SO CAL AB
STANDARD $5/$25 PLAN COBRA
SAN DIEGO 5 HMO ACTIVE
SAN DIEGO 5 HMO ACTIVE CBR
SAN DIEGO 10 HMO ACTIVE
SAN DIEGO 10 HMO ACT CBR
FEDERAL EMPLOYEES 1993
SP 10/100% DCHS NC 06
S DIEGO MEDICAL W/EPO DDS
SP 10/100% DCHS 07
S DIEGO MEDICAL W/HIOP DDS
SP 10/100% DCHS NC 06 AB
SP 10/100% DCHS NC 06 CB
S DIEGO MEDICAL W/OP DDS
DEC PLAN CODE NEVER USED
DEC PLAN CODE NEVER USED
101 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
DE1
DE2
DE3
DE4
DEC
DEF
DEH
DEJ
DEK
DF1
DF2
DFA
DFB
DFC
DFE
DFF
DFJ
DFZ
DGC
DGE
DGZ
DH2
DH3
DH4
DH5
DH6
DH7
DH8
DH9
DHA
DHB
DHC
DHD
DHE
DHG
DHJ
DHM
DHP
DHR
DHS
DHW
DIR
DJB
DJC
DJJ
DJP
DJZ
DK1
DK2
DK3
Plan / Benefit Description
SAN DIEGO 5 HMO EA RET
SAN DIEGO 5 HMO EA RET CBR
SAN DIEGO 10 HMO EA RET
SAN DIEGO 10 HMO EA RET CB
SV-S 15-30/250D DE17 06
SV 25/100% DUCOMMUN 07 CB
SV-S 15-30/250D DE17 06 CB
SV 5/100% 06 AB
SV-S 15-30/250D DE17 06 AB
NON STD CUSTOM $5 HMO
NON STD CUSTOM $5 HMO CBRA
SV 10/100% DELPHI 06
SV 10/100% DELPHI 06 CB
FRESNO COUNTY PLAN
II
SV 5/100% DCHS 07
SVA 15-30/250A DELUX 07 CB
SV 10/100% DELPHI 06 AB
FRESNO COUNTY PLAN CBRA II
GTE BENEFITS PLAN
SP 10/100% DCHS 07
GTE BENEFITS PLAN COBRA
SVA 40-60/2-DEDUC SG06 CB
SVA 40-60/2-DEDUC SG06 AB
SVA 40-60/2-DEDUC SG06 CC
SVA 40-60/2-DEDUC SG06 FD
SVA 40-60/2-DEDUC SG06 FD
SVA 40-60/2-DEDUC SG06 CD
SVA 40-60/2-DEDUC SG06 CE
SVA 40-60/2-DEDUC SG06 US
SV 15/100% DELPHI 06
SR PLAN BASIC DENTAL-SOCAL
FEDERAL EMPLOYEES
SV 15/100% DELPHI 06 CB
SV 5/100% DCHS 07 CB
SR GOLD DENTAL SO CAL
SV 15/100% DELPHI 06 AB
SVA 40-60/2-DEDUC SG06
SH BASIC DENTAL
PREFERRED PLAN/HIPC CA CBR
PREFERRED PLAN HIPC
PREFERRED PLAN HIPC COBRA
DUMMY-USED FOR VRU CODING
SV 5/100% DCHS NC 06
BECHTEL PLAN
SV 5/100% DCHS NC 06 AB
SV 5/100% DCHS NC 06 CB
BECHTEL PLAN COBRA
SV $10/$500D
SV $10/$500D CB
SV $10/$500D CAL CB
102 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
DK4
DK5
DK6
DK7
DKC
DKE
DKF
DKG
DKJ
DKU
DKZ
DL1
DL2
DL3
DLC
DLJ
DLP
DLS
DLW
DLY
DLZ
DM2
DM5
DMA
DMC
DMD
DME
DMF
DMG
DMI
DMJ
DMK
DMP
DMR
DMY
DMZ
DN2
DN3
DNA
DNB
DNC
DNE
DNG
DNP
DNS
DNT
DNY
DNZ
DOC
DOJ
Plan / Benefit Description
SV $10/$500D FED CB DIS
SV $10/$500D FED CB EXT
SV $10/$500D CAL CB EXT
SV $10/$500D CAL CB DIS
PBGH 5
SP 10/100% DCHS 07 CB
SP 10/100% DCHS 07 CB
SV 10/100% DCHS 07 CB
SV $10/$500D AB
SV $10/$500D USERRA
PBGH 5 (COBRA)
STANDARD - $0 ER PLAN
COUNTY OF LOS ANGELES
COUNTY OF LOS ANGELES CBRA
UNIVERSAL 5 PLAN
II
COUNTY OF LOS ANGELES AB
$5 POS COUNTY OF LA
HIGH OPTION PLAN
HIGH OPTION PLAN - COBRA
$5 POS COUNTY OF LA COBRA
UNIVERSAL 5 PLAN COBRA II
DME $50 / $2000
DME $50/$5000
SV 10/100% DCHS SC 06
PBGH 5
2-DEDUC DM06
DURABLE MED EQUIP $50
DME $0/$5000
SAN DIEGO MEDICAL
$50/$2000 DME INDIVIDUAL
SV 10/100% DCHS SC 06 AB
SV 10/100% DCHS SC 06 CB
$5 POS COUNTYOF LA
$5 BASIC DENTAL DN-GR08
$5 POS COUNTY OF LA COBRA
PBGH 5 - COBRA
PPO 460 GRP BILLED - GR
PPO 462 INDIV BILLED -GR
PREVENTIVE SH-DN07
PACIFICARE DENTAL - BASIC
HPA PLAN 02
EVERCARE $5 SH-DN07
SR BASIC DENTAL NO CAL
PACIFICARE DENTAL PREPAID
SR PLUS DENTAL NO CAL
DENTAL PLAN
DELUXE OPTION SH-DN07
HPA PLAN 02 COBRA
$5 EDISON INTERNATIONAL
$5 EDISON INTERNATIONAL AB
103 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
DOY
DOZ
DP1
DPA
DPB
DPC
DPM
DPN
DPP
DPS
DPW
DPY
DPZ
DQ6
DQC
DQE
DQZ
DR2
DRC
DRD
DRE
DRG
DRH
DRJ
DRP
DRR
DRY
DRZ
DS1
DS2
DS3
DS4
DS5
DS6
DS7
DSA
DSB
DSC
DSE
DSF
DSG
DSJ
DSL
DSM
DSP
DSS
DSU
DSY
DSZ
DT0
Plan / Benefit Description
$5 EDISON INTERNATIONAL CB
DUMMY
DEPENDENT LIFE BENE
DOMESTIC PARTNER AMENDMENT
DOMESTIC PARTNR COBRA-LIKE
PAC BELL PLAN
DOMESTIC PARTNER MID/LARGE
DCHS POS NO CAL
SR PREMIER DENTAL NO CAL
STANDARD 5 PLAN (DEC/POS)
DISABILITY PREMIUM WAIVER
DCHS POS NO CAL COBRA
PAC BELL PLAN
COBRA
SH EPO (469) DENTAL 06
DIGITAL EQUIP CO. PLAN
SV 5/100% DCHS 07 AB
DIGITAL EQUIP CO. COBRA
PDV DENTAL PLAN 130 GR
TRW PLAN
SP 10/100% DCHS SC 06
SP 10/100% DCHS 07 AB
BASIC DENTAL RETIREE GOLD
SP 10/100% DCHS SC 06 CB
SP 10/100% DCHS SC 06 AB
REDLANDS USD $5 POS
10-20/200A DERP GR07
REDLANDS USD $5 POS CBRA
TRW PLAN
COBRA
HMO 5 PLAN
HMO 5 PLAN CBRA
HMO 5 PLAN CAL CBRA
HMO 5 FED CBR DISABLED
HMO 5 FED CBR EXTENDED
HMO 5 CAL CBR EXTENDED
HMO 5 CAL CBR DISABLED
SV $5/100%
SV $5/100% CB
PERS PLAN
SV 5/100% 06
SV 5/100% 06 CB
SV 10/100% DCHS 07 AB
SV $5/100% AB
DOWNEY SAVING & LOAN PREM
RIVERSIDE CLASSIC I
STD. 5 POS - CUSTOM
SR SILVER DENTAL SO CAL
HMO 5 PLAN USERRA
STD 5 POS-CUSTOM COBRA
PERS PLAN
COBRA
DENTAL ONLY (INDEMNITY)
104 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
DT1
DT2
DT3
DT6
DTA
DTC
DTF
DTJ
DTO
DTX
DTY
DTZ
DUC
DUF
DUZ
DVC
DVD
DVE
DVF
DVH
DVS
DVZ
DWC
DWD
DWE
DWH
DWZ
DXC
DXF
DXG
DXZ
DYB
DYC
DYD
DYE
DYF
DYG
DYP
DZ1
DZC
DZF
DZG
DZN
DZP
DZS
DZZ
E0C
E10
E11
E12
Plan / Benefit Description
CDHP DENTAL PLAN 390
CDHP DENTAL PLAN 490
CDHP DENTAL PLAN 590
SH PPO (466) DENTAL 06
SV 20/200A DIRECTV 06
G-TEL PLAN
SVA 15-30/250A DELUX 07 AB
SV 20/200A DIRECTV 06 AB
DENTAL ONLY (INDEMNITY)
DENTAL ONLY (INDEMNITY)
SV 20/200A DIRECTV 06 CB
G-TEL PLAN
COBRA
HMO 5 SPM ANAHEIM DISABLED
SP 10/100% DCHS 07 AB
CUSTOM HMO 5 SPM ANAHEIMCB
UNIV OF CAL PLAN
SAN DIEGO VALUE W/OP DDS
SAN DIEGO VALUE W/EPO DDS
SV 25/100% DUCOMMUN 07 AB
SAN DIEGO VALUE W/HIOP DDS
SAN DIEGO VALUE
UNIV OF CAL PLAN
FHHN-HIGH OPTION PLAN
RIVERSIDE CLSC I W/OP DDS
RIVERSIDE CLSC I W/EPO DDS
RIVERSIDE CLSC I W/HI DDS
FHHN HIGH OPTION (COBRA)
$5 HMO AZUSA USD
SV 10/100% 1500D 06
SV 20-40/250A 500D 06
$5 HMO AZUSA USD COBRA
SV 20-40/80% DRW FRD 07
COUNTY OF FRESNO-RETIREES
SV 20-40/80% DRW FRD 07 CB
SV 20-40/80% DRW FRD 07 AB
SV 10/100% 1500D 06 CB
SV 20-40/250A 500D 06 CB
DCHS POS SO CAL COBRA
STANDARD-$0 ER PLAN COBRA
NON STANDARD $5 PLAN
SV 10/100% 1500D 06 AB
SV 20-40/250A 500D 06 AB
DCHS NORTHERN CALIF COBRA
STANDARD 5 (COBRA/DEC/POS)
DCHS SOUTHERN CALIF COBRA
NON STANDARD $5 PLAN CBRA
EVERCARE ALAMEDA IH SH07
SR PLAN RX-MARIN
SR PLUS RX-MARIN
SR PREMIER RX-MARIN
105 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
E13
E14
E15
E16
E17
E18
E19
E1C
E1L
E20
E21
E22
E23
E24
E25
E26
E2A
E2C
E3A
E3C
E3E
E3J
E3T
E4C
E5C
E6C
E7C
E8C
E8F
E8G
E8H
E8J
E8K
E8L
E8M
E8N
E8P
E8Q
E8R
E8S
E8T
E8U
E8V
E8W
E8X
E8Y
E8Z
E9C
EA2
EA3
Plan / Benefit Description
RETIREE GOLD RX SO
RETIREE GOLD RX
RG PREMIER RX
RETIREE GOLD RX 5/UNLIMITE
RETIREE GOLD RX 4/UNLIMITE
RETIREE GOLD RX 3G/6B NOMX
RETIRE GLD RX 1/NOMAX-PERS
EVERCARE ALAMEDA DH SH07
EL DORADO STANDARD PLAN
RETIREE GOLD RX 6/2000 MAX
RET.GOLD RX 5 CO-PAY/UNLIM
RET.GOLD $0 CO-PAY/UNLIM.
RETIREE GOLD RX 6/NO MAX
CUSTOM RX RETIREE GOLD
RX CUSTOM-MCDONNELL RETIRE
RET.GOLD $6 CO-PAY/UNLIM.
SV 25/100% 06
EVERCARE CC DH SH07
SV 25/100% 06 CB
EVERCARE CC IH SH07
SV 10/100% L3 ELCTRN 05 CB
SV 10/100% L3 ELCTRN 05 AB
SV 10/100% L3 ELECTRON 05
EVERCARE LA DH SH07
EVERCARE ORANGE DH SH07
EVERCARE RVSIDE DH SH07
EVERCARE SB DH SH07
EVERCARE SF DH SH07
EVERCARE SD MH-S SH08
EVERCARE SD MH SH08
EVERCARE ALMDA MH SH08
EVERCARE CC MH SH08
EVERCARE SF MH SH08
EVERCARE ALMDA DH SH08
EVERCARE CC DH SH08
EVERCARE SF DH SH08
EVERCARE ALMDA IH SH08
EVERCARE CC IH SH08
EVERCARE SF IH SH08
EVERCARE LA MH SH08
EVERCARE LA DH SH08
EVERCARE OR MH SH08
EVERCARE ORANGE DH SH08
EVERCARE RVSIDE DH SH08
EVERCARE RVSIDE MH SH08
EVERCARE S BERDO DH SH08
EVERCARE S BERDO MH SH08
EVERCARE SF IH SH07
SV 25/100% 06 AB
EAP PLAN A
106 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
EA5
EA8
EAA
EAD
EAH
EAI
EAJ
EAL
EAN
EAO
EAP
EAZ
EB3
EB5
EB8
EBA
EBB
EBC
EBD
EBE
EBF
EBG
EBJ
EBO
EBP
EBT
EBU
EBY
EBZ
EC3
EC5
EC8
ECA
ECB
ECC
ECD
ECE
ECH
ECJ
ECL
ECO
ECP
ECS
ECZ
ED1
ED2
ED3
ED4
ED5
ED6
Plan / Benefit Description
EAP PLAN A
EAP PLAN A
SV 20/100A EXPERIAN 06
SH ALAMEDA - ENDORSED
MCC ESS S DIEGO HIGH SH07
SV 20/250A EPSON
SV 20/250A EPSON AB
MCC ESS S DIEGO LOW SH07
MC COMP ESS S DIEGO SH07
EVERCARE LA DH-D SH08
EAP SERVICES/ LIFELINK
SV 20/250A EPSON CB
EAP PLAN B
EAP PLAN B
EAP PLAN B
ENDRSD RETRE -SLO/SB PRT B
ENDRSD RETRE-BAY AREA PRTB
SV 0/100% EBDD 06
SV 0/100% E B DRAYAGE
SH BUTTE - ENDORSED
SV 0/100% EBDD 06 CB
SV 0/100% EBDD 06 AB
SV 0/100% E B DRAYAGE AB
EVERCARE ORANGE DH-D SH08
EMPLOYER SPONSERED PLAN
ENDRSD RETRE BUTTE PART B
ENDRSD RETIREE BUTTE
ENDRSD RETRE-BAY AREA
SV 0/100% E B DRAYAGE CB
EAP PLAN C
EAP PLAN C
EAP PLAN C
ENDRSD RETREE -CENTRAL
ENDRSD RETRE-CENTRAL PRT B
SH CONTRA COSTA - ENDORSED
SAN DIEGO CLSC I W/OP DDS
SAN DIEGO CLSC I W/EPO DDS
SAN DIEGO CLSC I W/HI DDS
SV 20/100A EXPERIAN 06 AB
END RET SANTA CLARA B-ONLY
EVERCARE RVSIDE DH-D SH08
10/100% EDISON FLEX GR06
SAN DIEGO CLASSIC I
SV 20/100A EXPERIAN 06 CB
SCE PLAN $2 OV $25 ER
ALAMEDA II STANDARD PLAN
0/100% EDISION PRIME GR06
ALAMEDA II PLUS PLAN
ALAMEDA II STD W/OPT DDS
ALAMEDA II STD W/HI OP DDS
107 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
ED7
ED8
EDA
EDB
EDC
EDD
EDE
EDF
EDG
EDH
EDJ
EDK
EDL
EDM
EDN
EDO
EDZ
EEA
EEB
EED
EEF
EEJ
EEO
EET
EF3
EF5
EF9
EFA
EFB
EFH
EFJ
EFL
EFN
EFO
EFR
EFZ
EG1
EG3
EG5
EG6
EG9
EGA
EGB
EGC
EGD
EGE
EGF
EGG
EGH
EGJ
Plan / Benefit Description
ALAMDA II PLS PLN W/OP DDS
ALAMDA II PLS PLN W/HI DDS
ENDORSED RETIREE EL DORADO
ENDRSD RETRE SAC/EL PART B
SP 10/100% 35ER EDISON
SP 10/100% 35ER EDISON CB
SP 0/100% EDISON
SP 0/100% EDISON CB
SV 20-40/50%
SV 20-40/50% CB
SP 10/100% 35ER EDISON AB
SV 15/250A EDCO DPSL 06
SV 15/250A EDCO DPSL 06 CB
SV 15/250A EDCO DPSL 06 AB
0/100% EDISON-P AARP GR08
EVERCARE S BERDO DH-D SH08
SCE PLAN $2OV $25ER COBRA
SV 11/100% EDISON 08
ENDRSD KERN CO. B ONLY
SH EL DORADO - ENDORSED
SV 10/100% EDISON 07
SP 0/100% EDISON AB
EVERCARE SF DH-D SH08
PC HR EXPRESS
MCC 1 S DIEGO LO-PL SH07
MCC 1 S DIEGO HI-PL SH07
MCC 1 S DIEGO PLUS SH07
SV 20/250A EPSNAMR 06
ENDR RET SAN FRAN B-ONLY
MCC 1 S DIEGO HIGH SH07
SV 20/250A EPSNAMR 06 AB
MCC 1 S DIEGO LOW SH07
MC COMP 1 SAN DIEGO SH07
EVERCARE CC DH-D SH08
SH FRESNO - ENDORSED
SV 20/250A EPSNAMR 06 CB
EAP - CUSTOM PLAN GATE
MCC 3 S DIEGO LO-PL SH07
MCC 3 S DIEGO HI-PL SH07
SV 20/100% EGUSD 06
MCC 3 S DIEGO PLUS SH07
ELK GROVE USD $20 GR
ENDRSD RETIREE B ONLY S.D.
SV 20/250A EPSON 07
SV 20-40/600D ELGAR 07
SV 20/250A EPSON 07 CB
SV 10/100% EDISON 07 CB
SV 20/250A EPSON 07 AB
MCC 3 S DIEGO HIGH SH07
SV 20-40/50% AB
108 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
EGL
EGN
EGO
EGX
EGZ
EHA
EHJ
EHO
EHZ
EIA
EIB
EIM
EIO
EJ3
EJ5
EJ9
EJA
EJB
EJH
EJL
EJN
EJO
EKB
EKD
EKF
EKN
EKO
EKV
EL1
EL2
EL3
EL4
EL5
EL6
EL7
EL8
ELA
ELB
ELD
ELE
ELJ
ELO
ELZ
EM2
EM3
EM4
EM5
EM6
EM7
EM8
Plan / Benefit Description
MCC 3 S DIEGO LOW SH07
MC COMP 3 SAN DIEGO SH07
EVERCARE ALMDA DH-D SH08
SV 20/100% EGUSD 06 AB
SV 20/100% EGUSD 06 CB
SV 0/100% CA-EDISON 06
SV 0/100% CA-EDISON 06 AB
EVERCARE LA MH-D SH08
SV 0/100% CA-EDISON 06 CB
ENDRSD RETIREE -IMPERIAL
ENDRSD RETIREE -IMPER PART
SH IMPERIAL - ENDORESED
EVERCARE OR MH-D SH08
MCC 2 S DIEGO LO-PL SH07
MCC 2 S DIEGO HI-PL SH07
MCC 2 S DIEGO PLUS SH07
SV 11/100% EDISON 08 CB
ENDR RET SAN JOAQ B-0NLY
MCC 2 S DIEGO HIGH SH07
MCC 2 S DIEGO LOW SH07
MC COMP 2 SAN DIEGO SH07
EVERCARE S BERDO MH- SH08
ENDRSD RETRE KERN/VENT B
SV 20-40/600D ELGAR 07 CB
SV 10/100% EDISON 07 AB
SH KERN - ENDORSED
EVERCARE RVSIDE MH-D SH08
ENDRSD RETIREE -KERN/VENT
SH EL DORADO STD MED
SH EL DORADO STD W/ HI DEN
EL DORADO PART B STD MED
EL DORADO PART B W/ HI DEN
SH EL DORADO PLUS PLAN MED
EL DORADO PLUS W/ HI DEN
EL DORADO B PLUS W/ HI DEN
EL DORADO B PLUS W/ HI DEN
SH LOS ANGELES - ENDORSED
ENDRS RET. ELDORADO B ONLY
SV 20-40/600D ELGAR 07 AB
SV 15-30/600D ELGR 06
SV 15-30/600D ELGR 06 AB
EVERCARE ALMDA MH-D SH08
SV 15-30/600D ELGR 06 CB
SVA 10/500D SG05
SVA 10/500D SG05 CB
SVA 10/500D SG05 CAL CB
SVA 10/500D SG05 FED CBDIS
SVA 10/500D SG05 FED CBEXT
SVA 10/500D SG05 CAL CBEXT
SVA 10/500D SG05 CAL CBDIS
109 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
EMA
EMB
EMC
EMD
EMJ
EMN
EMO
EMR
EMU
EMY
EN2
EN3
EN4
EN5
EN6
EN7
EN8
ENA
ENB
ENC
END
ENE
ENH
ENJ
ENO
ENP
ENS
ENU
ENX
ENZ
EOB
EOC
EON
EOO
EP1
EPA
EPB
EPC
EPE
EPO
EPS
EQE
ER1
ER4
ER5
ER6
ER7
ER8
ERB
ERE
Plan / Benefit Description
ENDORSED RETIREE MARIN
ENDRSD RETRE MONTRY PART B
SH MERCED - ENDORSED
SH MADERA - ENDORSED
SVA 10/500D SG05 AB
SH MARIN - ENDORSED
EVERCARE CC MH-D SH08
ENDRSD RETIRE MARIN PRT B
SVA 10/500D SG05 USERRA
ENDRSD RETRE MONTEREY
SVA 35/600D SG05
SVA 35/600D SG05 CB
SVA 35/600D SG05 CC
SVA 35/600D SG05 FD
SVA 35/600D SG05 FE
SVA 35/600D SG05 CE
SVA 35/600D SG05 CD
ENDRSD RETRE NAPA
ENDRSD RETIREE NAPA PART B
SV 10/100% EDISON 06
S DIGO CLSC ENHNCD W/OPDDS
S DGO CLSC ENHNCD W/EPODDS
S DGO CLSC ENHNCD W/HI DDS
SVA 35/600D SG05 AB
EVERCARE SF MH-D SH08
SH NAPA - ENDORSED
S DIEGO CLASSIC ENHANCED
SVA 35/600D SG05 US
SV 10/100% EDISON 06 AB
SV 10/100% EDISON 06 CB
ENDRSD ORANGE CO B ONLY
SH ORANGE - ENDORSED
END RET SONOMA B-ONLY
EVERCARE SD MH-S-D SH08
EAP CUSTOM PLAN
SV 11/100% EDISON 08 AB
ENDRSD RETRE PLAC/SJQ PART
SH PLACER - ENDORSED
SV 20-40/50% 07
EVERCARE SD MH-D SH08
ENDRSD RETREE-PLACR S.JQN
SV 20-40/50% 07 CB
ORANGE PREMIER STD PLAN
ORANGE PREMIER PLUS PLAN
ORANGE PREM STD W/OPT DDS
ORANGE PREM STD W/HIOP DDS
O.C. PREM PLS PLN W/OP DDS
O.C. PREM PLS PLN W/HI DDS
ENDRSD ORANGE CO. B ONLY
SV 20-40/50% 07 AB
110 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
ERS
ES1
ES2
ES3
ES4
ES5
ES6
ES7
ES8
ES9
ESA
ESB
ESC
ESD
ESE
ESF
ESG
ESH
ESI
ESJ
ESK
ESL
ESM
ESN
ESO
ESP
ESQ
ESR
ESS
EST
ESU
ESV
ESW
ESX
ESY
ESZ
ET1
ET3
ET5
ET9
ETB
ETC
ETH
ETJ
ETL
ETN
ETU
ETZ
EU3
EU5
Plan / Benefit Description
SH RIVERSIDE - ENDORSED
SR PLAN RX SO. CAL
SR PLUS RX - SO CALIF
SR PLAN RX NO CAL
SR PLUS NO CAL
SR PLAN PREMIER-NO CAL
SR PLAN RX ELDORADO,SACTO.
SR PLAN RX-SOLANO,SONOMA
SR PLUS RX-SOLANO,SONOMA
SR PRMIER RX-SOLANO,SONOMA
ENDRSD RETIREE SO.CA STD
ENDRSD RETRE SO.-PART B ON
ENDRSD RETRE S.CRUZ
ENDRSD RETIREE SAC/ELDORD
SH SAN BERNARDINO - ENDORS
SH SAN FRANCISCO - ENDORSE
SH SANTA BARBARA - ENDORSE
SH STANISLAUS - ENDORSED
ENDR STANISLAUS B ONLY
SH SAN JOAQUIN - ENDORSED
SH SANTA CRUZ - ENDORSED
ENDRSD RETRE -SLO/SB
ENDR RET SAN MATEO B-ONLY
ENDORSED STANISLAUS
ENDRSD RETRE SOL/SONM PRTB
SH SLO - ENDORSED
SH SANTA CLARA - ENDORSED
SH SACRAMENTO - ENDORSED
ENDRSD RETRE SOLA/SONOM
ENDRSD RETREE STANISLAUS
ENDRSD RET.STNISLAS PRT B
SH SONOMA - ENDORSED
SH SOLANO - ENDORSED
SH SAN DIEGO - ENDORSED
SH SAN MATEO - ENDORSED
ENDRSD RETIREE S.CRUZ PRTB
EAP TELEPHONIC
MCC VALU S DEGO LO-PL SH07
MCC VALU S DEGO HI-PL SH07
MCC VALU S DEGO PLUS SH07
ENDRD RT CONT COSTA B ONLY
SP 10/100% EDISON 06
MCC VALU S DEGO HIGH SH07
SP 10/100% EDISON 06 AB
MCC VALU S DEGO LOW SH07
MC COMP VALUE S DEGO SH07
SH TULARE - ENDORSED
SP 10/100% EDISON 06 CB
MCC PRE S DIEGO LO-PL SH07
MCC PRE S DIEGO HI-PL SH07
111 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
EU9
EUH
EUL
EUN
EVB
EVT
EWD
EWE
EWH
EXC
EXD
EXE
EXJ
EXP
EXZ
EZ1
EZC
F01
F02
F03
F04
F05
F06
F07
F08
F09
F0C
F0J
F0N
F10
F11
F12
F13
F14
F15
F16
F17
F18
F19
F1C
F1D
F1E
F1F
F1G
F1J
F1K
F1N
F1P
F1Q
F1R
Plan / Benefit Description
MCC PRE S DIEGO PLUS SH07
MCC PRE S DIEGO HIGH SH07
MCC PRE S DIEGO LOW SH07
MC COMP PRE SAN DIEGO SH07
ENDRD RET-VENTURA B ONLY
SH VENTURA - ENDORSED
SAN DIEGO CLASS III DDS
SAN DIEGO CLASS III PPO
SAN DIEGO CLASS III HI DDS
SV 20/100A EXPERIAN 07
SV 20/100A EXPERIAN 07 CB
SV 20/100A EXPERIAN 07 AB
SV $20/$100A EXPERIAN AB
SV $20/$100A EXPERIAN
SV $20/$100A EXPERIAN CB
PREFERRED-$0 ER PLAN COBRA
10/100% EDISON-F AARP GR08
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
FEDERAL EMPLOYEES 2000
SV 10-15/250A FIDELITY AB
SELF FND OOA PREMIUM ALLOC
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
STANDARD 10 PLAN
II
ELITE 10 FED CBR DISABLED
ELITE 10 FED CBR EXTENDED
ELITE 10 CAL CBR EXTENDED
ELITE 10 CAL CBR DISABLED
SIGPOS 30 PLUS AB
POS 300 PLUS
FRESNO STANDARD PLAN
STANDARD 10 PLAN (POS)
INDIVIDUAL POS-$250 DEDUCT
ELITE 10
CAL COBRA
112 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
F1S
F1U
F1W
F1Y
F1Z
F20
F21
F22
F23
F24
F25
F26
F27
F28
F29
F2A
F2C
F2D
F2E
F2F
F2G
F2J
F2K
F2P
F2Q
F2R
F2S
F2W
F2Y
F2Z
F30
F31
F32
F33
F34
F35
F36
F37
F38
F39
F3A
F3B
F3C
F3D
F3E
F3F
F3G
F3J
F3K
F3P
Plan / Benefit Description
ELITE 10
POS 300 PLUS USERRA
ELITE 10
COBRA
STAND 10 (POS) COBRA
STANDARD 10 PLAN COBRA II
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
SV 15-30/250A FRMRS 06 CB
MFP STANDARD 10 PLAN II
PREMIER 10 FED CBR DISABLE
PREMIER 10 FED CBR EXTEND
PREMIER 10 CAL CBR EXTEND
PREMIER 10 CAL CBR DISABLE
MFP STANDARD 10 PLAN II AB
POS 300 PLUS COBRA
MFP STD 10 - POS
INDIVIDUAL POS $500 DEDUCT
PREMIER 10 PLAN CAL CBRA
PREMIER 10 PLAN
PREMIER 10 PLAN CBRA
MFP STD 10 - POS (COBRA)
MFP STANDARD 10 PLAN CBRII
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
ELITE POS 300
ELITE POS 300
COBRA
STANDARD 10/25 PLAN TEST
ELITE POS 300 FED CBR DISA
ELITE POS 300 FED CBR EXTE
ELITE POS 300 CAL CBR EXTE
ELITE POS 300 CAL CBR DISA
CITIGROUP $15/$25/$500A AB
POS 300 PLUS CAL CBRA
BENEFIT ALLIANCE - POS
113 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
F3Q
F3R
F3S
F3Y
F3Z
F41
F42
F43
F44
F45
F46
F47
F48
F49
F4A
F4B
F4C
F4D
F4E
F4F
F4G
F4J
F4K
F4P
F4Q
F4R
F4S
F4Y
F4Z
F50
F51
F52
F53
F54
F55
F56
F57
F58
F59
F5A
F5B
F5C
F5D
F5E
F5F
F5G
F5J
F5K
F5Q
F5R
Plan / Benefit Description
INDIVIDUAL POS $1000 DED.
ELITE POS 300 CAL COBRA
SUTTER HEALTH PLAN
BENEFIT ALLIANCE POS COBRA
STANDARD 10/25 PLAN-COBRA
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
PREMIER POS 300 PLAN
PREMIER POS 300 PLAN CBRA
BENEFIT ALLIANCE PLAN B
PREM POS 300 FED CBR DISAB
PREM POS 300 FED CBR EXTEN
PREM POS 300 CAL CBR EXTEN
PREM POS 300 CAL CBR DISAB
CALIFORNIA FAMILY HLTH AB
POS 300+ FED CBR DIS
SUTTER HEALTH $10 POS
IND POS $10/$250 (COP)
PREMIER POS 300 PLAN CCBRA
SUTTER HEALTH PLAN COBRA
SUTTER HEALTH $10 POS CBRA
BENEFIT ALLIANCE B COBRA
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
ELITE POS 500
ELITE POS 500
COBRA
PBGH 10
ELITE POS 500 FED CBR DISA
ELITE POS 500 FED CBR EXT
ELITE POS 500 CAL CBR EXTE
ELITE POS 500 CAL CBR DISA
SV VERIZON $15/100% AB
POS 300+ FED CBR EXTE
IND POS $10/$500 (COP)
ELITE POS 500 CAL COBRA
114 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
F5Z
F60
F62
F63
F64
F65
F66
F67
F6A
F6B
F6C
F6D
F6E
F6F
F6G
F6J
F6K
F6Q
F6R
F6Z
F72
F73
F74
F75
F76
F77
F7A
F7B
F7C
F7D
F7E
F7F
F7G
F7J
F7K
F7Q
F7R
F7S
F7Z
F82
F83
F84
F85
F86
F87
F8C
F8J
F8P
F8Q
F8R
Plan / Benefit Description
PBGH 10 COBRA
LIMITED FEE SCHEDULE PPO
KEC 3 FRESNO CG GR07
KEC 3 FRESNO EP CG GR07
KEC 3 FRESNO E-P CG GR07
KEC 3 FRESNO PP CG GR07
KEC 3 FRESNO P-P CG GR07
KEC 3 FRESNO PL CG GR07
PREMIER POS 500 PLAN
PREMIER POS 500 PLAN CBRA
PBGH 10/50
PREM POS 500 FED CBR DISAB
PREM POS 500 FED CBR EXTEN
PREM POS 500 CAL CBR EXTEN
PREM POS 500 CAL CBR DISAB
$10-$15/100% AB
POS 300+ CAL CBR DISA
IND POS $10/$1000 (COP)
PREMIER POS 500 PLAN CCBRA
PBGH 10/50 COBRA
KEC 3 FRESNO CGII GR07
KEC 3 FRESNO EP CGII GR07
KEC 3 FRESNO E-P CGII GR07
KEC 3 FRESNO PP CGII GR07
KEC 3 FRESNO P-P CGII GR07
KEC 3 FRESNO PL CGII GR07
PREMIER POS 300 PLUS
PREMIER POS 300 PLUS COBRA
MODIFIED STANDARD 10-RETA
PREM POS 300+ FED CBR DIS
PREM POS 300+ FED CBR EXTE
PREM POS 300+ CAL CBR DISA
PREM POS 300+ CAL CBR EXTN
SP 10/100% FRFLD 05 AB
POS 300+ CAL CBR EXTN
G/I INDIVIDUAL POS-250 DED
PREM POS 300 PLUS CAL CBRA
AB1401 SUTTER HEALTH PLAN
MODIFIED 10 STD RETA COBRA
KEC 3 FRESNO CGEH GR07
KEC 3 FRESNO EP CGEH GR07
KEC 3 FRESNO E-P CGEH GR07
KEC 3 FRESNO PP CGEH GR07
KEC 3 FRESNO P-P CGEH GR07
KEC 3 FRESNO PL CGEH GR07
CHW 10 HMO
SV 25/250A FRFLD 05 AB
CHW POS
INDIVID POS $500 7/00
SV 25/250A FRFLD 05 CB
115 of 640
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
F8Y
F8Z
F9A
F9J
F9P
F9Q
F9Y
F9Z
FA2
FA3
FAA
FAB
FAC
FAD
FAE
FAF
FAJ
FAK
FAQ
FAX
FAZ
FB1
FB2
FB3
FB4
FB6
FB8
FBA
FBC
FBJ
FBK
FBQ
FBZ
FC1
FC2
FC3
FC4
FC6
FC7
FC8
FC9
FCA
FCB
FCC
FCD
FCE
FCF
FCG
FCH
FCI
Plan / Benefit Description
CHW POS COBRA
CHW 10 HMO COBRA
CUSTOM 10 BOEING HMO
CUSTOM 10 BOEING HMO AB
NON STD POS 100/80/70
G/I INDIVID POS $500 7/00
NON STD POS 100/80/70 CBRA
CUSTOM 10 BOEING HMO COBRA
AT&T ADVANTAGE $10/$15
AT&T ADVANTAGE $10/$15 CBR
SV 15-30/250A FRMRS 06
SV $10/100%
AIWU HMO $10/250
SV $10/100% CB
SV $10/$20/$100D
SV $10/$20/$100D CB
SV $10/100% AB
SV $10/$20/$100D AB
INDIVID POS $1000 7/00
SV 15-30/250A FRMRS 06 AB
AIWU HMO $10/250 CBRA
BOEING IAM HMO $10
BOEING IAM HMO $10 COBRA
JOINT BENEFIT 20/40/400
JOINT BENEFIT 20/40/400 CB
JOINT BEN 20/40/400A
JOINT BEN 20/40/400A COBRA
$5G/$10B
BAXTER PLAN
PEPSICO AB
KEC 3 FRESNO EP GR07
G/I INDIVID POS $1000 7/00
BAXTER PLAN COBRA
SCHS HMO $10/$250
SCHS HMO $10/$250 COBRA
CALIFORNIA FAMILY HLTH
CALIFORNIA FAMILY HLTH CBR
$10-$15/100%
$10-$15/100% COBRA
RESERVED FOR RX PPO
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
DUMMY
$35/$150A
RESERVED FOR PPO RX
RESERVED FOR PPO RX
GM HOURLY HMO 2002
OON CHIRO CNTY OF FRESNO
RESERVED FOR PPO RX
116 of 640
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
FCJ
FCL
FCM
FCN
FCP
FCQ
FCY
FCZ
FD2
FD3
FD5
FDC
FDD
FDF
FDJ
FDQ
FDX
FDZ
FE1
FE2
FE3
FE4
FE5
FE6
FE7
FEB
FEC
FED
FEE
FEF
FEJ
FEP
FEQ
FEW
FEX
FEZ
FF1
FF2
FF3
FF4
FF5
FF6
FF7
FF8
FF9
FFA
FFB
FFC
FFF
FFI
Plan / Benefit Description
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
$35/$150A COBRA
INDIVIDUAL 1000 POS
GM HOURLY HMO 2002 COBRA
DUMMY
SDSU $10/$100A
SDSU $10/$100A COBRA
SV 10-30/100D FEDS 05
HMO 10 PLAN-CUSTOM
SV 35/240A FDLTY NIS 06
SV 35/240A FDLTY NIS 06 CB
SDSU $10/$100A AB
INDIVIDUAL 1000 POS HIPPA
SV 35/240A FDLTY NIS 06 AB
HMO 10 PLAN-CUSTOM COBRA
UNIVERSAL PLAN (STAND 3)
FEDERAL EMPLOYEES PLAN
FEDERAL EMPLOYEE PLAN 1992
FEDERAL EXPRESS $25/$100
FEDERAL EXPRESS 25/100 CBR
SV FED EX $25/$100A
SV FED EX $25/$100A CB
SV 10-30/100D FEDS 08
PBGH 10
FEHB SPECIAL ALLOCATION CD
SV 25/100A FEDEXPRS 06
SV 25/100A FEDEXPRS 06 CB
SV FED EX $25/$100A AB
EDISON INT'L POS 10-ACTIVE
EDISON INT'L POS PREFERRED
FRESNO CLASSIC I W/EPO DDS
SV 25/100A FEDEXPRS 06 AB
PBGH 10 (COBRA)
SAN BERNARDINO USD HMO
SAN BERNARDINO USD COBRA
HMO 10 PLAN
HMO 10 PLAN CBRA
HMO 10 PLAN CAL CBRA
HMO 10 FED CBR DISABLED
HMO 10 FED CBR EXTENDED
HMO 10 CAL CBR EXTENDED
HMO 10 CAL CBR DISABLED
SAN BERNARDINO USD POS
SAN BERNARDINO USD COBRA
WELLS FARGO BANK
ADMINISTRATIVE RETENTION
ADMIN RETENT IN-NETWORK
117 of 640
Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
FFJ
FFO
FFP
FFQ
FFR
FFU
FFW
FFY
FFZ
FG2
FG3
FG5
FG6
FG7
FGA
FGB
FGC
FGG
FGJ
FGP
FGQ
FGY
FGZ
FH1
FH2
FH4
FH5
FH6
FHA
FHB
FHC
FHJ
FHL
FHU
FHX
FHZ
FIC
FID
FIJ
FIN
FIP
FIY
FIZ
FJ1
FJ2
FJC
FJJ
FJK
FJN
FJP
Plan / Benefit Description
HMO 10
AB
ADMIN RETENT OUT-NETWORK
STD 10 POS-PEPSI/FRITO
INDIVIDUAL 500 POS
SP 10/100% FRFLD 05 CB
HMO 10 PLAN USERRA
INACTIVE
STD 10 POS PEP/FRITO-COBRA
WELLS FARGO BANK (COBRA)
CITIGROUP $15/$25/$500A
CITIGROUP $15/$25/$500A CB
SV 15-25/500A CITIGROUP
SV 15-25/500A CITIGROUP CB
$7/$10 FORMULARY/GENERIC
SV 25/250A FRFLD 07
SV 25/250A FRFLD 07 CB
PBGH 10
SV 25/250A FRFLD 07 AB
SV 15-25/500A CITIGROUP AB
$15 PEPSI/FRITO LAY
INDIVIDUAL 500 POS HIPPA
$15 PEPSI/FRITO LAY COBRA
PBGH 10 (COBRA)
$10/100%HMO MFP2000 SERIES
$10/100%HMO MFP2000 SER CB
SV 15/100% CAFHC 05
SV 15/100% CAFHC 05 CB
SV 10-30/100D FEDS 06
SV 15/100% CFHC 06
IBM-F2191 RETIREE GOLD
$10 HMO 2000 SER
$10 HMO 2000 AB
SV 15/100% CFHC 06 CB
$10 2000 SER USERRA
SV 15/100% CFHC 06 AB
$10 HMO 2000 CBRA
DUMMY PLAN-NOT IN USE
FEDS DENTAL INDEMNITY 2001
SV 15-30/250A FARMERS AB
SV 15-30/250A FARMERS
STANDARD 10/POS ITT
STANDARD 10/POS ITT COBRA
DUMMY PLAN-NOT IN USE
CUSTOM POS 100%/80%/70%
CSTM POS100%/80%/70% CBRA
CUSTOM HMO $10/$250
NON STD POS 100/80/70 AB
KEC 3 FRESNO EP-PL GR07
FEDS 2003
SJHS-STD 10 MFP POS
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
FJY
FJZ
FK1
FK2
FK3
FK4
FK5
FK6
FK7
FKA
FKC
FKJ
FKN
FKP
FKU
FKY
FKZ
FL1
FL2
FL3
FLC
FLJ
FLP
FLY
FLZ
FM2
FM3
FM4
FM5
FM6
FM7
FMA
FMB
FMC
FMD
FME
FMF
FMG
FMJ
FMK
FMY
FMZ
FN1
FN2
FN3
FN4
FN8
FN9
FNA
FNB
Plan / Benefit Description
SJHS-STD 10 MFP POS COBRA
CUSTOM HMO $10/$250 COBRA
HMO 10 PLAN
HMO 10 PLAN CBRA
HMO 10 PLAN CAL CBRA
HMO 10 FED CBR DISABLE
HMO 10 FED CBR EXTEND
HMO 10 CAL CBR EXTEND
HMO 10 CAL CBR DISABLE
SV 10-15/250A FIDNTL 06
KEENAN COMP 3 FRESNO GR07
SV 10-15/250A FIDNTL 06 AB
FEDS 2004
$10 POS MFP SJHS N CAL EXC
HMO 10 PLAN USERRA
$10 POS MFP SJHS EX COBRA
SV 10-15/250A FIDNTL 06 CB
$10/100% NON STANDARD
$10/100% NON STANDARD CBRA
LOCKHEED $10
DUMMY PLAN-NOT IN USE
SP 10/100% OPT 69 AB
LIBERTY MUTUAL POS
LIBERTY MUTUAL POS COBRA
DUMMY PLAN-NOT IN USE
TOYOTA MOTOR $10/100%
TOYOTA MOTOR $10/100% CBRA
MARSH & MCLENNAN 20/100
$5G/$10B $10/$20MAIL CL RX
MARSH & MCLENNAN 20/100 CB
RETIREE RX $7/$10 UNLIM.
FRESNO/MADERA BASIC PLAN
FRESNO/MADERA PRT B ONLY
10/50 PLAN
SV 25/10% FEDEXPRS 07
SV 25/10% FEDEXPRS 07 CB
SV 25/10% FEDEXPRS 07 AB
GM SLRY HMO 2002
MARSH & MCLENNAN 20/100 AB
KEC 3 FRESNO PP GR07
GM SLRY HMO 2002 COBRA
10/50 PLAN
HOTEL NIKKO 100/80/70
HOTEL NIKKO 100/80/70 CBRA
POS $10 - MFP
POS $10 - MFP COBRA
FIDELITY $10/$250
FIDELITY $10/$250 COBRA
SV 10-15/250A FIDELITY
SV 10-15/250A FIDELITY CB
119 of 640
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
FNC
FNJ
FNK
FNL
FNP
FNS
FNZ
FOA
FP2
FP3
FP4
FP5
FP6
FP7
FP8
FP9
FPA
FPB
FPC
FPD
FPE
FPF
FPJ
FPK
FPL
FPM
FPP
FPR
FPS
FPV
FPW
FPX
FPY
FPZ
FQ3
FQ4
FQC
FQJ
FQK
FQP
FQY
FQZ
FR1
FR6
FR7
FR8
FRA
FRB
FRC
FRH
Plan / Benefit Description
MARTIN MARIETTA ($20 ER)
FIDELITY $10/$250 AB
SV 25/240A FIDELITY 07
SV 25/240A FIDELITY 07 CB
SV 25/240A FIDELITY 07 AB
SV 15-30/250A FARMERS CB
MARTIN MARIETTA ($20)COBRA
FREEDOM PRVDR OPEN ACCESS
POWAY USD
POWAY USD COBRA
PHARMINGEN
PHARMINGEN COBRA
$30/100%
$30/100% COBRA
TRAVELERS PROP 15-25/250A
TRAVELERS 15-25/250A COBRA
FPA CLAIMS PROCESS-NO BENE
$10/100%
STANDARD 10 PLAN PEPSICO
PEPSICO
$10/100% COBRA
SP 10/100% FRFLD 07
SP 10/100% AB
SP 10/100%
SP 10/100% OPT 69
SP 10/100% 06
STAND 10 CHOICE/POLY COOK
PREMIUM REVERSAL
SP 10/100% 06 CB
SP 10/100% CB
SP 10/100% OPT 69 CB
SP 10/100% 06 AB
STAND 10 CHCE/PLY CK COBRA
STANDARD 10 PLAN PEP COBRA
CUSTOM POS 100/80/60
CUSTOM POS 10/80/60 COBRA
100%/80%/60% POS MFP
POS $10 - MFP AB
KEC 3 FRESNO PP-PL GR07
$10/250 POS MFP SJHS-NC
$10/250 POS MFP SJHS COBRA
100%/80%/60% POS MFP COBRA
FEDERAL RETIREES PLAN
FAIRFIELD RES $25/$250A
FAIRFIELD RES $25/$250A CB
SV 25/250A FRFLD 05
RISK CHARGE - AGGREGATE
MCD-A1325 RETIREE GOLD
ROCKWELL-SALARY
SP 10/100% FRFLD 05
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
FRI
FRJ
FRK
FRM
FRO
FRP
FRS
FRY
FRZ
FS1
FS2
FS3
FS4
FS5
FS6
FS7
FS8
FSA
FSC
FSD
FSE
FSF
FSG
FSJ
FSL
FSM
FSP
FSY
FSZ
FTC
FTD
FTJ
FTL
FTY
FTZ
FU6
FU7
FU9
FUE
FUF
FUJ
FUN
FUP
FUT
FUZ
FV2
FV3
FV4
FV5
FV6
Plan / Benefit Description
IN-NETWORK SPC/AGG RISK
FARMERS INS AB
KEC 3 FRESNO PLUS GR07
FARMERS INS
OUT-NETWORK SPC/AGG RISK
$10 POS AZUSA USD
RISK CHARGE - SPECIFIC
$10 POS AZUSA USD COBRA
ROCKWELL-SALARY
COBRA
SH FRESNO STD MED PLAN
SH FRESNO STD MED W/ HI DE
SH FRESNO PART B STD MED
SH FRESNO PART B W/ HI DEN
SH FRESNO PLUS PLAN MED
SH FRESNO PLUS W/ HI DEN
SH FRESNO PART B PLUS MED
SH FRESNO B PLUS W/ HI DEN
SO.CAL.SENIOR PLAN BASIC
10/50 CUSTOM
SV $10/100%
SV $10/100% CB
SV 10/100% 06
SV 10/100% 06 CB
SV $10/100% AB
SILVER SNEAKER SH/GR-WL07
FRESNO CLASSIC I
SJHS-STD 10 MFP POS
SJHS-STD 10 MFP POS COBRA
10/50 CUSTOM - COBRA
NORDSTROM HMO PLAN
NORDSTROM HMO 2001
SV 15/100% CAFHC 05 AB
SILVER SNEAKER SH/GR-WL08
NORDSTROM HMO 2001 COBRA
NORDSTROM HMO PLAN CBRA
MCC 1 FRESNO PP-PL SH07
MCC 1 FRESNO EP-PL SH07
MCC 1 FRESNO PLUS SH07
MCC 1 FRESNO EP SH07
SP 10/100% FRFLD 07 CB
SV 10/100% 06 AB
MC COMP 1 FRESNO SH07
MCC 1 FRESNO PP SH07
STANFORD CSTM 10/50 PLAN
STANFORD CSTM CBRA 10/50
VERIZON WIRELESS 10/100%
VERIZON WIRELESS 10/100%CB
SV VERIZON $15/100%
SV VERIZON $15/100% CB
SV 15/100% VERIZON 06
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
FV7
FVA
FVF
FVI
FVJ
FVQ
FVU
FVV
FVW
FVX
FVY
FVZ
FW1
FWC
FWP
FWZ
FXB
FXC
FXE
FXF
FXI
FXJ
FXQ
FXU
FXV
FXW
FXX
FXY
FXZ
FY6
FY7
FY9
FYB
FYC
FYE
FYJ
FYN
FYP
FYZ
FZ1
FZB
FZD
FZJ
FZL
FZM
G0C
G0D
G1C
G1J
G1K
Plan / Benefit Description
SV 15/100% VERIZON 06 CB
$10/100 NORTHROP GRUMMAN
SP 10/100% FRFLD 07 AB
ARP MCC 1 FRSNO EP-PL SH08
VERIZON WIRELESS 10/100%AB
ARP MCC 1 FRSNO PP-PL SH08
ARP MCC 1 FRSNO PP SH08
ARP MCC 1 FRSNO PLUS SH08
ARP MCC 1 FRSNO SH08
SV 15/100% VERIZON 06 AB
ARP MCC 1 FRSNO EP SH08
$10/100 NORTHROP GRUM CBR
FOOTWARE FOR DISFIGUREMENT
10/50-CUSTOM PLAN
FRESNO CLASSIC I W/ODP DDS
10/50 CUSTOM PLAN - COBRA
SP 10/100% FREMONT 07
$10 HMO AZUSA USD
SV 15/100A FOX 06
SV 15/100A FOX 06 CB
ARP MCC 3 FRSNO EP-PL SH08
$10 HMO AZUSA USD AB
ARP MCC 3 FRSNO PP-PL SH08
ARP MCC 3 FRSNO PP SH08
ARP MCC 3 FRSNO PLUS SH08
ARP MCC 3 FRSNO SH08
SV 15/100A FOX 06 AB
ARP MCC 3 FRSNO EP SH08
$10 HMO AZUSA USD COBRA
MCC 3 FRESNO PP-PL SH07
MCC 3 FRESNO EP-PL SH07
MCC 3 FRESNO PLUS SH07
SP 10/100% FREMONT 07 CB
10/50 NEW YORK COALITION
MCC 3 FRESNO EP SH07
STAND 10 (POS) AB
MC COMP 3 FRESNO SH07
MCC 3 FRESNO PP SH07
10/50 N.Y.COALITION (COBRA
UNIVERSAL PLAN (FEDS)COBRA
SP 10/100% FREMONT 07 AB
PEPSICO COBRA
STANDARD 10 PLAN II AB
LOCKHEED $10 - COBRA
FARMERS INS COBRA
FEDERAL EMPLOYEES 2001
FEDS DOD EMPLOYEES 2001
STANDARD 15 PLAN
$15/80-60 SG AB
$15/80-60 SG
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
G1P
G1Y
G1Z
G22
G23
G24
G25
G26
G27
G28
G29
G2C
G2J
G2K
G2P
G2Y
G2Z
G32
G33
G34
G35
G36
G37
G38
G39
G3J
G3K
G42
G43
G44
G45
G46
G47
G48
G49
G4J
G4K
G5J
G5K
G5M
G6J
G6K
G6M
G6N
G6R
G6X
G6Y
G6Z
G7J
G7K
Plan / Benefit Description
STANDARD 15 PLAN POS
STANDARD 15 PLAN POS CB
STANDARD 15 PLAN COBRA
KEC ORANGE CG GR07
KEC ORANGE LO CG GR07
KEC ORANGE LO-PL CG GR07
KEC ORANGE HI CG GR07
KEC ORANGE HI-PL CG GR07
KEC ORANGE PL CG GR07
KEC ORANGE DLXE CG GR07
KEC ORANGE PL-DX CG GR07
$20 HMO 2000 SER
$20 HMO 2000 SER AB
$15/80-60 SG COBRA
NONSTD 15 POS100/80/60
NONSTD 15 POS100/80/60 CB
$20 HMO 2000 SER CBRA
KEC ORANDE CGII GR07
KEC ORANGE LO CGII GR07
KEC ORANGE LO-PL CGII GR07
KEC ORANGE HI CGII GR07
KEC ORANGE HI-PL CGII GR07
KEC ORANGE PL CGII GR07
KEC ORANGE DLXE CGII GR07
KEC ORANGE PL-DX CGII GR07
SV CAPITAL 25/30/500A AB
$15/80-60 SG CAL COBRA
KEC ORANGE CGEH GR07
KEC ORANGE LO CGEH GR07
KEC ORANGE LO-PL CGEH GR07
KEC ORANGE HI CGEH GR07
KEC ORANGE HI-PL CGEH GR07
KEC ORANGE PL CGEH GR07
KEC ORANGE DLXE CGEH GR07
KEC ORANGE PL-DX CGEH GR07
20/250A 100 O/P AB
$15/80-60 SG FED CBR DIS
GROSSMONT UHSD $10/100% AB
$15/80-60 SG FED CBR EXT
GR 20/100% GM SAL
$20/$250A/$50 AB
$15/80-60 SG CAL CBR EXT
SV 20-30/100% GM 06
SV 10/100% GM 06
SV 10/100% GM 06 CB
SV 20-30/100% GM 06 AB
SV 10/100% GM 06 AB
SV 20-30/100% GM 06 CB
$20/$100 AB
$15/80-60 SG CAL CBR DIS
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
G7M
G8K
G9J
GA2
GA3
GA3
GA4
GA5
GA7
GA8
GA9
GAA
GAB
GAC
GAF
GAJ
GAN
GAX
GAZ
GB2
GB3
GB4
GB5
GB6
GB7
GB8
GBA
GBC
GBD
GBE
GBF
GBG
GBH
GBJ
GBK
GBM
GBN
GBY
GC1
GC2
GC3
GC5
GC6
GC8
GCA
GCB
GCD
GCE
GCJ
GCL
Plan / Benefit Description
SH 10/100% GM-H GR06
$15/80-60 SG USERRA
SV10/100 GNRL MTRS-HRLY AB
$20/$300
HMO $20/$300 COBRA
EAP PLAN A
GATE
$20/$300 COBRA
EAP PLAN A
GATE
$20/$100
EAP PLAN A
GATE
$20/$100 COBRA
SV $15/$30/80%
SV $15/$30/80% CB
SV 15/100% SC GLAZ 06
SV 15/100% SC GLAZ 06 CB
SV $15/$30/80% AB
SV 20/250A GANNETT
SV 15/100% SC GLAZ 06 AB
SV 20/250A GANNETT CB
20/250A 100 O/P
EAP PLAN B
GATE
20/250A 100 O/P COBRA
EAP PLAN B
GATE
$20/$250A/$50
$20/$250A/$50 COBRA
EAP PLAN B
GATE
POS 100/80/70 $20OV
$15/$100A
$15/$100A COBRA
PBGH $20/100%/$50ER
PBGH $20/100%/$50ER COBRA
$25/$250A
$25/$250A COBRA
$20/$250A 3000 OOP
$20/$250A 3000 OOP COBRA
$25/$250A
$25/$250A COBRA
POS 100/80/70 $20OV COBRA
CAPITAL GROUP
CAPITAL GROUP COBRA
EAP PLAN C
GATE
EAP PLAN C GATE
SV 25/250A GCBT 06
EAP PLAN C
GATE
KEENAN COMP ORANGE GR07
GOLD CST BENEFIT TRUST
ORANGE CLASSIC I W/OP DDS
ORANGE CLASSIC I W/EPO DDS
STANDARD 15 PLAN AB
SV 25/250A GCBT 06 CB
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Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
GCR
GCS
GCT
GCY
GCZ
GDA
GDC
GDD
GDE
GDF
GDJ
GDX
GDZ
GE2
GE3
GE4
GE5
GE6
GE7
GEA
GEB
GEC
GEE
GEF
GEG
GEJ
GEK
GEL
GEM
GEN
GEO
GEP
GES
GET
GEU
GEV
GEW
GEX
GEZ
GF2
GF3
GFA
GFE
GFF
GFJ
GGC
GGD
GGF
GGJ
GGX
Plan / Benefit Description
SV 25/250A GCBT 06 AB
ORANGE CLASSIC I
SV 25/25OA GCBT 05
SV 25/250A GCBT 05 CB
GOLD CST BENEFIT TRUST CBR
SP 10/100% GULFSTRM 06
SV 10/100% GOODRICH-SAL
SV 10/100% GOODRICH-SAL CB
SV 20/80% GOODRICH SAL
SV 20/80% GOODRICH SAL CB
$15/$100A AB
SP 10/100% GULFSTRM 06 AB
SP 10/100% GULFSTRM 06 CB
SV 15-30/250A GEVT1 06 AB
SV 15-30/250A GEVT2 06 AB
SV 15-30/250A GEVT3 06 AB
SV 15-30/250A GEVT4 06 AB
SV 15-30/250A GEVT5 06 AB
SV 15-30/250A GEVT6 06 AB
KEC ORANGE LOW GR07
SV 15-30/250A GEVT1 06
SV 15-30/250A GEVT2 06
SP 15/100% GULFSTRM 08
SV 15-30/250A GEVT3 06
SV 15-30/250A GEVT4 06
PBGH $20/100%/$50ER AB
SV 15-30/250A GEVT5 06
SV 15-30/250A GEVT6 06
SV20/100 GNRL MTRS-SLRY
SV20/100 GNRL MTRS-SLRY CB
SV10/100 GNRL MTRS-HRLY
SV10/100 GNRL MTRS-HRLY CB
ORANGE CLASSIC ENHANCED
SV 15-30/250A GEVT1 06 CB
SV 15-30/250A GEVT2 06 CB
SV 15-30/250A GEVT3 06 CB
SV 15-30/250A GEVT4 06 CB
SV 15-30/250A GEVT5 06 CB
SV 15-30/250A GEVT6 06 CB
FORD MOTOR CREDIT CORP
FORD MOTOR CREDIT CORP CBR
KEC ORANGE LO-PL GR07
SP 15/100% GULFSTRM 08 CB
SP 10/100% GROSSMONT 07
FORD MOTOR CREDIT CORP AB
SP 10/100% GULFSTRM 07
SV 25/100% GGUSD 06
SV 20-40/80% G&S 08
$25/$250A AB
SP 10/100% GIGANTE 06
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Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
GGY
GGZ
GH2
GH3
GHA
GHD
GHF
GHJ
GI3
GI5
GIF
GIH
GIL
GIO
GIP
GIV
GIW
GIX
GIY
GJA
GJF
GJG
GJJ
GKA
GKC
GKJ
GKZ
GL3
GL5
GLA
GLD
GLE
GLF
GLH
GLJ
GLL
GLO
GLV
GLW
GLX
GLZ
GM1
GM2
GM3
GM4
GM5
GM6
GM7
GM8
GM9
Plan / Benefit Description
SP 10/100% GIGANTE 06 CB
SP 10/100% GIGANTE 06 AB
$20/$200
$20/$200 COBRA
KEC ORANGE HIGH GR07
ORANGE CLSC ENHNCD W/HIDDS
SP 10/100% GROSSMONT 07 CB
$20/$200
AB
ARP MCC 2 OR LO-PL SH08
ARP MCC 2 OR HI-PL SH08
GIFT BENEFIT RIDER
ARP MCC 2 OR HI SH08
ARP MCC 2 OR LO SH08
ARP MCC 2 OR PL-DLX SH08
STANDARD 15/POS ITT
ARP MCC 2 OR PLUS SH08
ARP MCC 2 OR SH08
ARP MCC 2 OR DLX SH08
STANDARD 15/POS ITT COBRA
KEC ORANGE HI-PL GR07
SV 20-40/80% G&S 08 CB
SP 10/100% GEN INST 07
$20/$250A 3000 OOP AB
SV 10/80% GRC-H 06
SP 10/100% GULFSTRM 07 CB
SV 10/80% GRC-H 06 AB
SV 10/80% GRC-H 06 CB
ARP MCC PRE OR LO-PL SH08
ARP MCC PRE OR HI-PL SH08
SV 5/100% GRC-H 06
ORANGE CLSC ENHNCD W/OPDDS
SP 15/100% GULFSTRM 08 AB
SV 20-40/80% G&S 08 AB
ARP MCC PRE OR HI SH08
SV 5/100% GRC-H 06 AB
ARP MCC PRE OR LO SH08
ARP MCC PRE OR PL-DLX SH08
ARP MCC PRE OR PLUS SH08
ARP MCC PRE OR SH08
ARP MCC PRE OR DLX SH08
SV 5/100% GRC-H 06 CB
GENERAL MOTORS SALARIED
GENERAL MOTORS SALARIED CB
GEN MOTORS SAL CUST $3
GEN MTRS GRP RET SLRY
GENERAL MOTORS HOURLY
GENERAL MOTORS HOURLY CBRA
GEN MTRS GRP RET SLRY
SV $20/100%
SV $20/100% CB
126 of 640
Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
GMC
GMH
GMJ
GMK
GMR
GMS
GMT
GMZ
GN1
GN2
GNA
GNG
GNJ
GO3
GO5
GOH
GOJ
GOL
GOO
GOV
GOW
GOX
GP1
GPA
GPB
GPD
GPE
GPH
GPJ
GPP
GPS
GQ3
GQ5
GQA
GQH
GQJ
GQL
GQO
GQV
GQW
GQX
GR1
GR5
GRA
GRB
GRE
GS1
GS5
GS6
GSA
Plan / Benefit Description
GENERAL MOTORS-CUSTOM RET.
GENERAL MTRS GRP RET HRLY
SV $20/100% AB
20-30/100% GEN MOTRS GR06
$7G/$15B/$15NF
GENERAL MTRS GRP RET SLRY
SH RETIREE GM CUSTOM $3
SH RETIREE CUSTOM GM $0
NORTHROP GRUMMAN 10/20
NORTHROP GRUMMAN 10/20 CBR
KEC ORANGE PLUS GR07
SP 10/100% GEN INST 07 CB
SV 20/250A GANNETT AB
ARP MCC VA OR LO-PL SH08
ARP MCC VA OR HI-PL SH08
ARP MCC VA OR HI SH08
SV20/100 GNRL MTRS-SLRY AB
ARP MCC VA OR LO SH08
ARP MCC VA OR PL-DLX SH08
ARP MCC VA OR PLUS SH08
ARP MCC VA OR SH08
ARP MCC VA OR DLX SH08
SUTTER 100%/90%/70% COBRA
SUTTER 100%/90%/70%
PITNEY BOWES 20/30/250
ORANGE PREMIER W/OPT DDS
ORANGE PREMIER W/EPO DDS
ORANGE PREMIER W/HI OP DDS
SV 20/80% GOODRICH SAL AB
PITNEY BOWES 20/30/250 COB
ORANGE PREMIER
ARP MCC OR LO-PL SH08
ARP MCC OR HI-PL SH08
KEC ORANGE DELUXE GR07
ARP MCC OR HI SH08
SV 10/100% GOODRICH-SAL AB
ARP MCC OR LO SH08
ARP MCC OR PL-DLX SH08
ARP MCC OR PLUS SH08
ARP MCC 1 OR SH08
ARP MCC OR DLX SH08
SUTTER CUSTOM 5 PLAN CBRA
AB1401 SUTTER CUSTOM 5 PLN
SUTTER CUSTOM 5 PLAN
SV 25/100% GGUSD 06 CB
SV 25/100% GGUSD 06 AB
SUTTER CUSTOM 15 PLAN CBRA
GROSSMONT UHSD $10/100%
GROSSMONT UHSD $10/100% CB
SUTTER CUSTOM 15 PLAN
127 of 640
Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
GSE
GSF
GSH
GSJ
GSM
GT1
GT3
GT5
GT9
GTA
GTD
GTF
GTG
GTH
GTJ
GTL
GTN
GTO
GUA
GUH
GUJ
GUX
GUY
GUZ
GV2
GV3
GV4
GV5
GV6
GV7
GVA
GVB
GVC
GVD
GVE
GVF
GVG
GVH
GVJ
GVK
GVL
GVS
GVT
GVU
GVV
GVW
GVX
GVY
GVZ
GW2
Plan / Benefit Description
ORANGE MEDICAL W/EPO DDS
SPECIALIZED FTWEAR 20% 06
ORANGE MEDICAL W/HI OP DDS
SUTTER CUSTOM 15 PLAN AB
ORANGE MEDICAL
EAP TELEPHONIC GATE
MCC ESS ORNGE LO-PL SH07
MCC ESS ORNGE HI-PL SH07
MCC ESS ORNGE PLUS SH07
KEC ORANGE PL-DX GR07
MCC ESS ORNGE DELUXE SH07
SP 10/100% GROSSMONT 07 AB
SP 10/100% GEN INST 07 AB
MCC ESS ORNGE HIGH SH07
SV 25/250A GCBT 05 AB
MCC ESS ORNGE LOW SH07
MC COMP ESS ORNGE SH07
MCC ESS ORNGE PL-DLXE SH07
SV 10/500D 05
SP 10/100% GUHSD 06
SV 10/500D 05 AB
SP 10/100% GUHSD 06 AB
SP 10/100% GUHSD 06 CB
SV 10/500D 05 CB
SV 20-40/500D GEVT1 06 AB
SV 20-40/500D GEVT2 06 AB
SV 20-40/500D GEVT3 06 AB
SV 20-40/500D GEVT4 06 AB
SV 20-40/500D GEVT5 06 AB
SV 20-40/500D GEVT6 06 AB
SV 10/100% GRC-S 06
SV 20-40/500D GEVT1 06
SV 20-40/500D GEVT2 06
ORANGE VALUE W/OP DDS
ORANGE VALUE W/EPO DDS
SV 20-40/500D GEVT3 06
SV 20-40/500D GEVT4 06
ORANGE VALUE W/ HI OP DDS
SV 10/100% GRC-S 06 AB
SV 20-40/500D GEVT5 06
SV 20-40/500D GEVT6 06
ORANGE VALUE
SV 20-40/500D GEVT1 06 CB
SV 20-40/500D GEVT2 06 CB
SV 20-40/500D GEVT3 06 CB
SV 20-40/500D GEVT4 06 CB
SV 20-40/500D GEVT5 06 CB
SV 20-40/500D GEVT6 06 CB
SV 10/100% GRC-S 06 CB
WELLS FARGO ADV
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Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
GW3
GWA
GWD
GWE
GWJ
GX3
GX5
GX9
GXA
GXC
GXD
GXH
GXJ
GXL
GXN
GXO
GXZ
GY3
GY5
GY9
GYA
GYC
GYD
GYE
GYF
GYH
GYL
GYN
GYO
GZ1
GZ3
GZ5
GZ9
GZA
GZD
GZH
GZL
GZN
GZO
H01
H02
H03
H04
H05
H06
H07
H08
H09
H10
H11
Plan / Benefit Description
WELLS FARGO ADV COBRA
SP 10/100% GIGANTE 07
ORANGE MEDICAL W/OP DDS
ORNGE CLSC ENHNCD W/EPODDS
WELLS FARGO ADV AB
MCC ORANGE LO-PL SH07
MCC ORANGE HI-PL SH07
MCC ORANGE PLUS SH07
SV 20/80% GRC-S 06
SP 10/100% GULFSTRM 07 AB
MCC ORANGE DELUXE SH07
MCC ORANGE HIGH SH07
SV 20/80% GRC-S 06 AB
MCC ORANGE LOW SH07
MC COMP ORANGE SH07
MCC ORANGE PL-DLXE SH07
SV 20/80% GRC-S 06 CB
MCC PRE ORNGE LO-PL SH07
MCC PRE ORNGE HI-PL SH07
MCC PRE ORNGE PLUS SH07
SP 10/100% GIGANTE 07 CB
SV 15-30/80% 07
MCC PRE ORNGE DELUXE SH07
SV 15-30/80% 07 CB
SV 15-30/80% 07 AB
MCC PRE ORNGE HIGH SH07
MCC PRE ORNGE LOW SH07
MC COMP PRE ORNGE SH07
MCC PRE ORNGE PL-DLXE SH07
STAN. 10 ALLG.SER. COBRA
MCC VALU ORNGE LO-PL SH07
MCC VALU ORNGE HI-PL SH07
MCC VALU ORNGE PLUS SH07
SP 10/100% GIGANTE 07 AB
MCC VALU ORNGE DELUXE SH07
MCC VALUE ORANGE HIGH SH07
MCC VALU ORNGE LOW SH07
MC COMP VALUE ORANGE SH07
MCC VALU ORNGE PL-DLX SH07
DOMESTIC PARTNERSHIP PPO
VISION CARE BENEFIT PPO
FAMILY PLANING BENEFIT PPO
24/HOUR HEALTH INFO PPO
HEARING AID BENEFIT PPO
MENTAL NON-SMI PPO 90/70
MENTAL NON-SMI PPO 90/60
MENTAL NON-SMI PPO 90/50
MENTAL NON-SMI PPO 80/60
MENTAL NON-SMI PPO 80/50
MENTAL NONSMI INDEMNITY 80
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Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
H12
H13
H14
H15
H16
H17
H18
H19
H1J
H1Z
H20
H21
H22
H23
H24
H25
H26
H27
H28
H29
H2J
H2Z
H30
H31
H32
H33
H34
H35
H36
H37
H38
H39
H3J
H3Z
H40
H41
H42
H43
H44
H45
H46
H47
H48
H49
H4K
H4S
H4V
H4W
H4Y
H4Z
Plan / Benefit Description
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
2002 HMO STD PLAN 1 AB
2002 HMO STD PLAN 1 COBRA
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
2002 HMO STD PLAN 2 AB
2002 HMO STD PLAN 2 COBRA
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
2002 HMO STD PLAN 3 AB
2002 HMO STD PLAN 3 CBRA
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
0/800A 3YRS DX GR-HA07
0/500A 3YRS PL GR-HA07
0/500A 2YRS GR-HA07
0/1300A 2YRS DX GR-HA07
0/1000A 2YRS P-EH GR-HR07
2003 STD 10/20 $200 COBRA
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Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
H50
H51
H52
H53
H54
H55
H56
H57
H58
H59
H5Z
H60
H61
H62
H63
H64
H65
H66
H67
H68
H69
H6P
H6Z
H70
H71
H72
H73
H74
H75
H76
H77
H78
H79
H7L
H7Z
H80
H81
H82
H83
H84
H85
H86
H87
H88
H89
H8A
H8B
H8D
H8E
H8F
Plan / Benefit Description
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
2003 STD 15/30 $400 COBRA
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
15-25/100A GR06
2003 STD 20/40 $600 COBRA
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
15/2000A EAR 3YRS GR-HA07
2003 HMO $20/$250 COBRA
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
0/500A 3YRS PL HA-SH08
0/1300A 3YRS DX HA-SH08
0/800A 3YRS DX HA-SH08
25/400A 3YRS HA-SH08
25/900A 3YRS PL HA-SH08
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
H8G
H8J
H8K
H8L
H8P
H8Q
H8R
H90
H91
H92
H93
H94
H95
H96
H97
H98
H99
HA0
HA1
HA2
HA3
HA4
HA5
HA6
HA7
HA8
HA9
HAA
HAB
HAC
HAD
HAE
HAF
HAG
HAH
HAJ
HAL
HAN
HAP
HAR
HAS
HAT
HAU
HAV
HAW
HAX
HB1
HB2
HB3
HBA
Plan / Benefit Description
0/800A 3YRS HA-SH08
5/400A 3YRS HA-SH08
0/600A 2YRS HA-SH08
0/400A 3YRS HA-SH08
15-25/100A AARP GR08
25/1700A 3YRS DX HA-SH08
2000A/EAR 3YRS HA-GR08
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
HEARING AID BENEFIT
HEARING AID BENEFIT
HEARING AID BENEFIT
HEARING AID BENEFIT
HEARING AID - $800 PER AID
HEARING AIDS $500 PER AID
HEARING AID $500 - POS
HEARING AID $1000 MAX/MBR
HEARING AID (1 PER EAR)
HEARING AID (1 EVERY 36MO)
HI-OP MED W/O BSC DNT STAN
HI-OP MED&DNT ALAME B-ONLY
SANTA CLA H-O DNTL B ONLY
HEARING AID $1000/$1500
HEARING AID $1000/$1500POS
$500 HA (1 EVERY 36 MOS)
$0 1AID PER EAR EVRY36MOS
HEAR AID $1000 EVERY 3 YRS
HEARING AID $500 EVERY 3YR
HI-OP MED/DNTL ALAMEDA
300A/24M GR-VN07
HOMEMAKER 100H 1YR GR07
HEARING $500 PER EAR 12MO
HEAR AID $750 PER AID 36MO
H-O DTL SAN MATEO B ONLY
HEAR AID 50%/$2000MAX 36MO
HEAR AID 50% EVERY 24 MOS
HEARING AID $2000/36 MONTH
HEARING AIDE $600
RESERVED FOR PPO PRODUCT
RESERVED FOR PPO PRODUCT
RESERVED FOR PPO PRODUCT
HI-OP DENTAL PLN BAY AREA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
HBB
HBC
HBD
HBY
HCA
HCB
HCC
HCE
HCF
HCH
HCI
HCJ
HCL
HCT
HD2
HD3
HD6
HDA
HDB
HDC
HDE
HDF
HDJ
HDM
HDN
HDS
HDW
HE1
HE2
HE3
HE4
HE5
HE6
HE7
HEA
HEB
HED
HEE
HEF
HEJ
HEM
HET
HEV
HEW
HEX
HEY
HF6
HFA
HFF
HFJ
Plan / Benefit Description
HI DNTL BAY AREA-PRT B ONL
BSC MED H-O DTL S.F. B ONL
INCOMPLETE SH PLAN CODE
STAND MED HIGH DENTAL-BAY
HI MED/DNTL BAY PRT B ONLY
HIGH MED CNTRAL PRT B ONLY
HI-OP MED/DNTL CONTRA COST
HIGH MED CENTRAL REGION
SV 15-25/250A HCA 06
SV 15-25/250A HCA 06 CB
HEALTH CREDITS INCENTIVE
SV 15-25/250A HCA 06 AB
HI-OP MED/DNTL SANTA CLARA
H-OP M&D CNTR CSTA B ONLY
SV 20-40/500A HUSD 05
SV 20-40/500A HUSD 05 CB
$5/$400A 3YRS HREXAM+AID06
HI-OP DNTL-SAN DIEGO PRT B
HI-OP DNT SAN DIEGO B ONLY
HIGH OPTION DENTAL-CENTRAL
300A 2YRS HA-GR08
SV 15-25/250A HCA 07
SV 20-40/500A HUSD 05 AB
HOME DELVD MEALS 30 GR07
HIGH OPTION DENTAL- NORTH
HIGH OPTION DENTAL - SOUTH
LADWP CUSTOM HEARING AID
SR PLAN/PLUS HEARING
SR PLUS HEARING - SO CAL
RG HEARING PREMIER CUSTOM
RETIREE GOLD HEARING
GM CUSTOM HEARING
RETIREE GOLD HEARING
RETIREE HEARING AID CUSTOM
SV 10/100% HEMET 07
BSC MED/H-O DTL ALAM B ONL
HI-OP MED/BSC DNTL ELDORAD
SV 20/200A HUGHES ELEC
SV 20/200A HUGHES ELEC CB
SV 20/200A HUGHES ELEC AB
SV 10/100% HUSD 05 CB
SV 10/350A HLTHCARE 05 CB
SV 20/350A HTAU 05 CB
SV 20-40/500A HP 07
SV 20-40/500A HP 07 CB
SV 20-40/500A HP 07 AB
$25/$400 3YRS HREXAM+AID06
SV 10/100% HEMET 07 CB
SV 15-25/250A HCA 07 CB
SV 10/100% HEATFROST 05 AB
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
HFR
HGA
HGF
HHE
HHF
HHH
HIB
HIP
HJB
HJF
HJQ
HK8
HKA
HKB
HKE
HKF
HKV
HLA
HLB
HLC
HLD
HLF
HLH
HLJ
HLP
HLS
HM1
HM2
HM3
HM4
HM5
HM6
HM7
HMA
HMB
HMC
HMD
HMF
HMJ
HMN
HMO
HMR
HMT
HMX
HMY
HMZ
HNA
HNB
HNC
HND
Plan / Benefit Description
SV 10/100% HEATFROST 05
SV 10/100% HEMET 07 AB
SV 10/100% HEATFROST 07
500A 3YRS HA-GR08
SV 15-25/250A HCA 07 AB
UNLIMITED 1AID/EAR HA-GR08
HI-DNTL POS IMPERIAL PRT B
HI-DNTL CHOICE IMPERIAL
SAN JOAQ B-ONLY HI-OP MED
SV 10/100% HEATFROST 07 CB
SAN JOAQUIN HI-OP MED
500A 3YRS 0PREM HA-GR08
HI-OP DNTL-KERN PART B
HI-DNTL POS KRN/VNTRA PT B
HI-OP DNTL-KERN BASIC
SV 10/100% HEATFROST 07 AB
HI-DNTL CHOICE KERN/VNTURA
HI-OP DNTL-LA,OR,SB,RIV
HI-OP BSC DTL B ONLY EL DO
HI-OP DTL LA/RV/SB PART B
HI-OP MED W/O BSC DTL ELDO
SV 10/100D HACIENDA 07
SV 10/100D HACIENDA 07 CB
SV 15-25/250A HCA INC AB
SV 15-25/250A HCA INC
LACERS CUSTOM HEARING AID
2002 HMO STD PLAN 1
2002 HMO STD PLAN 2
2002 HMO STD PLAN 3
2003 STD 10/20 $200
2003 STD 15/30 $400
2003 STD 20/40 $600
2003 HMO $20/$250
HI-OP MED-BASIC DTL SONOMA
MARIN PRT B ONLY HI-MED
SV 15-25/250A HCAMN 06
SVA 20-40/250A HM 06
SV 15-25/250A HCAMN 06 CB
SV 15-25/250A HCAMN 06 AB
H-OP BASIC DTL SONOMA-B ON
MONTEREY HI-MED
MARIN HI-OP MED NO BSC DTL
HI-OP M&D SAN MATEO B ONLY
SVA 20-40/250A HM 06 AB
MONTEREY PRT B ONLY HI-MED
SVA 20-40/250A HM 06 CB
NAPA PRT B ONLY HI-MED
HI-OP MED SACTO/ELDR PRT B
HI-OP MED SACTO/EL DORADO
HI-OPT DENTAL SAN DIEGO CO
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
HNH
HNP
HOA
HOB
HOC
HOE
HOI
HOK
HOM
HON
HOS
HPA
HPB
HPC
HPE
HPF
HPG
HPJ
HPK
HPL
HPS
HPX
HPZ
HQA
HR0
HR1
HR2
HR3
HRA
HRB
HRD
HRE
HRF
HRG
HRI
HRJ
HRL
HRM
HRN
HRP
HRR
HRS
HRY
HSA
HSB
HSC
HSD
HSE
HSJ
HSL
Plan / Benefit Description
SV 10/100D HACIENDA 07 AB
NAPA HI-OP MED NO BSC DTL
RESERVED HEARING PFFS
HI-OPT DNTL - O.C. B ONLY
HI-OPT DNTL - ORANGE CO.
RESERVED HEARING PFFS
RESERVED HEARING PFFS
10/300A 3YRS MAX GR-HA07
HI-OPT DENTAL CENTRAL CA
HI-OP DNTL NORTHERN CALIF
HI-OP DNTL SOUTHERN CALIF.
SV HPA $15/$30/$500
SV HPA $15/$30/$500 CB
SV 15-40/500A HP 06
RESERVED PFFS
SV 15-30/500A HP 06
20-40/500A HP GR07
SV HPA $15/$30/$500 AB
20-40/500A HP NO-AARP GR08
SV 15-25/250A HCA INC CB
PLA/SANJ HI-OP MED NO DTL
SV 15-30/500A HP 06 AB
SV 15-30/500A HP 06 CB
SP 20/250A HAZARD CO 07
HEARING AID 1PR/EAR Q 36MO
HRNG AID CSTM $750 P/EAR
HRING AID $500 ALLOWANCE
HRING AID $300 ALLOWANCE
HI-OP DNTL CNTR CSTA B ONL
0/500A 3YRS SH-HA07
0/800A 3YRS DX SH-HA07
5/400A 3YRS SH-HA07
25/400A 3YRS SH-HA07
SH INDIV. HEARING
PPO HEARING AID RIDER
0/800A 3YRS SH-HA07
25/900A 3YRS PL SH-HA07
25/1700A 3YRS DX SH-HA07
CODE CAN BE USED AGAIN .
0/500A 3YRS PL SH-HA07
300A GR-HA07
CODE CAN BE USED AGAIN .
0/1300A 3YRS DX SH-HA07
HI-OP MED-SBB/SLO PRT B
HI-OP MED SBB/SLO
HI-OP MED/DNTL BAY AREA
HI-OP DNTL-SAN DIEGO BASIC
H-OP MD/DT B ONLY SANT CLA
HI-MED SJA/PLA PRT B ONLY
HI-OP DNTL-IMPERIAL BASIC
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
HSM
HSN
HSO
HSP
HSR
HSS
HST
HSZ
HTA
HTB
HTC
HTE
HTF
HTJ
HTU
HUA
HUB
HUF
HUJ
HUS
HUT
HUV
HVA
HVB
HVC
HVD
HVE
HVJ
HVT
HWA
HWD
HXA
HXB
HXC
HXD
HXE
HYA
HYB
HYC
HYD
HYG
HYJ
HYX
HYZ
HZ1
HZA
HZB
HZC
HZG
HZX
Plan / Benefit Description
HI-OP MED/DTL SAN MATEO
SOL./SON.HI-MED PRT B ONLY
SONO/SOL HI-OP MED NO DTL
CHOICE HI-OP DNTL SOUTHERN
HI-MED SNTA CRZ PRT B ONLY
HI DNTL IMPERL PRT B ONLY
HI-OP MED/DNTL SANTA CLARA
SANTA CRUZ HI-MED
HI-OP MED STANISLAUS
HI-OP MED.-STNSLAUS PRT B
500A 2YRS HA-GR08
SV 5/350A HCT/AMR UN 05 CB
SV 10/100% HEATFROST 05 CB
SV 5/350A HCT/AMR UN 05 AB
SV 5/350A HCT/AMR UNION 05
SP 20/250A HAZARD CO 07 CB
HI-OP MED/WO-BSC DTL STANI
HEARING AID 50% $2000 MAX
SV 10/100% HUSD 05 AB
SV 10/100% HUSD 05
SV 10/350A HEALTHCARE 05
SV 20/350A HTAU 05
HI-OP DNTL-KRN/VNT PRT B
HI-OP DNTL-VENTURA B-ONLY
VEBA HA (1EVERY 24 MONTHS)
LADWP HEARING AID GR08
HI-OP DNTL-VENTURA BASIC
SV 20/350A HTAU 05 AB
HI-OP DNTL-VENTURA BASIC
SP 20/250A HAZARD CO 07 AB
UNLIMITED 3YRS HA-GR08
SV 20-40/90% HP 08
SV 10/100% HEMET 07
SV 20-40/90% HP 08 CB
1000A 3YRS HA GR08
SV 20-40/90% HP 08 AB
SV 10/100% HEMET USD 06
SV 10/100% HEMET 07 CB
HEARING AID - $2500 MAX
1PR/EAR 3YRS HA-GR08
SP 15/100% HAZARD CO 06 CB
SV 10/350A HLTHCARE 05 AB
SV 10/100% HEMET USD 06 AB
SV 10/100% HEMET USD 06 CB
STANDARD 5 PLAN (COBRA)
SV 20-40/500A HEM USD06
SV 10/100% HEMET 07 AB
SP 15/100% HAZARD CO 06
SP 15/100% HAZARD CO 06 AB
SV 20-40/500A HEM USD06 AB
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
HZZ
I00
I01
I02
I03
I04
I05
I06
I07
I08
I09
I0A
I0B
I0C
I0D
I0E
I0F
I0G
I0H
I0J
I0K
I0L
I0M
I0N
I0P
I0Q
I0R
I0S
I0T
I0U
I0X
I0Z
I10
I1M
I1Q
I1R
I1S
I1T
I1U
I1Z
I20
I2Q
I2R
I2S
I2T
I2U
I2Z
I30
I3Q
I3R
Plan / Benefit Description
SV 20-40/500A HEM USD06 CB
INDEMNITY COVERAGE
INDEMNITY PLAN W/PPO
INDEMNITY PLAN NO/PPO
IND./ARC HMO BEN./UFCW BIS
IND./F1C BEN./DAIRY MERCED
INDEMNITY PPO-90/70
INDEMNITY PPO-90/70 COPAY
INDEMNITY PPO-80/60
INDEMNITY PPO-80/60 COPAY
INDEMNITY PPO-90/80 COPAY
INDEMNITY PLAN/WITH PPO
INDEMNITY PLAN/NO PPO
INDEMNITY/SMALL GROUP PPO
INDEMNITY SMALL GROUP PPO
INDEMNITY SMALL GROUP PPO
SMALL GROUP PPO $250 DED.
SMALL GROUP PPO $500 DED.
SMALL GROUP PPO $1000 DED.
KEENAN HIPC INDEMNITY
KEENAN HIPC PPO
AFFORDABLE PPO 250 SMALL
SM GRP PPO 250 OUT OF STAT
INDEMNITY NATIONAL PPO
INDEMNITY PPO-CUSTOM
ELITE PPO 250
ELITE PPO 500
ELITE OOS INDEMNITY
PREMIER PPO 500
PREMIER OOS INDEMNITY
INDEMNITY PLAN-NO PPO
KEENAN HIPC PPO
IHS PPO (AFFORDABLE NET)
IMPERIAL STANDARD PLAN
ELITE PPO 250
COBRA
ELITE PPO 500
COBRA
ELITE OOS INDEMNITY COBRA
PREMIER PPO 500 CBRA
PREMIER OOS INDEMNITY CBR
IHS PPO (AFFORDABLE NET)
IHS INDEMNITY
ELITE PPO 250 CAL COBRA
ELITE PPO 500 CAL COBRA
ELITE OOS INDEMNITY CCOBRA
PREMIER PPO 500 CAL CBRA
PREMIER OOS INDEMNITY CCBR
IHS INDEMNITY (COBRA)
INDEMNITY-SELF FUNDED
ELITE PPO 250 FED CBR EXT
ELITE PPO 500 FED CBR EXT
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
I3S
I3T
I3U
I3Z
I40
I4Q
I4R
I4S
I4T
I4U
I4Z
I5Q
I5R
I5S
I5T
I5U
I6J
I6Q
I6R
I6S
I6T
I6U
I81
IA0
IAA
IAD
IAJ
IAZ
IBA
IBD
IBJ
IBP
IBX
IBZ
IC2
IC3
ICB
ICE
ICF
ICH
ICI
ICJ
ICK
ICP
ICX
ICZ
IDB
IDT
IDZ
IEA
Plan / Benefit Description
ELITE OOS FED CBR EXTENDED
PREM PPO 500 FED CBR EXTEN
PREM OOS FED CBR EXTENDED
INDEMNITY SELF FUNDED COBR
DUMMY PLAN-NOT IN USE
ELITE PPO 250 FED CBR DISA
ELITE PPO 500 FED CBR DISA
ELITE OOS FED CBR DISABLED
PREM PPO 500 FED CBR DISAB
PRE OOS FED CBR DISABLED
DUMMPY PLAN-NOT IN USE
ELITE PPO 250 CAL CBR EXT
ELITE PPO 500 CAL CBR EXT
ELITE OOS CAL CBR EXTENDED
PREM PPO 500 CAL CBR EXTEN
PREM OOS CAL CBR EXTENDED
SV 20/250A+20% IC06
ELITE PPO 250 CAL CBR DISA
ELITE PPO 500 CAL CBR DISA
ELITE OOS CAL CBR DISABLED
PREM PPO 500 CAL CBR DISAB
PREM OOS CAL CBR DISABLED
IND.CONV.PLAN-880
ARMSTRONG INDEMNITY
SV 15/100% SCIBEW 06
SV 30-40/250A ITT 06 CB
SV 30-40/250A ITT 06 AB
ARMSTRONG INDEMNITY-COBRA
SV 20/100% IBEW 06
INFERTILITY BASIC D&T
ITT AB
IMPERIAL CHOICE-PRT B ONLY
SV 20/100% IBEW 06 AB
SV 20/100% IBEW 06 CB
INDIV CONVERSION $15
IC PLAN $35/30%
IMPERIAL CNTY PRT B ONLY
SV 35/70% IP05
SV 15-30/100% ICIPT 06
SV 35/70% IC06
SV 15-30/100 ICIPAINTS
SV 15-30/100 ICIPAINTS AB
SV 15-30/100% ICIPT 06 CB
SV 15-30/100 ICIPAINTS CB
SV 15-30/100% ICIPT 06 AB
INDEMNITY 80/20 $250 D CBR
SV 20-30/250A INGRAM 08
INDEMNITY DENTAL
INDEMNITY 80/20 $500 D CBR
SV 15/100% SCIBEW 06 CB
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
IEB
IED
IEJ
IF6
IFA
IFB
IFC
IFD
IFE
IFF
IFG
IFH
IG4
IG5
IG6
IG7
IG8
IG9
IGB
IGC
IGD
IGF
IGG
IGH
IGQ
IH2
IH3
IH4
IH5
IH6
IH7
IHE
II0
IIE
IIZ
IJE
IK1
IK2
IKA
IKC
IKD
IKJ
IKM
IKX
IL1
ILA
ILB
ILC
ILD
ILG
Plan / Benefit Description
SV 20-30/250A INGRAM 08 CB
SV 35-45/250A ITT 06 CB
SV 35-45/250A ITT 06 AB
INFERTILITY EDISON INTL 06
INFERTILITY SCS VEBA 06
INFERTILITY ALAMEDA 06
INFERTILITY SCS VEBA 06
INFERTILITY SCS VEBA 06
INFERTILITY SCS VEBA 06
INFERTILITY SCS VEBA 06
INFERTILITY L3 ELECTRON 06
INFERTILITY DX ONLY 06
SV IND HMO20-35/80% GBHIPA
SV IND HMO10-35/250D GBHIP
SV IND HMO10-35/250D GBHIP
SV IP 20-35/80% GBILLHIPA
SV IP $35/70% GBILL HIPPA
SV 35/50%A GB HIP IP05
SV 20-30/250A INGRAM 08 AB
SV IND HMO10-35/250D GBILL
SV IND HMO20-35/80% G-BILL
SV IND HMO10-35/250D GBILL
SV IP 20-35/80% GBILLED
SV IP $35/70% GRP BILLED
SV 35/50%A GBILL IP05
INDIV $10/$30/$250A HIPPA
INDIV $10/$30/$250A HIPPA2
INDIV $10/$30/$250A HIPPA3
INDIV $15/$30/80% HIPPA
INDIV $15/$30/80% HIPPA 2
INDIV $15/$30/80% HIPPA 3
SV 20/100% IAP WS 07
IHS PPO (PCCA NETWORK)
SV 20/100% IAP WS 07 CB
IHS PPO-COBRA PCCA NETWORK
SV 20/100% IAP WS 07 AB
IKON 15/250 PLAN
IKON 15/250 PLAN COBRA
SV 15/100% SCIBEW 06 AB
SV 20/250A+80% IK 06
SV 5/100% ITT 06 CB
SV 5/100% ITT 06 AB
SV 20/250A+80% IK 06 CB
SV 20/250A+80% IK 06 AB
INDEMNITY CUSTOM 500
SV 25-35/450A INTPUB 07
SV 25-35/450A INTPUB 07 CB
INDEMNITY 80/20 $250 DED
INDEMNITY 80/20 $500 DED
SV 25-35/450A INTPUB 07 AB
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
ILZ
IM1
IM2
IM3
IM4
IM5
IM6
IM7
IM8
IMA
IMB
IMP
IOA
IP1
IP2
IP3
IP4
IP5
IP6
IP7
IP8
IP9
IPA
IPB
IPC
IPD
IPF
IPG
IPH
IPQ
IPR
IPS
IPT
IPU
IRD
IRJ
IRX
IS1
ITA
ITB
ITJ
ITR
ITT
ITV
ITX
ITY
ITZ
IUF
IVN
IZ0
Plan / Benefit Description
INDEMNITY CUSTOM 500 CBR
SH IMPERIAL STD MED
SH IMPERIAL STD W/ HI DEN
SH IMPERIAL PART B STD MED
SH IMPERIAL PT B W/ HI DEN
SH IMPERIAL PLUS PLAN MED
SH IMPERIAL PLUS W/ HI DEN
SH IMPERIAL PART B PLUS
SH IMPERIAL B PLS & HI DEN
IMPERIAL STANDARD PLAN
IMPERIAL STND PRT B ONLY
IMPERIAL CHOICE PLAN
INDEMNITY PLAN/WITH PPO
SV 20-35/80% HP06
SV 35/70% HP06
SV 10-35/250D HP06
SV IND HMO20-35/80% HIPPA
SV IND HMO10-35/250D HIPPA
SV IND HMO10-35/250D HIPPA
SV IP 20-35/80% HIPPA
SV IP $35/70% HIPPA
SV 35/50%A HIPPA IP05
INDIVIDUAL $10/$30/$250A
INDIVIDUAL $15/$30/80%
SV IND HMO10-35/250D
SV IND HMO20-35/80%
SV IND HMO10-35/250D
SV IP 20-35/80%
SV IP $35/70%
SV 35/50%A IP05
SV 35/50% IP06
SV 20-35/80% IP06
SV 35/70% IP06
SV 10-35/250D IP06
SV 25-35/250A ITT 06 CB
SV 25-35/250A ITT 06 AB
IND RX VIA PRSCRPTN SOL
IND.CONV.PLAN-STANDARD
SP ITT
SP 20/100% ITT 06
SP ITT AB
PPO INFERTILITY TX RIDER
ITT
SP 20/100% ITT 06 CB
SP 20/100% ITT 06 AB
SP ITT CB
ITT COBRA
INFERTILITY $0 UFCW 06
INDEMNITY VISION
INDEMNITY COVERAGE
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
IZ1
IZ2
IZ3
IZ4
IZ5
IZ6
IZ7
IZ8
IZ9
IZA
IZB
IZC
IZD
IZE
IZF
IZG
IZH
IZJ
IZK
IZL
IZM
IZN
IZO
IZP
IZQ
IZT
IZU
IZV
IZX
J0Q
J0R
J0S
J0T
J0U
J1C
J1I
J1P
J1Q
J1R
J1S
J1T
J1U
J1Y
J1Z
J2P
J2Q
J2R
J2S
J2T
J2U
Plan / Benefit Description
INDEMNITY PLAN W/PPO COBRA
INDEMNITY PLAN NO/PPO COBR
IND./ARZ HMO BEN./UFCW BIS
IND./F1Z BEN./DAIRY MERCED
INDEMNITY PPO-90/70
INDEMNITY PPO-90/70-COPAY
INDEMNITY PPO-80/60
INDEMNITY PPO-80/60 COPAY
INDEMNITY PPO-90/80 COPAY
INDEMNITY PLAN/WITH PPO CB
INDEMNITY PLAN/NO PPO CBR
INDEMNITY SMALL GROUP/PPO
INDEMNITY SMALL GROUP/PPO
INDEMNITY SMALL GROUP/PPO
SMALL GROUP PPO $250 DED.
SMALL GROUP PPO $500 DED.
SMALL GROUP PPO $1000 DED.
KEENAN HIPC INDEMN. COBRA
KEENAN HIPC PPO COBRA
AFFORDABLE PPO 250 SMALLCB
SM GRP PPO250 OUT/STATE CB
INDEMNITY NATIONAL PPO
INDEMNITY PLN NO PPO CC
INDEMNITY PPO-CUSTOM
INDEMNITY PLAN W/PPO CC
SMALL GROUP PPO $250DED CC
SMALL GROUP PPO $500DED CC
SMALL GRP PPO $1000DED CC
CNDEMNITY (NON PPO) COBRA
ELITE PPO 250 7/00
ELITE PPO 500 7/00
ELITE OOS INDEMN 7/00
PREMIER PPO 500 7/00
PREMIER PPO 500 (80/60)
880 PLAN
II
INDIVIDUAL CONVERSION 880
880 PLAN
ELITE PPO 250 7/00 COBRA
ELITE PPO 500 7/00 COBRA
ELITE OOS INDEMN 7/00 CBR
PREMIER PPO 500 7/00 CBRA
PREM PPO 500 (80/60) COBRA
880 PLAN COBRA
880 PLAN
COBRA II
MFP 880 PLAN
ELITE PPO 250 7/00 CCOBRA
ELITE PPO 500 7/00 CCOBRA
ELITE OOS INDEMN 7/00 CCBR
PREMIER PPO 500 7/00 CCBRA
PRM PPO 500(80/60) CAL CBR
141 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
J2Y
J3Q
J3R
J3S
J3T
J3U
J4Q
J4R
J4S
J4T
J4U
J5Q
J5R
J5S
J5T
J5U
J6Q
J6R
J6S
J6T
J6U
JAA
JAJ
JAZ
JB7
JBA
JBF
JBJ
JBT
JBX
JBZ
JDF
JJA
JJJ
JJN
JJY
JJZ
JNJ
JPA
JPC
JPF
JPG
JPJ
JPK
JPL
JPM
JPN
JPS
JPX
JPZ
Plan / Benefit Description
MFP 880 PLAN - COBRA
ELITE PPO 250 FED CBR EXT
ELITE PPO 500 FED CBR EXT
ELITE OOS FED CBR EXTENDED
PREM PPO 500 FED CBR EXTEN
PR PPO 500(80/60) FD CB EX
ELITE PPO 250 FED CBR DISA
ELITE PPO 500 FED CBR DISA
ELITE OOS FED CBR DISABLED
PREM PPO 500 FED CBR DISAB
PR PPO 500(80/60) FD CB DS
ELITE PPO 250 CAL CBR EXT
ELITE PPO 500 CAL CBR EXT
ELITE OOS CAL CBR EXTENDED
PREM PPO 500 CAL CBR EXTEN
PR PPO 500(80/60) CL CB EX
ELITE PPO 250 CAL CBR DISA
ELITE PPO 500 CAL CBR DISA
ELITE OOS CAL CBR DISABLED
PREM PPO 500 CAL CBR DISAB
PR PPO 500(80/60) CL CB DS
SV 20-30/250A JPMCC 06
SV 20-30/250A JPMCC 06 AB
SV 20-30/250A JPMCC 06 CB
SV 20-40/400A JTBENTRST CB
SV 20-40/400A JBT 06
SV 15-35/250A J&J 07
SV 20-40/400A JTBENTRST AB
SV 20-40/400A JTBENTRST
SV 20-40/400A JBT 06 AB
SV 20-40/400A JBT 06 CB
SV 15-35/250A J&J 07 CB
SV 15-35/250A J&J 06
SV 15-35/250A J&J 06 AB
SV J&J NUTRO 15-35/250A
SV 15-35/250A J&J 06 CB
SV J&J NUTRO 15-35/250A CB
SV J&J NUTRO 15-35/250A AB
SVA 10/100% JPGT 06
SV 20-30/250A JPMCC 07
SV 20-30/250A JPMCC 07 CB
SV 20/100% JP GETY 06
SV 20-30/250A JPM AB
SV 20-30/250A JPMCC 07 AB
SVA 10/100% JPGT 06 CB
SV 20-30/250A JPM
SV 20-30/250A JPM CB
SVA 10/100% JPGT 06 AB
SV 20/100% JP GETY 06 AB
SV 20/100% JP GETY 06 CB
142 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
JRF
JUA
JUJ
JUZ
JZ2
JZ3
JZ4
JZ5
JZ6
JZ7
JZ8
JZ9
JZA
K1D
K1E
K1F
K1G
K1N
K1P
K1R
K1S
K1W
K1Y
K1Z
K22
K23
K24
K25
K2C
K2K
K2V
K2Z
K32
K33
K34
K35
K3C
K3J
K3Z
K42
K43
K44
K45
K4N
K5N
KA2
KA3
KA4
KA5
KA6
Plan / Benefit Description
SV 15-35/250A J&J 07 AB
SVA 10/500D 05
SVA 10/500D 05 AB
SVA 10/500D 05 CB
SP 15/250A SG06 CB
SP 15/250A SG06 AB
SP 15/250A SG06 CC
SP 15/250A SG06 CE
SP 15/250A SG06 CD
SP 15/250A SG06 FE
SP 15/250A SG06 FD
SP 15/250A SG06 US
SP 15/250A SG06
ELITE 80 FED CBR DISABLED
ELITE 80 FED CBR EXTENDED
ELITE 80 CAL CBR EXTENDED
ELITE 80 CAL CBR DISABLED
KERN STANDARD PLAN
10/80 PLAN (POS)
ELITE 80
CAL COBRA
ELITE 80
ELITE 80
COBRA
10/80 PLAN - POS (COBRA)
INACTIVE
KEC KERN CG GR07
KEC KERN LOW CG GR07
KEC KERN HI CG GR07
KEC KERN DX CG GR07
MFP 10/80 PLAN
DUMMY
DUMMY
MFP 10/80 PLAN-COBRA
KEC KERN CGII GR07
KEC KERN LOW CGII GR07
KEC KERN HI CGII GR07
KEC KERN DX CGII GR07
STANDARD $10/80 PLAN
STANDARD $10/80 PLAN AB
STANDARD $10/80 PLAN COBRA
KEC KERN CGEH GR07
KEC KERN LOW CGEH GR07
KEC KERN HI CGEH GR07
KEC KERN DX CGEH GR07
KERN STANDARD W/OPT DENTAL
KERN STANDARD W/HI DENTAL
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
143 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
KA7
KA8
KA9
KAA
KAB
KAD
KAH
KAJ
KAL
KAN
KB2
KB3
KB4
KB5
KB6
KB7
KB8
KB9
KBA
KBB
KBC
KBD
KBG
KBH
KBJ
KBL
KBN
KBP
KCA
KCB
KCC
KCD
KCH
KCJ
KCP
KD2
KD3
KD4
KD5
KD6
KD7
KD8
KD9
KDA
KDB
KDD
KDE
KDG
KDJ
KE2
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 10/100% 06
SV 10/100% 06 CB
MCC KERN DELUXE SH07
MCC KERN HIGH SH07
SV 10/100% 06 AB
MCC KERN LOW SH07
MC COMP KERN SH07
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 20-30/90% IKON 08
SV 10/100% PUBSECTR 06
SV 10/100% PUBSECTR 06 CB
MCC ESS KERN DELUXE SH07
SV 15-25/10% KARYKEI 07
MCC ESS KERN HIGH SH07
SV 10/100% PUBSECTR 06 AB
MCC ESS KERN LOW SH07
MC COMP ESS KERN SH07
KRN/VNTRA PRTB ONLY-CHOICE
SV 20-30/90% IKON 08 CB
KEENAN COMP KERN GR07
CODE CANCELLED-DO NOT USE
CODE CANCELLED-DO NOT USE
KERN CLASSIC I W/HIOP DDS
CODE CANCELLED-DO NOT USE
KERN CLASSIC I W/EPO DDS
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 20-30/90% IKON 08 AB
KEC KERN LOW GR07
CODE CANCELLED-DO NOT USE
CODE CANCELLED-DO NOT USE
SV 15-25/10% KARYKEI 07 CB
CODE CANCELLED-DO NOT USE
RESERVED PPO
144 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
KE3
KE4
KE5
KE6
KE7
KE8
KE9
KEB
KEF
KF2
KF3
KF4
KF5
KF6
KF7
KF8
KF9
KFB
KFI
KG2
KG3
KG4
KG5
KG6
KG7
KG8
KG9
KGF
KGH
KGL
KGW
KGX
KH8
KH9
KHA
KHJ
KHZ
KJ2
KJ3
KJ4
KJ5
KJ6
KJ7
KJ8
KJ9
KK6
KKA
KKB
KKD
KKF
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
KEC KERN HIGH GR07
SP 10/100% KNAPP 06
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
KEC KERN DELUXE GR07
FREEDOM PLAN 108
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SP 10/100% KNAPP 06 CB
ARP MCC KERN HI SH08
ARP MCC KERN LO SH08
ARP MCC KERN SH08
ARP MCC KERN DLX SH08
RESERVED PPO
RESERVED PPO
SV 20/100% 06
SV 20/100% 06 AB
SV 20/100% 06 CB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 15-25/90% KARYK 06
SV 15/100% 05
SV 20-30/250A IKON 07
SV 20-30/250A IKON 07 CB
SV 20-30/250A IKON 07 AB
145 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
KKJ
KKX
KKY
KKZ
KL2
KL3
KL4
KL5
KL6
KL7
KL8
KL9
KLA
KLB
KLG
KLJ
KM2
KM3
KM4
KM5
KM6
KM7
KM8
KM9
KMD
KME
KMH
KMS
KN1
KN2
KN3
KN4
KN5
KN6
KN7
KN8
KNE
KP5
KP6
KPJ
KQF
KR2
KR3
KR4
KR5
KR6
KR7
KR8
KR9
KRC
Plan / Benefit Description
SV 15/100% 05 AB
SV 15-25/90% KARYK 06 AB
SV 15-25/90% KARYK 06 CB
SV 15/100% 05 CB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SP 10/100% 06
SP 10/100% 06 CB
SV 15-25/10% KARYKEI 0 AB
SP 10/100% 06 AB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
KERN MEDICAL W/OP DDS
KERN MEDICAL W/EPO DDS
KERN MEDICAL W/HI OP DDS
KERN MEDICAL
SH KERN STD MED
SH KERN STD MED W/ HI DEN
SH KERN PART B STD MED
SH KERN PART B W/ HI DEN
SH KERN PLUS MED
SH KERN PLUS MED W/ HI DEN
SH KERN PART B PLUS MED
KERN PART B PLUS W/ HI DEN
ENDORSE KERN BAS W/ NO DEN
SV $10-$20/80%
SV $10-$20/80% CB
SV $10-$20/80% AB
SP 10/100% KNAPP 06 AB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/80 PLAN
146 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
KRZ
KS2
KS3
KS4
KS5
KS6
KS7
KS8
KS9
KSA
KSJ
KSL
KSM
KSR
KSX
KSZ
KT2
KT3
KT4
KT5
KT6
KT7
KT8
KT9
KU2
KU3
KU4
KU5
KU6
KU7
KU8
KU9
KV2
KV3
KV4
KV5
KV6
KV7
KV8
KV9
KVP
KW2
KW3
KW4
KW5
KW6
KW7
KW8
KW9
KWD
Plan / Benefit Description
10/80 PLAN
COBRA
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 20/500A KSL 06
SV 20/500A KSL AB
SV 20/500A KSL
KERN CLASSIC I
SV 20/500A KSL CB
SV 20/500A KSL 06 AB
SV 20/500A KSL 06 CB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
KERN/VENTURA BASIC CHOICE
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
KERN CLASSIC I W/OP DDS
147 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
KX2
KX3
KX4
KX5
KX6
KX7
KX8
KX9
KY2
KY3
KY4
KY5
KY6
KY7
KY8
KY9
KZ1
KZ2
L01
L02
L03
L04
L05
L06
L07
L08
L09
L0J
L10
L11
L12
L13
L14
L15
L16
L17
L18
L19
L1A
L1C
L1D
L1E
L1F
L1G
L1J
L1R
L1S
L1W
L1Z
L20
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RWELL/PREF-50-OPMH COBRA
STANDARD 10 - $25 ER COBRA
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
SV 15/100A LA MACHINIST AB
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFELINK CRISIS CM
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LOS ANGELES STANDARD PLAN
STANDARD 20 PLAN
ELITE 20 FED CBR DISABLED
ELITE 20 FED CBR EXTENDED
ELITE 20 CAL CBR EXTENDED
ELITE 20 CAL CBR DISABLED
SV 25/100A LA MACHINIST AB
ELITE 20 PLAN CAL CBRA
ELITE 20 PLAN
ELITE 20 PLAN CBRA
STANDARD 20 PLAN COBRA
LIFE COVERAGE PLAN
148 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
L21
L22
L23
L24
L25
L26
L27
L28
L29
L2A
L2B
L2D
L2E
L2F
L2G
L2H
L2J
L2R
L2S
L2W
L2Z
L30
L31
L32
L33
L34
L35
L36
L37
L38
L39
L3A
L3C
L3G
L3H
L3J
L3L
L3M
L3N
L3P
L3Q
L3T
L3U
L3X
L3Y
L3Z
L40
L4A
L4C
L4G
Plan / Benefit Description
LIFE PLAN W/SEATBELT RIDER
LIFE PLAN W/SEATBELT RIDER
LIFE PLAN W/SEATBELT RIDER
LIFE PLAN W/SEATBELT RIDER
LIFELINK FOCUS CM 25
LIFE PLAN W/SEATBELT RIDER
LIFE PLAN W/SEATBELT RIDER
LIFE PLAN W/SEATBELT RIDER
LIFE PLAN W/SEATBELT RIDER
KEC 1 LA CG GR07
KEC 1 LA CGII GR07
PREMIER 20 FED CBR DISABLE
PREMIER 20 FED CBR EXTEND
PREMIER 20 CAL CBR EXTEND
PREMIER 20 CAL CBR DISABLE
KEC 1 LA CGEH GR07
STANDARD $10-$20/80 AB
PREMIER 20 PLAN CAL CBRA
PREMIER 20 PLAN
PREMIER 20 PLAN CBRA
STANDARD $10-$20/80 COBRA
LIFE PLAN W/SEATBELT RIDER
LIFE PLAN W/SEATBELT RIDER
LIFE PLAN
(SMALL GRP)
LIFE PLAN
(SMALL GRP)
LIFE PLAN
(SMALL GRP)
LIFELINK FOCUS CM 35
LIFE PLAN/SEATBELT (SMALL)
GROUP LIFE ELITE
GROUP LIFE ELITE
SMALL GROUP LIFE
LOS ANGELES PLUS PLAN
HMO 20 PLAN
SP 10/100% L3/CS 06
SV 20-30/100D L3 ELEC 06
HMO 20 PLAN
AB
KEC 1 LA LO CG GR07
SV 20-30/100D L3 ELE 06 CB
KEC 1 LA LO CGII GR07
SP 10/100% L3/CS 06 AB
KEC 1 LA LO CGEH GR07
SV 15/100% L3ETI 05 CB
HMO 20 PLAN USERRA
SV 20-30/100D L3 ELE 06 AB
SP 10/100% L3/CS 06 CB
STANDARD $15-$30/80 COBRA
GROUP LIFE PREMIER
LOS ANGELES STD. W/OPT DDS
HMO 20 PLAN CBRA
KEC 1 LA LO-PL CG GR07
149 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
L4H
L4J
L4K
L4L
L4M
L4X
L4Z
L50
L51
L52
L53
L54
L55
L56
L57
L58
L59
L5A
L5C
L5E
L5F
L5G
L60
L61
L62
L63
L64
L65
L66
L67
L68
L69
L6A
L6C
L6E
L6F
L6G
L70
L71
L72
L73
L74
L75
L76
L77
L78
L79
L7A
L7C
L7E
Plan / Benefit Description
SV 15/100% L3 ELEC 06
STANDARD $20-$40/$250A AB
KEC 1 LA LO-PL CGII GR07
KEC 1 LA LO-PL CGEH GR07
SV 15/100% L3 ELEC 06 CB
SV 15/100% L3 ELEC 06 AB
STANDARD $20-$40/$250A CBR
DUMMY
DUMMY
DUMMY
DUMMY
DUMMY
DUMMY
DUMMY
DUMMY
DUMMY
DUMMY
LOS ANGELES STAND W/HI DNT
HMO 20 PLAN CAL CBRA
KEC 1 LA HI CG GR07
KEC 1 LA HI CGII GR07
KEC 1 LA HI CGEH GR07
DUMMY
DUMMY
DUMMY
DUMMY
DUMMY
DUMMY INACTIVATED
DUMMY
DUMMY
DUMMY
DUMMY
LOS ANGELES PLUS W/OPT DDS
HMO 20 FED CBR DISABLED
KEC 1 LA HI-PL CG GR07
KEC 1 LA HI-PL CGII GR07
KEC 1 LA HI-PL CGEH GR07
DUMMY
DUMMY
DUMMY
DUMMY
DUMMY
DUMMY
DUMMY
DUMMY
DUMMY
DUMMY
LOS ANGELES PLUS W/HI DNTL
HMO 20 FED CBR EXTENDED
KEC 1 LA PL CG GR07
150 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
L7F
L7G
L8C
L8E
L8F
L8G
L93
L95
L99
L9C
L9D
L9E
L9F
L9G
L9H
L9L
L9N
L9O
LA0
LA1
LA2
LA3
LA4
LA5
LA6
LA7
LA8
LA9
LAA
LAB
LAC
LAD
LAE
LAF
LAG
LAH
LAJ
LAK
LAM
LAN
LAP
LAR
LAS
LAT
LAU
LAZ
LBA
LBB
LBD
LBG
Plan / Benefit Description
KEC 1 LA PL CGII GR07
KEC 1 LA PL CGEH GR07
HMO 20 CAL CBR EXTENDED
KEC 1 LA DX CG GR07
KEC 1 LA DX CGII GR07
KEC 1 LA DX CGEH GR07
MCC VALUE LA LO-PL SH07
MCC VALUE LA HI-PL SH07
MCC VALUE LA PLUS SH07
HMO 20 CAL CBR DISABLED
MCC VALUE LA DELUXE SH07
KEC 1 LA PL-DX CG GR07
KEC 1 LA PL-DX CGII GR07
KEC 1 LA PL-DX CGEH GR07
MCC VALUE LA HIGH SH07
MCC VALUE LA LOW SH07
MC COMP VALUE LA SH07
MCC VALUE LA PL-DLXE SH07
ACE PARKING
SH LOS ANGELES STD MED
LOS ANGELES STD W/ HI DEN
LOS ANGELES PART B STD MED
LOS ANGELES PT B W/ HI DEN
SH LOS ANGELES PLUS MED
LOS ANGELES PLUS W/ HI DEN
LOS ANGELES PART B PLUS
LOS ANGELES B PL W/ HI DEN
ACE PARKING COBRA
LA COUNTY-PART B ONLY
LOS ANGELES PHAN B ONLY
LOS ANGELES BASIC PLAN
20-30/250A LOKHEED GR06
ENDORSE LA BASIC W/ NO DEN
SV 25/100A LA MACHINIST
SV 25/100A LA MACHINIST CB
SP 10/100% LARISA 06
LAUSD $10/100% AB
SP 10/100% LARISA 06 CB
SV 15/100A LA MACHINIST
SV 15/100A LA MACHINIST CB
LOS ANGELES PHAN
SP 10/100% LARISA 06 AB
LAUSD $5 GRP RETIREE
SPT 10-25/250A LCDS 06
LAUSD $10/100%
LAUSD $10/100% COBRA
PBHI FOCUS CM 20
SV 10/100% LARISA 06
KEC 1 LA PLUS GR07
SVA 20/250A LOWES 07
151 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
LBJ
LBK
LBL
LBM
LBN
LBU
LBX
LBY
LBZ
LC1
LCD
LCE
LCF
LCH
LCK
LCL
LCM
LCR
LCT
LCZ
LD1
LD2
LD3
LD4
LD5
LD6
LD7
LDA
LDB
LDJ
LDU
LE8
LEA
LED
LEF
LEG
LEH
LEJ
LEP
LET
LEV
LEX
LEZ
LF1
LFA
LFB
LFJ
LFT
LFZ
LG2
Plan / Benefit Description
SV 10/100% LARISA 06 AB
SV PUB SECTOR $10/100%
SV PUB SECTOR $15/100%
SV PUB SECTOR $20/100%
SV PUB SECTOR $10/100%
SV 5/100% LBUSD 06
SV 5/100% LBUSD 06 AB
SV 5/100% LBUSD 06 CB
SV 10/100% LARISA 06 CB
LACERS $5 GRP RET
LIMITED COVERAGE-TOT. DIS.
L.A. CLSC ENHNCD W/EPO DDS
SV 10/100% LCKMARTIN 07
L.A. CLSC ENHNCD W/HI DDS
$20/100%
L.A. CLSC ENHNCD W/OP DDS
LOS ANGELES CLSC ENHANCED
LACERA-GRP RETIREE $5
SPT 10-25/250A LCDS 06 CB
$20/100% COBRA
SV $20-$40/500D
SV $20-$40/500D CB
SV $20-$40/500D CAL CB
SV $20-$40/500D FED CB DIS
SV $20-$40/500D FED CB EXT
SV $20-$40/500D CAL CB EXT
SV $20-$40/500D CAL CB DIS
EL DORADO STANDARD PLAN
SH ELDORADO PART B ONLY
SV $20-$40/500D AB
SV $20-$40/500D USERRA
LIFELINK-EE ONLY COVERAGE
SV 20-30/500A LOWE 06
L.A. ENHNCED VALUE W/OPDDS
SV 10/100% LCKMARTIN 07 CB
SVA 20/250A LOWES 07 CB
L.A. ENHNCED VALU W/HI DDS
SV 20-30/500A LOWE AB
L.A. ENHNCD VALU W/EPO DDS
SV 15/100% L3ETI 05
L.ANGLES ENHANCED VALUE
SV 20-30/500A LOWE 06 AB
SV 20-30/500A LOWE 06 CB
LIFE COVERAGE PLAN
SV 5/100% LBUSD 06
SVA 20-30/100A LM 07
SV 5/100% LBUSD 06 AB
SPT 10-25/250A LCDS 06 AB
SV 5/100% LBUSD 06 CB
LOS ANGELES II STD PLAN
152 of 640
Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
LG4
LG5
LG6
LG7
LG8
LGA
LGB
LGC
LGG
LGH
LHA
LHB
LHC
LHE
LHF
LHH
LHJ
LI4
LIC
LID
LIE
LIH
LIJ
LIR
LIT
LJA
LJB
LJD
LJE
LJF
LJG
LJH
LJJ
LJL
LJN
LK1
LK2
LK3
LK4
LK5
LK6
LK7
LKA
LKB
LKD
LKG
LKH
LKI
LKJ
LKK
Plan / Benefit Description
LOS ANGELES II PLUS PLAN
LOS ANGLES II STD W/OP DDS
LOS ANGLES II STD W/HI DDS
L.A. II PLUS PLAN W/OP DDS
L.A. II PLUS PLAN W/HI DDS
SV 25/250A LODI 07
SV 25/250A LODI 07 CB
SV 25/250A LODI 07 AB
SVA 20/250A LOWES 07 AB
ORANGE CLASSIC I W/HI DDS
SP 10/100% LARISA 06
SP 10/100% LARISA 06
SP 10/100% LARISA 06 CB
SP 10/100% LARISA 06 CB
SP 10/100% LARISA 06 AB
SP 10/100% LARISA 06 AB
SV 10/100% LOCKHEED AB
LIFELINK - INDEMNITY
LOW INC. CHIRO/ACU/MASSAGE
LOW INCOME DENTAL
LOW INCOME EDUCATION
SECURE GLD HEARNG EXAM+AID
SV 10/100 LOCKHEED AB
LOW INCOME EDUC 12 SESSION
LOW INC SH CA TRANSPORTATN
SV 15/100A LHMRTN 08
SV 20-30/100A LHMRTN 07
MCC SANTA CLARA DELUX SH07
SV 20-30/100A LHMRTN 07 CB
SV 10/100% LCKMARTIN 07 AB
SV 20-30/100A LHMRTN 07 AB
MCC SANTA CLARA HIGH SH07
SV 20/100 LOCKHEED AB
MCC SANTA CLARA LOW SH07
MC COMP SANTA CLARA SH07
HMO 20 PLAN
HMO 20 PLAN CBRA
HMO 20 PLAN CAL CBRA
HMO 20 FED CBR DISABLE
HMO 20 FED CBR EXTEND
HMO 20 CAL CBR EXTEND
HMO 20 CAL CBR DISABLE
SV 15/100A LHMRTN 08 CB
SVA 20-30/100A LM 07 CB
KEC 1 LA DELUXE GR07
SV 10/100% LOCKHEED
SV 10/100% LOCKHEED CB
SV 10/100 LOCKHEED
SV PUB SECTOR $10/100% AB
SV 10/100 LOCKHEED CB
153 of 640
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
LKL
LKM
LKN
LKO
LKU
LKZ
LL1
LL2
LL3
LL9
LLA
LLB
LLC
LLD
LLE
LLF
LLG
LLH
LLI
LLJ
LLL
LLP
LLQ
LLS
LLZ
LM1
LM2
LMA
LMC
LMD
LME
LMF
LMH
LMJ
LMS
LMZ
LNB
LNC
LNF
LNJ
LNZ
LO2
LO3
LO4
LOF
LOJ
LOK
LOL
LP1
LP2
Plan / Benefit Description
SV 20/100 LOCKHEED
SV 20/100 LOCKHEED CB
SVA 20/100% LOCKHEED
SVA 20/100% LOCKHEED CB
HMO 20 PLAN USERRA
SV PUB SECTOR $10/100% CB
LIFE LINK
LIFELINK-MENTAL HLTH. ONLY
LIFELINK CHEM & PSYCH
PBHI GENERIC-REFER TO PBHI
SV 0/100% LAMTF 06
SV 10/100% LARISA 06
SV 0/100% LAMTF 06 CB
SV 10/100% LARISA 06 CB
SV 10/100% LARISA 06 AB
LIFELINK/COOKSON/POLYCLAD
SV 0/100% LAMTF 06 AB
LIFELINK - HIPC PREFERRED
LIFELINK - HIPC STANDARD
SV PUB SECTOR $15/100% AB
15/100% LACERS GR07
15/250A LLNS GR08
15 LACERS NON-AARP GR08
15/250A LLNS AARP GR08
SV PUB SECTOR $15/100% CB
LIBERTY MUTAL SO
LIBERTY MUTAL SO COBRA
SV 15/100A LHMRTN 08 AB
LOCKHEED-MARTIN CUSTOM
L.ANGELES MEDICAL W/OP DDS
L.ANGELES MED W/EPO DDS
SV 15/250A LLNS 07
L.ANGLES MEDICAL W/HI DDS
SV PUB SECTOR $20/100% AB
LOS ANGELES MEDICAL
SV PUB SECTOR $20/100% CB
SV PUB SECTOR $10/100% CB
NASSCO BASE PLAN
SV 15/250A LLNS 07 CB
SV PUB SECTOR $10/100% AB
NASSCO BASE PLAN COBRA
STANDARD $10-$20/80
STANDARD $15-$30/80
STANDARD $20-$40/$250A
SV 15/250A LLNS 07 AB
STANDARD $15-$30/80 AB
20-30/250A LOKHEED GR07
20-30 LOKHEED NON-AARP GR8
PITNEY BOWES $20/$250
PITNEY BOWES $20/$250 CBRA
154 of 640
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
LPJ
LPM
LQ3
LQ5
LQ9
LQA
LQD
LQE
LQH
LQL
LQN
LQO
LR2
LRA
LRB
LRC
LRD
LRE
LRH
LRJ
LRZ
LSA
LSB
LSC
LSD
LSE
LSJ
LSP
LSZ
LTA
LTB
LTD
LTE
LTF
LTH
LTJ
LTM
LTN
LUD
LUJ
LUS
LVB
LVC
LVE
LW1
LW3
LWC
LWE
LWJ
LWZ
Plan / Benefit Description
SVA 20/100% LOCKHEED AB
SAN LUIS OBISPO MEDICAL
MCC ESS LA LO-PL SH07
MCC ESS LA HI-PL SH07
MCC ESS LA PLUS SH07
SV 10/100% 1500D LODI07
MCC ESS LA DELUXE SH07
SVA 20-40/250A LHMTN 08 CB
MCC ESS LA HIGH SH07
MCC ESS LA LOW SH07
MC COMP ESS LA SH07
MCC ESS LA PL-DLXE SH07
PLACER II STANDARD PLAN
SV 10/100% 1500D LODI07 CB
SV 10/100% LAUSD 06
SANTA CLARA CLASSIC I
S CLARA CLSC I W/OP DDS
S CLARA CLSC I W/EPO DDS
S CLARA CLSC I W/HI OP DDS
SV 10/100% LAUSD 06 AB
SV 10/100% LAUSD 06 CB
SV 10/100% 1500D LODI07 AB
SV 10/100% CSB 05
SV 10/100% CSB 05 CB
KEC 1 LA PL-DLXE GR07
S.L. OBSPO MEDICL W/EPODDS
SV 10/100% CSB 05 AB
S.L. OBSPO MEDICL W/ODPDDS
LAUSD $5 GRP RET COBRA
LABOR & TRUST ADMIN
SV 10/100% LOCKHEED 07
RESERVED FOR PPO LIFE
SV 20/250A LOWES 07
SV 10/100% LOCKHEED 07 CB
SV 10/100% LOCKHEED 07 AB
SV 15/100% L3ETI 05 AB
RESERVED FOR LIFETIME MAX
RETEST FOR CDHP
SV 10/100 LAUSD
SV 10/100 LAUSD AB
SV 10/100 LAUSD CB
SVA 20-30/100A LM 07 AB
KEENAN COMP 1 LA GR07
SV 20/250A LOWES 07 CB
SP 10/100% L3/CS
SV 20-30/500A LOWE CB
KEC 1 LA LOW GR07
SV 20-30/500A LOWE
SP 10/100% L3/CS AB
SP 10/100% L3/CS CB
155 of 640
Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
LX3
LX5
LX9
LXA
LXB
LXC
LXD
LXE
LXF
LXH
LXJ
LXL
LXM
LXN
LXO
LXW
LXZ
LY3
LY5
LY9
LYA
LYB
LYC
LYD
LYE
LYF
LYH
LYJ
LYL
LYM
LYN
LYO
LYW
LYZ
LZ3
LZ5
LZ7
LZ9
LZA
LZB
LZC
LZD
LZE
LZF
LZH
LZJ
LZL
LZM
LZN
LZO
Plan / Benefit Description
MCC 2 LA LO-PL SH07
MCC 2 LA HI-PL SH07
MCC 2 LA PLUS SH07
SV 25/100A LA MACH 06
SV 5/100% LARISA 06
KEC 1 LA LO-PL GR07
MCC 2 LA DELUXE SH07
SVA 20-40/250A LHMTN 08 AB
SV 10-20/100DSEL LAR 06
MCC 2 LA HIGH SH07
SV 25/100A LA MACH 06 AB
MCC 2 LA LOW SH07
SV 15/100% LARISA 06
MC COMP 2 LA SH07
MCC 2 LA PL-DLXE SH07
SV 20-40/250A LHMRTN 08
SV 25/100A LA MACH 06 CB
MCC 1 LA LO-PL SH07
MCC 1 LA HI-PL SH07
MCC 1 LA PLUS SH07
SV 3/100% LA MACH 06
SV 5/100% LARISA 06 CB
KEC 1 LA HIGH GR07
MCC 1 LA DELUXE SH07
SV 20/250A LOWES 07 AB
SV 10-20/100DSEL LAR 06 CB
MCC 1 LA HIGH SH07
SV 3/100% LA MACH 06 AB
MCC 1 LA LOW SH07
SV 15/100% LARISA 06 CB
MC COMP 1 LA SH07
MCC 1 LA PL-DLXE SH07
SV 20-40/250A LHMRTN 08 CB
SV 3/100% LA MACH 06 CB
MCC 3 LA LO-PL SH07
MCC 3 LA HI-PL SH07
SH 5/100% LACERA GR06
MCC 3 LA PLUS SH07
SV 15/100A LA MACH 06
SV 5/100% LARISA 06 AB
KEC 1 LA HI-PL GR07
MCC 3 LA DELUXE SH07
SVA 20-40/250A LHMTN 08
SV 10-20/100DSEL LAR 06 AB
MCC 3 LA HIGH SH07
SV 15/100A LA MACH 06 AB
MCC 3 LA LOW SH07
SV 15/100% LARISA 06 AB
MC COMP 3 LA SH07
MCC 3 LA PL-DLXE SH07
156 of 640
Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
LZW
LZZ
M01
M02
M03
M04
M05
M06
M11
M12
M13
M14
M15
M16
M17
M1D
M1J
M1R
M1Z
M2J
M2Z
M3J
M3X
M3Z
M4G
M4J
M4T
M5G
M6J
MAA
MAB
MAC
MAF
MAG
MAH
MAJ
MAM
MAR
MAX
MB2
MB3
MBB
MBC
MBF
MBJ
MC0
MC1
MC2
MC3
MC5
Plan / Benefit Description
SV 20-40/250A LHMRTN 08 AB
SV 15/100A LA MACH 06 CB
MEDICAL-PUBLIC ASST-FAMILY
MEDICAL-MED NEED FAM
MEDICAL-MED IND CHILD
MEDICAL-PUBLIC ASST AGED
MEDICAL-PUB ASST DISABLED
MEDICAL-PUBLIC ASST BLIND
MEDICAID/CALOP-FAMILY
MEDICAID/CALOP-CHILD
MEDICAID/CALOP-ADULT
MEDICAID/CALOP-AGED
LIFELINK CRISIS MH
MEDICAID/CALOP-LTC
MEDICAID/CALOP-BLND/DISABL
MADERA STANDARD PLAN
SELECT HOSP $10/$100 AB
MARIN STANDARD PLAN
SELECT HOSP $10/$100 CBRA
SELECT HOSP $15/$250 AB
SELECT HOSP $15/$250 COBRA
SV 15/250A MABC 05 AB
AB1401 SELECT HOSP 20/400
SELECT HOSP $20/400 CBRA
SV 20/100% 06
SV 20/100% 06 AB
10/5V 1YR MSG THRPY GR07
SV 20/100% 06 CB
$25-$30/$500A AB
MARIN CNTY STNRD PLAN
MARIN STNDRD PART B ONLY
SV 15-25/100A MARTT 06
SV 20/100% 07
SV 20/100% 07 CB
SV 20/100% 07 AB
SV $15/100% ST MARY MED AB
SV 15-25/100A MARTT 06 CB
SVA 15-25/100A MARRIOTT
SV 15-25/100A MARTT 06 AB
SP 10/100 MORLEY BUILD CB
SV 15/250A MABC 05 CB
SP 10/100 MORLEY BUILDER
SV 15/250A MABC 05
SV 15-25/100A MARTT 07
SP 10/100 MORLEY BUILD AB
RX $0 CO-PAY MANAGED CL RX
STAND. 10 ALLERGY SER.PLAN
MARRIOTT $15/$100
MARRIOTT $15/$100 COBRA
SV 15-25/100A MARRIOTT
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
MC6
MC7
MCA
MCF
MCJ
MCM
MCP
MCS
MD1
MD2
MD3
MD4
MD5
MD6
MD7
MD8
MDA
MDB
MDC
MDD
MDF
MDG
MDJ
MDK
ME1
ME2
ME3
ME4
ME5
ME6
ME7
ME8
MEA
MEB
MED
MEJ
MEK
MEP
MER
MET
MEV
MF1
MF2
MF3
MF4
MF5
MF6
MF7
MF8
MF9
Plan / Benefit Description
$25-$30/$500A
$25-$30/$500A COBRA
SV SELECT 10-20/100D 07
SV 5/100% MILLS PEN 07
MARRIOTT $15/$100 AB
MADERA CLASSIC I
MEDICARE COST PLUS PLAN
MEDICARE COST STANDARD PLN
SH MADERA STD MED
SH MADERA STD W/ HI DEN
SH MADERA PART B STD MED
SH MADERA PART B W/ HI DEN
SH MADERA PLUS MED
SH MADERA PLUS W/ HI DEN
SH MADERA PART B PLUS MED
MADERA PT B PLUS W/ HI DEN
SV 20-30/90% MCKES 06
SV 10/100% MSD 08
MCDONNELL-DOUGLAS CSTM RET
SV 20-30/90% MCKES 06 CB
SV 15-25/100A MARTT 07 CB
SV 20-30/200D MODEST 07
SV 20-30/90% MCKES 06 AB
SV 25-50/50% MODTECH 08
SH MERCED STD MED
SH MERCED STD W/ HI DEN
SH MARIN PART B STD MED
SH MERCED PART B W/ HI DEN
SH MERCED PLUS MED
MERCED PLUS MED W/ HI DEN
SH MERCED PART B PLUS MED
SH MERCED B PLUS W/ HI DEN
SV SELECT 10-20/100D 07 CB
SV 10/100% MSD 08 CB
SV $15/100% ST MARY MED CB
SV SELECT 10-20/100D AB
SV 25-50/50% MODTECH 08 CB
MADERA CLASSIC I W/EPO DDS
SV 15/250A MERCK 07
SV 15/250A MERCK 07 CB
SV 15/250A MERCK 07 AB
RX $1 CO-PAY MANAGED CL RX
RX $2 CO-PAY MANAGED RX
RX $3 CO-PAY MANAGED CL RX
RX $4 CO-PAY MANAGED CL RX
RX $5 CO-PAY MANAGED CL RX
RX $6 CO-PAY MANAGED CL RX
RX $7 CO-PAY MANAGED CL RX
RX $8 CO-PAY MANAGED CL RX
RX $9 CO-PAY MANAGED CL RX
158 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
MFA
MFB
MFC
MFD
MFG
MFK
MFX
MGA
MGB
MGJ
MH0
MH1
MH2
MH8
MHA
MHC
MHD
MHJ
MHS
MHX
MHZ
MI2
MIJ
MJA
MJB
MJR
MKA
MKB
MKF
MKH
MKL
MKW
ML2
MLB
MLC
MLF
MLJ
MM2
MM3
MMA
MMB
MMC
MMG
MMH
MML
MMN
MMO
MMU
MMY
MN6
Plan / Benefit Description
SV SELECT 10-20/100D 07 AB
SV 15/250A MERLE NOR 07
SV 15/250A MERLE NOR 07 CB
SV 15/250A MERLE NOR 07 AB
SV 20-30/200D MODEST 07 CB
SV 25-50/50% MODTECH 08 AB
RX $10 CO-PAY MANAGD CL RX
SV SELECT 20-40/400D 07
SV 10/100% MSD 08 AB
SV SELECT 20-40/400D AB
LIFELINK MH100 1995
LIFELINK-MENTAL HEALTH 100
LIFELINK MH80 1995
LIFELINK-MENTAL HEALTH 80%
SV 15-25/240A MHS 06
SV 15-25/240A MHS 06 CB
2-DEDUC MH06
SV MEMORIAL 15-25/240A AB
SV MEMORIAL 15-25/240A
SV 15-25/240A MHS 06 AB
SV MEMORIAL 15-25/240A CB
SV 15-25/100A MARRIOTT CB
SV 15-25/100A MARRIOTT AB
SV SELECT 20-40/400D 07 CB
SV SELECT 15-30/250D 07
SVA 15-25/100A MARRIOTT CB
SV SELECT 20-40/400D 07 AB
SV SELECT 15-30/250D 07 CB
SV 15-25/100A MARTT 07 AB
ARP MCC S MATEO HI SH08
ARP MCC S MATEO LO SH08
ARP MCC S MATEO SH08
SV 20/250A MERRILL CB
SV SELECT 15-30/250D 07 AB
SV 20/250A MERRILL
SV 5/100% MILLS PEN 07 CB
SV 20/250A MERRILL AB
2003 SMI ONLY HMO 10
2003 SMI ONLY HMO 15/20
SMI+SUPP A (MULTI TIER)
SMI + SUPPLEMENTAL
SP 10/100% MOSSY 06
SV 15/250A MGM 08
SP 10/100% MOSSY 06 CB
SP 10/100% MOSSY 06 AB
SMI+NATL UB SUPP (M TIER)
2002 SMI ONLY (MUL TIER)
SMI + SUPP U (MULTI TIER)
2002 SMI PLAN U PLUS MULTI
MCC 1 MADERA PP-PL SH07
159 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
MN7
MN9
MNA
MNE
MNG
MNJ
MNN
MNP
MNZ
MOA
MOB
MPA
MPB
MPC
MPD
MPE
MPG
MPH
MPI
MPK
MPL
MPM
MPN
MPO
MPP
MPQ
MPR
MPS
MPT
MPU
MPV
MPW
MPX
MPY
MPZ
MR1
MR2
MR3
MR4
MR5
MR6
MR7
MR8
MRJ
MRY
MS1
MSA
MSC
MSD
MT1
Plan / Benefit Description
MCC 1 MADERA EP-PL SH07
MCC 1 MADERA PLUS SH07
SV 15/250A MERLE NOR 06
MCC 1 MADERA EP SH07
SV 15/250A MGM 08 CB
SV 15/250A MERLE NOR 06 AB
MC COMP 1 MADERA SH07
MCC 1 MADERA PP SH07
SV 15/250A MERLE NOR 06 CB
MONTEREY BASIC PLAN
MONTEREY PART B ONLY
SMI + SUPPLEMENT A
SMI + SUPPLEMENT B
SMI+CUSTOM HMO SUPPLEMENT
MED. COST PLUS UNDER 65
SMI ONLY 05
SV 15/250A MGM 08 AB
SMI+PACADVANTAGE PREF/PLUS
SMI + PACADVANTAGE STD
SMI CARVE OUT RIALTO BH05
SMI + SUPPLEMENT L
SMI + SUPPLEMENT M
SMI + NAT'L UB SUPPLEMENT
SMI ONLY
SMI ONLY - PPO/INDEMNITY
SUTTER LOW OPT MH/CD/SMI
CUSTOM POS PBH RETAIL
SMI+CUSTOM POS SUPPLEMENT
SUTTER
SMI + SUPPLEMENT U
MENTAL HEALTH CARVE OUT
SMI CARVE OUT 3
CUSTOM HMO PBH RETAIL
SMI PLAN U PLUS
SMI CARVE OUT 4
SH MARIN STD MED
SH MARIN STD MED W/ HI DEN
SH MARIN PART B STD MED
SH MARIN PART B W/ HI DEN
SH MARIN PLUS MED
SH MARIN PLUS MED W/ HI DE
SH MARIN PART B PLUS MED
MARIN PT B PLUS W/ HI DEN
SVA 15-25/100A MARRIOTT AB
SV $15/100% ST MARY MED
STANDARD 5 PLAN
SANTA CRUZ PART B ONLY
SANTA CRUZ BASIC PLAN
MED COST STAND. UNDER 65
SELECT HOSP $10/$100
160 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
MT2
MT3
MTA
MTB
MTC
MTD
MTE
MTF
MTG
MTH
MTJ
MTK
MTM
MU6
MU7
MU9
MUE
MUN
MUP
MVA
MVJ
MVZ
MWF
MWG
MWI
MWP
MWQ
MWU
MWV
MWW
MWY
MYB
MYD
MYG
MYI
MYQ
MYU
MYV
MYW
MYY
N01
N02
N03
N04
N05
N06
N07
N08
N09
N0J
Plan / Benefit Description
SELECT HOSP $15/$250
SELECT HOSP $20/$400
SH BASIC PLAN SAN MATEO
SH SAN MATEO CO. B ONLY
SV SELECT 15-30/250D
SV SELECT 15-30/250D CB
SV SELECT 10-20/100D
SV SELECT 10-20/100D CB
SV SELECT 20-40/400D
SV SELECT 20-40/400D CB
SV SELECT 15-30/250D AB
10/5V 1YR MSG THRPY SH07
10/5V 1YR MSG THRPY SH08
MCC 3 MADERA PP-PL SH07
MCC 3 MADERA EP-PL SH07
MCC 3 MADERA PLUS SH07
MCC 3 MADERA EP SH07
MC COMP 3 MADERA SH07
MCC 3 MADERA PP SH07
SV 20/100% MRYVALE 06
SV 20/100% MRYVALE 06 AB
SV 20/100% MRYVALE 06 CB
SV 5/100% MILLS PEN 07 AB
SV 20-30/200D MODEST 07 AB
ARP MCC 1 MADRA EP-PL SH08
MADERA CLASSIC I W/ODP
ARP MCC 1 MADRA PP-PL SH08
ARP MCC 1 MADRA PP SH08
ARP MCC 1 MADRA PLUS SH08
ARP MCC 1 MADRA SH08
ARP MCC 1 MADRA EP SH08
SV 20/250A MOTOROLA 07
SV 20/250A MOTOROLA 07 CB
SV 20/250A MOTOROLA 07 AB
ARP MCC 3 MADRA EP-PL SH08
ARP MCC 3 MADRA PP-PL SH08
ARP MCC 3 MADRA PP SH08
ARP MCC 3 MADRA PLUS SH08
ARP MCC 3 MADRA SH08
ARP MCC 3 MADRA EP SH08
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
SV 10-20/100A NAT'L 06 AB
161 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
N10
N11
N12
N13
N14
N15
N16
N17
N18
N19
N1J
N1N
N1Z
N20
N21
N22
N23
N24
N25
N26
N27
N28
N29
N2J
N2N
N2Z
N30
N3J
N3N
N3Z
N42
N47
N48
N4J
N4N
N4U
N4Z
N52
N57
N58
N5J
N5N
N5U
N5Z
N62
N67
N68
N6J
N6N
N7J
Plan / Benefit Description
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
2002 UB PLAN 1 AB
SV 5/100% NAT'L 06 CB
2002 UB PLAN 1 COBRA
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLAN
INDEMNITY PLAN
INDEMNITY PLAN
INDEMNITY PLANS
INDEMNITY PLANS
2002 UB PLAN 2 AB
SV 10/100% NAT'L 06 CB
2002 UB PLAN 2 COBRA
INDEMNITY PLANS
2002 UB PLAN 3 AB
SV 15/100% NAT'L 06 CB
2002 UB PLAN 3 COBRA
KEC NEVADA CG GR07
KEC NEVADA EP CG GR07
KEC NEVADA PP CG GR07
SV NAT'L $10/$20/$100A AB
SV 10-20/100A NAT'L 06 CB
0/12-1W NON-ER TRANS GR07
2002 UB PLAN 4 COBRA
KEC NEVADA CGII GR07
KEC NEVADA EP CGII GR07
KEC NEVADA PP CGII GR07
SV NATL $15-$30/250A AB
SV 15-30/250A NAT'L 06 CB
0/30-1W NON-ER TRANS GR07
2002 UB PLAN 5 COBRA
KEC NEVADA CGEH GR07
KEC NEVADA EP CGEH GR07
KEC NEVADA PP CGEH GR07
SV NAT'L $15/$30/$400A AB
SV 15-30/400A NAT'L 06 CB
SV NATL $20-$40/$250D AB
162 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
N7N
N8J
N8N
N9J
N9N
NA0
NA1
NA2
NA3
NA4
NA5
NA6
NA7
NA8
NA9
NAA
NAB
NAC
NAD
NAE
NAF
NAG
NAH
NAI
NAJ
NAK
NAL
NAM
NAN
NAP
NAQ
NAR
NAS
NB2
NB3
NBJ
NC3
NCA
NCB
NCC
NCE
NCF
NCJ
NCL
NCP
NCS
NDJ
NDL
NDP
NEJ
Plan / Benefit Description
SV 20-40/250D NAT'L 06 CB
SV NATL $20-$40/$400D AB
SV 10/250A NAT'L 06 CB
SV 15/250A NAT'L 06 AB
SV 15/250A NAT'L 06 CB
NAT'L $20/$250 100% COBRA
PHS NATL $5/100% CBRA
PHS NATL $10/100% CBRA
PHS NATL $10/$100/100%CBRA
PHS NATL $10/$250/100%CBRA
PHS NATL $15/$250/100%CBRA
PHS NATL $15/100% CBRA
NATL HMO $15OV 100% COBRA
NATL STD$15/$100/100% CBRA
NAT'L $20/$250 100%
PHS NATL $5/100%
PHS NATL $10/100%
PHS NATL $10/$100/100%
PHS NATL $10/$250/100%
PHS NATL $15/$250/100%
PHS NATL $15/100%
NATL POS $10OV 100%/70%
NATL POS $10OV 90%/70%
NATL STD $15/$100/100%
NATL POS $10OV $250/60%
NATL POS $15OV 80%/60%
NATL POS $15OV $150/70%
NATL HMO $15OV 100%
PHS NATL $20/$500
PHS NATL $20/$500 COBRA
NAT'L HMO $10OV 100%
S CAL GAS NAT'L HMO $10
SEMPRAS NAT'L HMO $5
$10/100% PLAN
$10/100% PLAN COBRA
SV NATL $10/100%
FRITOLAY NATL $15/100% CBR
SH-SACRAMENTO COUNTY
SACTO COUNTY-PART B
FRITO LAY NAT'L $15/100%
NEVADA CLASSIC I W/EPO DDS
SV 20-40/250A NATION 07
SV NATL $15/100% AB
KEENAN COMP NEVADA GR07
NEVADA CLASSIC I W/ODP
NEVADA CLASSIC I
SV NATL $10/$100A AB
KEC NEVADA EP GR07
NORTHERN DENTAL PLAN
SV NATL $10/$250A AB
163 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
NEL
NF4
NF5
NF6
NF7
NF8
NFD
NFE
NFF
NFG
NFH
NFJ
NFM
NG1
NG2
NG3
NG4
NG5
NG6
NG7
NGA
NGC
NGE
NGF
NGG
NGJ
NGN
NGP
NGZ
NH
NHA
NHB
NHC
NHE
NHF
NHJ
NHU
NHW
NHY
NHZ
NIG
NIJ
NJJ
NJZ
NKJ
NKZ
NL8
NLG
NLH
NLJ
Plan / Benefit Description
KEC NEVADA PP GR07
SV NAT'L $10/$20/$100A CB
SV NATL $15-$30/250A CB
SV NAT'L $15/$30/$400A CB
SV NATL $20-$40/$250D CB
SV NATL $20-$40/$400D CB
SV NAT'L $10/$20/$100A
SV NATL $15-$30/250A
SV NAT'L $15/$30/$400A
SV NATL $20-$40/$250D
SV NATL $20-$40/$400D
SV NATL $15/$250A AB
SV 15-30/400A NATL 07
NAT'L PLAN 1 $5 GRP RET
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 3 $15 GRP RET
NAT PLAN 2A $10 GRP RET
NAT PLAN 2B $10 GRP RET
NAT PLAN 3A $15 GRP RET
NAT PLAN 3B $15 GRP RET
NAT'L PLN 2C $20 GRP RET
NAT'L PLN 2D $20 GRP RET
MCC NEVADA EP SH07
SVA 15-30/300A 07
SV 15-30/300A 07
SV NATL $15/$100A AB
MC COMP NEVADA SH07
MCC NEVADA PP SH07
NATL POS $10OV 100%/70% CB
NOT USED
SVA 20-40/400A 07
SVA 20-40/400A 07 CB
SVA 20-40/400A 07 AB
SV 40-50/80% NORTH 06
SV 20-40/250A NATION 07 CB
PHS NATL $20/$500 AB
ARP MCC NEVDA PP SH08
ARP MCC NEVDA SH08
ARP MCC NEVDA EP SH08
NATL POS $10OV 90%/70% CB
SV 15-30/300A 07 CB
SV 10/100% NAT'L 06 AB
SV 5/100% NAT'L 06 AB
NATL POS $10OV $250/60% CB
SV 10/250A NAT'L 06 AB
NATL POS $15OV 80%/60% CB
24HR NURSLINE WL-SH/GR08
24HOUR NURSE LINE SH07
SV 20-40/250A+10% NI 08
SV 15/100A NAT'L 06 AB
164 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
NLZ
NM1
NM2
NM3
NM4
NM5
NME
NMF
NMG
NMP
NMS
NN1
NN2
NN3
NN4
NN5
NN6
NN7
NNA
NNB
NNC
NND
NNE
NNF
NNG
NNJ
NNK
NNL
NNM
NNN
NNP
NNQ
NNR
NNS
NNT
NNU
NNV
NNX
NNY
NO1
NOJ
NP1
NP2
NP3
NP4
NP5
NP6
NP7
NP8
NPA
Plan / Benefit Description
NATL POS $15OV $150/70% CB
2002 UB PLAN 1
2002 UB PLAN 2
2002 UB PLAN 3
2002 UB PLAN 4
2002 UB PLAN 5
NEVADA MEDICAL W/EPO DDS
SVA 15-30/300A 07 CB
SVA 15-30/300A 07 AB
NEVADA MEDICAL W/PPO DDS
NEVADA MEDICAL
SV NATL $5/100% CB
SV NATL $10/100% CB
SV NATL $15/100% CB
SV NATL $10/$100A CB
SV NATL $10/$250A CB
SV NATL $15/$250A CB
SV NATL $15/$100A CB
SV NATL $5/100%
SV NATL $10/100%
SV NATL $15/100%
SV NATL $10/$100A
SV NATL $10/$250A
SV NATL $15/$250A
SV NATL $15/$100A
SV NATL $5/100% AB
SV 10/250A NAT'L 06
SV 15/100A NAT'L 06
SV 10/100% NAT'L 06
SV 5/100% NAT'L 06
SV 15/250A NAT'L 06
SV 10-20/100A NAT'L 06
SV 10/100% NAT'L 06
SV 15-30/400A NAT'L 06
SV 20-40/250D NAT'L 06
SV 15/100% NAT'L 06
SV 15-30/250A NAT'L 06
SV 15-30/250A NAT'L 06 AB
SV 20-40/400D NAT'L 06
NORTHROP PLAN
SV 15/100% NAT'L 06 AB
SH NAPA STD MED
SH NAPA STD MED W/ HI DEN
SH NAPA PART B STD MED
SH NAPA PART B W/ HI DEN
SH NAPA PLUS MED
SH NAPA PLUS MED W/ HI DEN
SH NAPA PART B PLUS MED
NAPA PART B PLUS W/ HI DEN
NAPA BASIC PLAN NO DTL
165 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
NPB
NPJ
NQJ
NQN
NQZ
NR1
NR2
NR3
NR4
NR5
NR6
NR7
NR8
NR9
NRA
NRB
NRC
NRJ
NRZ
NS2
NS3
NSA
NSB
NSJ
NSL
NSS
NSZ
NT8
NTB
NTC
NTE
NTG
NTH
NTJ
NTL
NTM
NTN
NTP
NTQ
NTR
NUJ
NVA
NVC
NVE
NVF
NVJ
NWA
NWC
NWE
NWF
Plan / Benefit Description
NAPA/SONOMA PART B ONLY
PHS NATL $5/100% AB
PHS NATL $10/100% AB
SV 10/100% NAT'L 06 CB
NAT'L HMO $10OV 100% COBRA
$10G/$20B
$10G/$20B/$30NF
$10G/$25B/$40NF
$10G/$25B/$50NF
$10G/$25B
$10G/$35B
$15G/$25B
$15G/$35B
$15G/$25B/$40NF
$5G/$10B
$5G/$15B
$10G/$35B
PHS NATL $10/$100/100% AB
S CAL GAS NAT'L HMO $10 CB
$3G/$3B
$15-$25/$240A
NAPA,SOLANO,SONOMA PRT B
SOLANO, SONOMA PRT B ONLY
PHS NATL $10/$250/100% AB
CREATED IN ERROR/CAN REUSE
SOLANO,SONOMA BASIC PLAN
SEMPRA NAT'L HMO $5 COBRA
0/24-1W NON-ER TRANS GR08
0/24-1W NON-ER TRANS SH07
0/24-1W NON-ER TRANS SH07
MCC ESS NEVADA EP SH07
SV 15-30/300A 07 AB
SV 20-40/250A+10% NI 08 CB
PHS NATL $15/$250/100% AB
0/24-1W NON-ER TRANS SH08
MC COMP ESS NEVADA SH07
SV 15/100A NAT'L 06 CB
MCC ESS NEVADA PP SH07
0/24-1W NON-ER TRANS SH08
0/24-1W NON-ER TRANS GR07
PHS NATL $15/100% AB
SVA 15-30/300A WB 06
SVA 15-30/300A WB 06 CB
SV 40-50/80% NORTH 06 CB
SVA 15-30/300A WB 06 AB
SV 15-30/400A NAT'L 06 AB
SVA 20-40/400A WB 06
SVA 20-40/400A WB 06 CB
SV 20-40/400A 07
SVA 20-40/400A WB 06 AB
166 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
NWH
NWJ
NWK
NXJ
NYJ
NYN
NZ1
NZ3
NZE
NZF
NZH
NZJ
O01
O02
O03
O04
O05
O06
O07
O08
O09
O10
O11
O12
O13
O14
O15
O16
O17
O18
O19
O1C
O1P
O1Q
O1R
O1W
O1Y
O20
O21
O22
O23
O24
O25
O26
O27
O28
O29
O2G
O2N
O2Q
Plan / Benefit Description
SV 20-40/400A 07 CB
NATL STD $15/$100/100% AB
SV 20-40/400A 07 AB
SV 10/100% NAT'L 06 AB
SV 20-40/250D NAT'L 06 AB
SV 20-40/400D NAT'L 06 CB
NORTHROP PLAN (COBRA)
$15-$25/$240A COBRA
SV 40-50/80% NORTH 06 AB
SV 20-40/250A NATION 07 AB
SV 20-40/250A+10% NI 08 AB
$15-$25/$240A AB
100/70 $5 OV/$250 DED OON
100/70 $5 OV/$500 DED OON
100/70 $10 OV/$250 DED OON
100/70 $10 OV/$500 DED OON
100/70 $15 OV/$250 DED OON
100/70 $15 OV/$500 DED OON
90/70 $5 OV/$250 DED OON
90/70 $5 OV/$500 DED OON
90/70 $10 OV/$250 DED OON
90/70 $10 OV/$500 DED OON
90/70 $15 OV/$250 DED OON
90/70 $15 OV/$500 DED OON
100/90/70 $5/$10 $250 DED
100/90/70 $5/$10 $500 DED
100/90/70 $5/$15 $250 DED
100/90/70 $5/$15 $500 DED
100/90/70 $5/$20 $250 DED
100/90/70 $5/$20 $500 DED
100/90/70 $10/$15 $250 DED
ORANGE STANDARD PLAN
STANDARD 90%/$5 - POS
10-20/750A T2A GR07
15-25/200D T3A GR07
10-15/50A T1A GR07
STANDARD 90%/$5-POS COBRA
100/90/70 $10/$15 $500 DED
100/90/70 $10/$20 $250 DED
100/90/70 $10/$20 $500 DED
100/80/70 $5/$10 $250 DED
100/80/70 $5/$10 $500 DED
100/80/70 $5/$15 $250 DED
100/80/70 $5/$15 $500 DED
100/80/70 $5/$20 $250 DED
100/80/70 $5/$20 $500 DED
100/80/70 $10/$15 $250 DED
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 2 $10 GRP RET
10-20/750A T2A GR07
167 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
O2R
O2W
O30
O31
O32
O33
O34
O35
O36
O37
O38
O39
O3C
O3Q
O3R
O3W
O40
O41
O42
O43
O44
O45
O46
O47
O48
O49
O4C
O4G
O4H
O4Q
O4R
O4W
O50
O51
O52
O53
O54
O55
O56
O57
O58
O59
O5C
O5N
O5Q
O5R
O5W
O60
O61
O62
Plan / Benefit Description
15-25/200D T3A GR07
10-15/50A T1A GR07
100/80/70 $10/$15 $500 DED
100/80/70 $10/$20 $250 DED
100/80/70 $10/$20 $500 DED
100/80/60 $5/$10 $250 DED
100/80/60 $5/$10 $500 DED
100/80/60 $5/$15 $250 DED
100/80/60 $5/$15 $500 DED
100/80/60 $5/$20 $250 DED
100/80/60 $5/$20 $500 DED
100/80/60 $10/$15 $250 DED
ORANGE PLUS PLAN
10-20/750A T2A GR07
15-25/200D T3A GR07
10-15/50A T1A GR07
100/80/60 $10/$15 $500 DED
100/80/60 $10/$20 $250 DED
100/80/60 $10/$20 $500 DED
90/80/70 $5/$10 $250 DED
90/80/70 $5/$10 $500 DED
90/80/70 $5/$15 $250 DED
90/80/70 $5/$15 $500 DED
90/80/70 $5/$20 $250 DED
90/80/70 $5/$20 $500 DED
90/80/70 $10/$15 $250 DED
ORANGE STANDARD W/OPT DENT
NAT PLAN 2A $10 GRP RET
BOEING HOURLY $15 GRP RET
15-25/130D T2B GR07
15-30/220D T3B GR07
5-20/100A T1B GR07
90/80/70 $10/$15 $500 DED
90/80/70 $10/$15 $250 DED
90/80/70 $10/$20 $500 DED
90/80/60 $5/$10 $250 DED
90/80/60 $5/$10 $500 DED
90/80/60 $5/$15 $250 DED
90/80/60 $5/$15 $500 DED
90/80/60 $5/$20 $250 DED
90/80/60 $5/$20 $500 DED
90/80/60 $10/$15 $250 DED
ORANGE STANDARD W/HI DENTL
NAT PLAN 2B $10 GRP RET
15-25/130D T2B GR07
15-30/220D T3B GR07
5-20/100A T1B GR07
90/80/60 $10/$15 $500 DED
90/80/60 $10/$20 $250 DED
90/80/60 $10/$20 $500 DED
168 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
O63
O64
O65
O66
O67
O68
O69
O6C
O6G
O6N
O6Q
O6R
O6W
O70
O7C
O7G
O7Q
O7R
O7W
O88
O8G
O8Q
O8R
O8W
O9E
O9G
O9H
O9Q
O9R
O9W
OA4
OAA
OAB
OAN
OAS
OB2
OB4
OB8
OBL
OC1
OC2
OC3
OC4
OC5
OC6
OC7
OC8
OCE
OCQ
OD4
Plan / Benefit Description
100/90/70 $10/10%/30% 250D
100/90/70 $10/10%/30% 250D
100/80/60 $10/20%/40% 250D
100/80/60 $10/20%/40% 250D
100/80/50 $10/$20/50% 500D
100/80/50 $15/$30/50% 500D
100/80/50 10/20/50% 500D
ORANGE PLUS PLAN W/OP DENT
NAT PLAN 3A $15 GRP RET
NAT PLAN 3A $15 GRP RET
15-25/130D T2B GR07
15-30/220D T3B GR07
5-20/100A T1B GR07
RESERVED POS OPTION
ORANGE PLUS PLAN W/HI DENT
NAT PLAN 3B $15 GRP RET
10-25/150D T2C GR07
20-35/250D T3C GR07
10-20/200A T1C GR07
STD $10 GRP RETIREE
STD $10 GRP RETIREE
10-25/150D T2C GR07
20-35/250D T3C GR07
10-20/200A T1C GR07
10/100% AARP GR08
STD $15 GRP RETIREE
10/100% NON-AARP GR08
10-25/150D T2C GR07
20-35/250D T3C GR07
10-20/200A T1C GR07
NAT'L PLN 2C $20 GR 06
NAT'L PLN 2C $20 GRP RET
20/100% NON-AARP GR08
NAT'L ACCTS EXTENDED OOA
LAUSD $5 GRP RETIREE
NAT PLAN 2A $10 GR 06
NAT PLAN 2A $10 GR 06
10-20/250A NON-AARP GR08
10 SDCERA NON-AARP GR08
SH ORANGE STD MED
SH ORANGE STD MED W/ HI DE
SH ORANGE PART B STD MED
SH ORANGE PART B W/ HI DEN
SH ORANGE PLUS MED
SH ORANGE PLUS W/ HI DEN
SH ORANGE PART B PLUS MED
ORANGE PT B PLUS W/ HI MED
END ORANGE BASIC W/ NO DEN
$15 IBEW GRP RET
NAT'L PLN 2D $20 GR 06
169 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
OD5
OD6
OD8
ODA
ODC
OE2
OEA
OF1
OF2
OF3
OF4
OF5
OF6
OF7
OF8
OF9
OFA
OFB
OFC
OFD
OFE
OG1
OG2
OG4
OG5
OG6
OG7
OG8
OG9
OGA
OGC
OGF
OGG
OGN
OGO
OGS
OGU
OGW
OGX
OGY
OGZ
OH1
OH2
OH4
OHC
OHD
OHO
OHP
OHU
OJ2
Plan / Benefit Description
10-15/50A T1A GR07
NAT'L PLN 2D $20 GR 06
15/250A AARP GR08
10/100% NON-AARP GR08
MCDONNELL-DOUGLAS CSTM RET
NAT PLAN 2B $10 GR 06
5/100% NON-AARP GR08
RESERVE FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO RX
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
NAT'L PLAN 1 $5 GRP RET
ORANGE II STANDARD PLAN
ORANGE II PLUS PLAN
ORANGE II STD W/OPT DDS
ORANGE II STD W/HI OP DDS
ORANGE II PLS PLN W/OP DDS
ORANGE II PLS PLN W/HI DDS
STD $15 GRP RETIREE
ELK GROVE USD $20 GR
NAT'L PLN 2D $20 GRP RET
20-40/250A NON-AARP GR08
NAT'L PLAN 1 $5 GRP RET
NAT'L PLAN 1 $5 GRP RET
NAT'L PLN 2 $10 GRP RET
STD $10 GRP RETIREE
5/100% AARP GR08
10-20/250A AARP GR08
15-25/500A AARP GR08
15-25/500A NON-AARP GR08
15/250A AARP GR08
BOEING NA-HRLY $10 GRP RET
BOEING NA-HRLY $10 GRP RET
BOEING HOURLY $15 GRP RET
0 UFCW NON-AARP GR08
20/100% AARP GR08
BOEING NA-HRLY $10 GRP RET
SH PREFERRED
UFCW
NAT PLAN 3A $15 GR 06
170 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
OJP
OK4
OK6
OKD
OKG
OKM
OL1
OL4
OLD
OLH
OLL
OLY
OM8
OMA
OMH
OMJ
OMK
OML
OMM
ON2
ON4
ON5
ON6
ON7
ON9
ONA
ONC
ONG
ONJ
ONV
ONX
OO7
OO9
OOF
OON
OP2
OPB
OPC
OPG
OPJ
OQ8
OQA
OQP
ORB
ORC
ORI
ORX
OS2
OS3
OS4
Plan / Benefit Description
NAT'L PLAN 1 $5 GRP RET
NAT PLAN 3B $15 GR 06
NAT PLAN 3B $15 GR 06
5/100% LAUSD NON-AARP GR08
15 BO HRLY-F NO-AARP GR08
20-40/250A NON-AARP GR08
LACERS $5 GRP RET
STD $10 GR 06
5/100% LAUSD NON-AARP GR08
10 BO HRLY NO-AARP GR08
LACERS $5 GRP RET
20/100% NON-AARP GR08
10-20/250A NON-AARP GR08
SH PREFERRED NON-AARP GR08
GENERAL MTRS GRP RET HRLY
SV 20-40/250D OC PET 07
20-30/100% GEN MOTRS GR06
SV 20-40/250D OC PET 07 CB
SV 20-40/250D OC PET 07 AB
NAT'L PLN 2 $10 GRP RET
NAT PLAN 2A $10 GRP RET
NAT PLAN 2B $10 GRP RET
NAT PLAN 3A $15 GRP RET
NAT PLAN 3B $15 GRP RET
20/100% PBGH NON-AARP GR08
15/100% IBEW NON-AARP GR08
SH STANDARD $10
NAT'L PLN 2C $20 GRP RET
10-20/250A AARP GR08
5/100% NON-AARP GR08
SH RETIREE STD 10
NAT'L PLN 2C $20 GR 06
10-20/250A NON-AARP GR08
POS OON SB1221
POS - OUT OF AREA
PBGH $20 GRP RET PLAN
PBGH $20 GRP RET PLAN
RX NOT THRU RXSOL $250INJ
20 PBGH NON-AARP GR08
15/250A NON-AARP GR08
10-20/500A NON-AARP GR08
15/250A NON-AARP GR08
5/100% NON-AARP GR08
SH-B ONLY ORANGE COUNTY
15/100% TRIBUNE AARP GR08
$15 100% TRIBUNE GR
OTHR RX NOT THRU RX SOL
STD $15 GR 06
CITY OF SAN DIEGO GR 2004
STD $15 GR 06
171 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
OS6
OSI
OST
OSZ
OT2
OT4
OT5
OT7
OTH
OTK
OTZ
OU2
OU4
OUF
OUJ
OUQ
OV2
OV4
OV6
OV8
OW2
OW4
OW6
OWC
OWP
OWU
OYA
OZG
P00
P0J
P1C
P1D
P1E
P1F
P1G
P1J
P1L
P1R
P1S
P1W
P1Z
P2C
P2D
P2G
P2J
P2P
P2V
P2Z
P30
P38
Plan / Benefit Description
STD $15 GR 06
CITY OF SAN DIEGO GR 06
PUBLIC SECTOR $10 GRP RET
LAUSD $5 GRP RET COBRA
SACRAMENTO II STD PLAN
SACRAMENTO II PLUS PLAN
SACRAMENTO II STD W/OP DDS
SACTO II PLS PLN W/OP DDS
5/100% AARP GR08
5/100% AARP GR08
20-40/250A AARP GR08
SH PREFERRED GR 06
SH PREFERRED GR 06
UFCW RETIREE $25
25 UFCW NON-AARP GR08
10/100% NON-AARP GR08
SH STANDARD $10 GR 06
SH STANDARD $10 GR 06
SH STANDARD $10 GR 06
10-20/250A AARP GR08
SH RETIREE STD 10 06
SH RETIREE STD 10 06
SH RETIREE STD 10 06
0/100% LADWP NON-AARP GR08
SH RETIREE LADWP CUSTOM
15/250A NON-AARP GR08
10/100% AARP GR08
10/100% NON-AARP GR08
INPATIENT PSYCHIATRIC 100%
SV $10/100%PACIFIC LIFE AB
580 PLAN
II
PREMIER 30 FED COBRA DIS
PREMIER 30 FED COBRA EXT
PREMIER 30 CAL COBRA EXT
PREMIER 30 CAL COBRA DIS
SV 15-30/100A PBGH AB
PLACER STANDARD PLAN
PREMIER 30 CAL COBRA
PREMIER 30
PREMIER 30 COBRA
580 PLAN COBRA
II
$5/250 HMO MFP SJHS NCAL
SV 20-30/250A PITNEY 07
SV 20-30/100D PBG
VEBA A10 $10/$200/$250 AB
RESERVED PPO
SP 10/200A SCSV B10 06
$5/250 MFP HMO SJHSNC COBR
RX $9/$18G ONLY & NO LIMIT
RESERVED
172 of 640
Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
P3G
P3J
P3K
P3L
P3M
P3P
P3V
P45
P4D
P4J
P4P
P4V
P4Z
P50
P5J
P5N
P5P
P5Q
P5R
P5S
P5V
P5Z
P6F
P6J
P6N
P6P
P6Q
P6R
P6S
P6X
P6Y
P6Z
P7B
P7J
P7N
P7P
P7Q
P7R
P7S
P80
P8J
P8P
P9D
P9J
P9N
P9P
P9R
P9S
P9U
P9V
Plan / Benefit Description
SV 20-30/100D PBG CB
SV $15/$250A PBGH AB
SV 10/100% SC PAINT 07
SV 10/100% SC PAINT 07 CB
SV 10/100% SC PAINT 07 AB
RESERVED PPO
SP 15/200A SCSVEBA 06
IMPAT. PSYCH. 100% 45 DAYS
SV 20-30/250A PITNEY 07 CB
SV 20/250A PBGH AB
RESERVED PPO
SP 10/200A SCSV A10 06
PBGH 20 PLAN COBRA
INPAT. PSYCH. 50% 45 DAYS
SV 20/250A PBGH AB
KEC PLACER CG GR07
RESERVED PPO
SV 20/100% SC PAINT 07
KEC PLACER CGII GR07
KEC PLACER CGEH GR07
SP 15/200A SCSVEBA 06
PBGH 15 PLAN COBRA
SV 15-20/100A PRDNTL 06
SVA 20/250A PBGH AB
KEC PLACER EP CG GR07
RESERVED PPO
SV 20/100% SC PAINT 07 CB
KEC PLACER EP CGII GR07
KEC PLACER EP CGEH GR07
SV 15-20/100A PRDNTL 06 AB
SV 15-20/100A PRDNTL 06 CB
PBGH COBRA
MC COMP 4 PART B SH07
VEBA B10 $10/$200/$250 AB
KEC PLACER PP CG GR07
RESERVED PPO
SV 20/100% SC PAINT 07 AB
KEC PLACER PP CGII GR07
KEC PLACER PP CGEH GR07
INPATIENT PSYCHIATRIC 80%
$15/$250A AB
RESERVED PPO
SV 20-30/250A PITNEY 07 AB
SV PHS $15-$30/$100A AB
KEC PLACER DX CG GR07
RESERVED PPO
KEC PLACER DX CGII GR07
KEC PLACER DX CGEH GR07
SV 25-35/250A 07
SV 25-35/250A 07 CB
173 of 640
Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
P9W
PA2
PA3
PA4
PA5
PA6
PA7
PA8
PA9
PAA
PAB
PAC
PAD
PAE
PAF
PAG
PAH
PAI
PAJ
PAK
PAL
PAM
PAN
PAO
PAP
PAQ
PAR
PAT
PAU
PAW
PAX
PAZ
PB2
PB3
PB4
PB5
PB6
PB7
PB8
PBA
PBB
PBC
PBD
PBE
PBF
PBG
PBH
PBJ
PBK
PBL
Plan / Benefit Description
SV 25-35/250A 07 AB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
PPO - PFFS
PPO - PFFS
PPO ADMINISTRATIVE CHARGE
PPO - PFFS
PPO - PFFS
RESERVED PFFS
RESERVED PFFS
RESERVED PFFS
RSERVED FOR PFFS
VEBA TRIPLE OPT 10/100A AB
RESERVED PFFS
SV 20-30/100D PBG 06
SV 15-30/100A PBGH
PERSONAL ASSIST. NETWORK
SV 20/250A PAUSD 08
SVA 20-40/250D 07
KEENAN COMP PLACER GR07
KEC PLACER EP GR07
SV 15-30/100A PBGH CB
KEC PLACER PP GR07
KEC PLACER DELUXE GR07
SV 20-30/100D PBG 06 AB
SV 20-30/100D PBG 06 CB
PBGH $5/100%
PART B: STD I PRESCRIPTION
PBGH 20 PLAN
PBGH 15 PLAN
PBGH
PBGH-UNION BANK
PBGH-UNION BANK COBRA
PBGH-MERVYNS
BROKER COMMISSION SPECIAL
PBGH-MERVYNS COBRA
PBGH-MCKESSON
ENDORSED PART B: RX BENFT
PBGH-MCKESSON COBRA
ENDORSED- $9/$18 GEN. ONLY
PBGH-VONS
PBGH-VONS COBRA
PBGH-ESCO TECH
PBGH-ESCO TECH COBRA
174 of 640
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
PBM
PBN
PBO
PBP
PBQ
PBR
PBS
PBT
PBU
PBV
PBW
PBX
PBY
PBZ
PC1
PC2
PC3
PC4
PC5
PC6
PC7
PC8
PCA
PCB
PCC
PCD
PCE
PCG
PCH
PCJ
PCM
PCN
PCO
PCP
PCR
PCS
PCT
PCU
PCX
PCY
PCZ
PD1
PD2
PD3
PD4
PD5
PD6
PDA
PDB
PDD
Plan / Benefit Description
PBGH-BECHTEL
PBGH-BECHTEL COBRA
2005 PART B ONLY PLAN
2002 PART B ONLY PLAN
$10/100
PBGH $20/$250 $100 ER
PBGH $20/$250 $100ER COBRA
PEPSI BOTTLING GROUP
PEPSI BOTTLING GROUP
$10/100 COBRA
$5/100%
$5/100% COBRA
UNLM GNRC/$1600 BRAND MAX
PBGH $5/100% - COBRA
SH PLACER STD MED
SH PLACER STD MED W/ HI DE
SH PLACER PART B STD MED
SH PLACER PART B W/ HI DEN
SH PLACER PLUS MED
SH PLACER PLUS W/ HI DEN
SH PLACER PART B PLUS MED
PLACER PT B PLUS W/ HI DEN
ALREADY USED
ALREADY USED
SV 25/250A 06
SVA 15-30/200A PHS 06
UNLM GEN/$2000 ANN. BRAND
SV 25/250A 06 CB
SV PHS $15-$30/$100A
SV PBGH $10-100% AB
SV $15/$250A PBGH
SVA 15-30/200A PHS 06 CB
SV 20/250A PAUSD 08 CB
SVA 20-40/250D 07 CB
PBHI-CUSTOM RATE
PLACER CLASSIC I
SV $15/$250A PBGH CB
SV 20-30/200A PEPSI 07
SV 25/250A 06 AB
SVA 15-30/200A PHS 06 AB
PPO 90/70 $250 D $15OV CBR
PDV DENTAL ONLY
PDV CUSTOM DENTAL ONLY
PDV VISION ONLY
PDV CUSTOM VISION ONLY
PDV DENTAL & VISION
PDV CUSTOM DENTAL & VISION
SV 20-30/200A PEPSI 06
25/250A PBGH GR06
SV 15/100% SC PAINT 07
175 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
PDE
PDF
PDG
PDH
PDI
PDJ
PDK
PDM
PDN
PDO
PDP
PDR
PDS
PDT
PDW
PDX
PDY
PDZ
PE1
PE2
PE3
PE4
PE5
PE6
PE7
PE8
PE9
PEA
PEB
PEC
PEE
PEG
PEH
PEI
PEJ
PEK
PEL
PEM
PEN
PEO
PEP
PER
PES
PEU
PEV
PEX
PEY
PEZ
PF2
PF3
Plan / Benefit Description
O/3V 1YR POD SH07
SV 20-30/250A 07
SV 10/100% PG&E 08
O/4V 1YR POD SH07
RSERVED FOR PFFS
SV PBGH $20-$30/$250A AB
SV 20/100% 07
SV 20/250A PBGH
O/6V 1YR POD SH07
SV 20/250A PAUSD 08 AB
SVA 20-40/250D 07 AB
O/4V 1YR POD SH08
O/3V 1YR POD SH08
SV 20/250A PBGH CB
O/6V 1YR POD SH08
SV 20-30/200A PEPSI 06 AB
SV 20-30/200A PEPSI 06 CB
PPO 90/70 $250 D $0 OV CBR
EN: $7G/$15B $2000-BRND MX
EN: $7G/$20B $2000 COM LMT
EN: $8G/$25B $1500 COM LMT
EN: $8G/$30B $1500 COM LMT
RX ENDRSD $5/10 UNLM G/BR
EN: $8G/$30B $1200 COM LMT
EN: $8G/$25B $1000 COM LMT
EN: $8G/$30B $1000 COM LMT
EN: $8G/$30B $750 COMB LMT
SV 25/500A 06
RX EBDRSD 7/25 $1600 BRND
RX ENDS UNLM GEN/$2000 BRD
SV 25/500A 06 CB
RX ENDS GEN UNLM/$1600 BRD
RX ENDS UNLM GEN/$1500 BRD
RX ENDRSD 5/20 $1000 BRND
SV PBGH 20-35/100A AB
RX ENDRSD 5/20 $1500 BRND
RX ENDS UNLM GEN/$2000 BRD
RX ENDRSD $7/25 $500 CMBND
RX ENDS UNLM GEN/$1200 BRD
END. NO RX-20% INJECT/CHEM
RX ENDS UNLM GEN/$1000 BRD
RX ENDS $1000 COMB GEN/BRD
RX ENDRSD 7/25 $1500 BRND
SV 20-30/200A PEPSI 07 CB
SH ENDS UNLM GEN/$1500 BRD
SV 25/500A 06 AB
$20/Q PHB CREDIT SH08
PPO 90/70 $500 D $0 OV CBR
RESERVED PPO
RESERVED PPO
176 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
PF4
PF5
PF6
PF7
PF8
PF9
PFA
PFB
PFC
PFD
PFE
PFF
PFG
PFH
PFI
PFJ
PFK
PFL
PFM
PFX
PFY
PFZ
PG2
PG3
PG4
PG5
PG6
PG7
PG8
PG9
PGA
PGB
PGC
PGD
PGE
PGF
PGG
PGH
PGI
PGJ
PGK
PGL
PGM
PGN
PGO
PGP
PGQ
PGR
PGS
PGT
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SVA 20/250A 06
SVA 20/250A 06 CB
SV 20/250A 06
SV 20/250A 06 CB
SV 10/100% PEBT 07
SV 10/100% PEBT 07 CB
SV 10/100% PEBT 07 AB
SV 20-40/90% ALVA HOS 07
RSERVED FOR PFFS
SV PBGH $25/$250A AB
SV 20/100% 07 CB
DUMMY
$500 GENERIC/BRAND ANN MAX
SVA 20/250A 06 CB
SV 20/250A 06 AB
PPO 80/60 $250 D $0 OV CBR
$10/100%
$10/100% COBRA
$20/$250
$20/$250 COBRA
ADVANTAGE $20/$250A
ADVANTAGE $20/$250A COBRA
$15/$250A
$15/$250A COBRA
$9G/$30B G-UNLIM/B$1000
RX $9G/$25B $2000 COMB LMT
$5G/$10B G/B UNLIMITED
$9/$18G ONLY & NO LIMIT
END. RX-$9/$18GENERIC ONLY
$5G/$10B G-UNLIM/B $1000
$9G/$30B G-UNLIM/B$500
$5G/$10B G-UNLIM/B $500
$9G/$40B G-UNLIM/B$350
$5G/$10B G-UNLIM/B $400
SV 10/100% 06
2004 MID YR SH RX CHANGE
$9G/$30B G-UNLIM/B $1,300
$9/$18G ONLY & NO LIMIT
RX $9/$18G ONLY & NO LIMIT
PERF GUARANTEE PENALTY ADM
SV 10/100% 06 CB
$9G/$40B G-UNLIM/B $500
$9/$18G ONLY & NO LIMIT
$9G/$40B UNLIM-CUSTM MEDS
177 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
PGV
PGX
PGZ
PH2
PH3
PH4
PH5
PH6
PH7
PH8
PH9
PHA
PHB
PHC
PHD
PHF
PHG
PHH
PHI
PHJ
PHK
PHL
PHM
PHP
PHR
PHS
PHT
PHV
PHW
PHX
PHY
PHZ
PIE
PIF
PIG
PIH
PII
PIJ
PIK
PIL
PIM
PIN
PIO
PIP
PIQ
PIR
PIT
PIU
PIV
PIW
Plan / Benefit Description
$9G/$30B G-UNLIM/B-UNLIM
SV 10/100% 06 AB
PPO 80/60 $250 D $15OV CBR
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 20-40/200A PHS 06
SVA 20/250A 06
SV 20-40/200A PHS 06 CB
SVA 20/250A 06 CB
SP 10/80% PVH 06
SP 10/80% PVH 06 CB
SP 10/80% PVH 06 AB
RSERVED FOR PFFS
SV PBGH $20/$250A AB
SV 20-30/250D PETCO 07
$9G/$30B G-UNLIM/B $1,300
SVA 25/500A PBGH 08
SV 10/80% PVH 05 CB
PAC ADVAN PREF PLAN CCOBRA
$9/$18 GEN ONLY & NO LIMIT
PAC ADVAN PREF PLAN
$45/Q PHB CREDIT SH07
PAC ADVAN PREF PLAN COBRA
SVA 20/250A 06 AB
SV 20-40/200A PHS 06 AB
PPO 80/60 $500 D $0 OV CBR
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESEVED RX PFFS
RESERVED RX PFFS
SVA $20/$250A PBGH AB
RESERVED RX PFFS
RESERVED RX PFFS
$1000 GENERC/BRAND ANN.MAX
RESERVED RX PFFS
RESERVED RX PFFS
RSERVED FOR PFFS
RSERVED FOR PFFS
RSERVED FOR PFFS
RSERVED FOR PFFS
RESERVED PFFS RX
RESERVED PFFS RX
RESERVED PFFS RX
178 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
PIX
PIY
PIZ
PJ6
PJC
PJD
PJF
PJH
PJI
PJJ
PJK
PJM
PJP
PJQ
PJR
PJS
PJX
PJZ
PK1
PK2
PK3
PK4
PK5
PK6
PK7
PKA
PKE
PKF
PKG
PKI
PKJ
PKK
PKL
PKM
PKN
PKS
PKU
PKV
PKX
PKZ
PL1
PL5
PLA
PLB
PLC
PLD
PLE
PLF
PLG
PLH
Plan / Benefit Description
RESERVED PFFS RX
RESERVED PFFS RX
RESERVED PFFS RX
SV 15/100% SC PAINT 06 AB
SV 20-35/100A 06
SV 20-35/100A 06 CB
SV 20/100% POWER 07
SV 20-40/90% ALVA HOS 07CB
RSERVED FOR PFFS
SVA 20-30/250A PITNEY AB
SV 20/100% 07 AB
SV 20-40/300A PEPSI 08
SV 20-30/100D PBG 07
SV 20-40/300A PEPSI 08 CB
SV 20-40/300A PEPSI 08 AB
SV 20-30/250A PETCO 07
SV 20-35/100A 06 AB
NAT'L PPO $15OV 80/60 CBRA
HMO 30
HMO 30 COBRA
HMO 30 CAL COBRA
HMO 30 FED COBRA DIS
HMO 30 FED COBRA EXT
HMO 30 CAL COBRA EXT
HMO 30 CAL COBRA DIS
SV 15-25/100A 06
SV 25/250A 07
SV 20-30/250A 07 CB
SV 10/100% PG&E 08 CB
RSERVED FOR PFFS
HMO 30 PLAN AB
SV 20-30/250D PETCO 07 CB
SV 15-25/100A 06 CB
SV 20/250A PBGH CB
RX UNLM GEN/$1500 BR $7/20
SV 20-30/250A PETCO 07 CB
HMO 30 USERRA
UNLM GEN/$1500 ANN BRAND
SV 15-25/100A 06 AB
NAT'L PPO $15OV 90/70 CBRA
PPO CUSTOM 500 SERIES
SV $10/100%PACIFIC LIFE CB
PLACER COUNTY BASIC PLAN
PLACER COUNTY-PRT B ONLY
PPO 90/70 $250 DED $15OV
PPO 90/70 $250 DED $0 OV
PPO 90/70 $500 DED $0 OV
PPO 80/60 $250 DED $0 OV
PPO 80/60 $250 DED $15 OV
PPO 80/60 $500 DED $0 OV
179 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
PLI
PLJ
PLK
PLL
PLM
PLN
PLP
PLS
PLV
PLW
PLX
PLZ
PM1
PM2
PM3
PM4
PM5
PM6
PM8
PM9
PMA
PMB
PMC
PMD
PME
PMF
PMG
PMH
PMI
PMJ
PMK
PML
PMM
PMN
PMO
PMP
PMQ
PMR
PMS
PMT
PMU
PMW
PMX
PMZ
PN6
PNB
PNC
PNE
PNF
PNG
Plan / Benefit Description
RSERVED FOR PFFS
NAT'L PPO $15OV 80/60
NAT'L PPO $15OV 90/70
SV 15/250A 06
SVA 20/250A PBGH CB
SV $10/100%PACIFIC LIFE
PAYMENT LAG PREMIUM ALLOC
$5G/$20B GEN/BRAND UNLIM.
$9G/$30B/$55NF UNLIMITED
SV 15/250A 06 CB
SV 15/250A 06 AB
PPO CUSTOM 500 SERIES CBRA
PERS- RET. MED. SH BENEFIT
SV PBGH $20/250A CB
SV PBGH $10-100% CB
SV PBGH $20-$30/$250A CB
SV PBGH 20-35/100A CB
SV PBGH $25/$250A CB
SV PBGH $20/$250A CB
SVA $20/$250A PBGH CB
SR PREMIER MARIN PT B
SV PBGH $20/250A
SV PBGH $10-100%
SV PBGH $20-$30/$250A
SV PBGH 20-35/100A
SV PBGH $25/$250A
SVA 15/250A 07
SV PBGH $20/$250A
SVA $20/$250A PBGH
SV PBGH $20/250A AB
SV 20/250A PBGH
SVA 20/250A PBGH
SR PREMIER MARIN
SV PBGH $20/$250A
SVA PBGH $20/$250A
25/250A PBGH NON-AARP GR08
SV PBGH $10/100%
$1000 GENERC/BRAND ANN.MAX
SV $20/$250A PBGH
SV $25/250A PBGH
SV PBGH $5/100%
SV25-35/250A PBGHMRVYNS
PPO 90/60 STANDARD PLAN
PPO 90/60 STANDARD PLAN CB
NO. CA: $8G/$30B $1200 MAX
RX UNLM GEN/$1600 BR $7/25
UNLM GEN/$2100 ANN. BRAND
SVA 20-30/250A PITNEY
SV 20/100% POWER 07 CB
SV 20-30/250A
180 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
PNH
PNI
PNJ
PNK
PNM
PNS
PNZ
POD
POE
POF
POG
POH
POI
POJ
POK
POL
PON
POO
POQ
POR
POS
POT
POU
POV
POW
POX
POY
POZ
PP1
PP2
PP5
PPA
PPB
PPC
PPD
PPE
PPF
PPG
PPH
PPI
PPJ
PPK
PPL
PPM
PPN
PPP
PPQ
PPR
PPS
PPT
Plan / Benefit Description
SV 15/100% 07
RSERVED FOR PFFS
SV PBGH $20/$250A AB
SV 20-30/250D PETCO 07 AB
SVA 25/500A PBGH 08 CB
SV 20-30/250A PETCO 07 AB
SV PBGH $20/$250A CB
RSERVED FOR PFFS
RSERVED FOR PFFS
RSERVED FOR PFFS
RSERVED FOR PFFS
RSERVED FOR PFFS
RSERVED FOR PFFS
SVA PBGH $20/$250A AB
10/6V 1YR GR-PD07
RSERVED FOR PFFS
RSERVED FOR PFFS
RSERVED FOR PFFS
RESERVED PFFS RX
RESERVED PFFS RX
RESERVED PFFS RX
RESERVED PFFS RX
RESERVED PFFS RX
RESERVED PFFS RX
RESERVED PFFS RX
RESERVED PFFS RX
RESERVED PFFS RX
SVA PBGH $20/$250A CB
SH PLUS MED PODIATRY
2002 SH PLUS-PODIATRY PLAN
SV 20/250A 06 CB
RESERVED PPO
SO.CAL.PLUS PLAN NO PRT A
580 PLAN/$800-$2400 MAX
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RSERVED FOR PFFS
SV 20/250A 06 AB
RESERVED PPO
RESERVED PPO
RESERVED PPO
PACIFICARE PPO NETWORK
SV 20/250A 06
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
181 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
PPU
PPV
PPW
PPX
PPY
PPZ
PQA
PQE
PQF
PQG
PQH
PQI
PQJ
PQL
PQM
PQP
PQX
PQZ
PR0
PR1
PR5
PR6
PR7
PRA
PRB
PRC
PRD
PRE
PRF
PRG
PRI
PRJ
PRL
PRN
PRP
PRS
PRX
PRZ
PS1
PS2
PS3
PS4
PS5
PS6
PS7
PS8
PS9
PSA
PSB
PSC
Plan / Benefit Description
RESERVED PPO
RESEREVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
580 PLAN/$800-$2400 MAX
SV 20/250A PRVDNCE 06
SV 25/250A 07 CB
SV 20-30/250A CB
SV 10/100% PG&E 08 AB
SV 20-40/90% ALVA HOS 07AB
RSERVED FOR PFFS
SV PBGH $10/100% CB
SV 20-40/250A 07
SV PBGH $10/100% CB
10 PUPLIC SECTOR AARP GR08
SV 20/250A PRVDNCE 06 AB
SV 20/250A PRVDNCE 06 CB
PREFERRED PLAN INACTIVE
PREFERRED PLAN
RX UNLIM.ANNUAL MAX $5/$10
SV 25-40/250A PBGH
SV 25-40/250A PBGH CB
$9G/$30B/$55NF-G-UNLM/B500
$9G/$30B/$55NF-G ULM-B1000
$15/$30 GEN ONLY-NO LIMIT
PREMIUM DELAY
SV 20/250A 06
PPO RENTAL NETWORK FEE
$5G/$20B GEN-UNLIM/B $1000
RX CMBND $1000 G/BR $7/25
SV 25-40/250A PBGH AB
SV 20-40/250A 07 CB
RX UNLM GEN/$1200 BR $7/25
SV 20/250A 06 CB
PPO CUSTOM RET SAN DIEGO
SV 20/250A 06 AB
PPO CUSTOM RET S DIEGO CBR
PERS PLAN (PREFERRED)
RX $7G/15B $2000 BRAND MAX
RX $7G/$20B $2000 COMB LMT
RX $8G/$25B $1500 COMB LMT
RX $8G/$30B $1500 COMB LMT
RX $8G/$30B $1200 COMB LMT
RX $8G/$25B $1000 COMB LMT
RX $8G/$30B $1000 COMB LMT
RX $8G/$30B $750 COMB LIMT
SO.CAL SENIOR PLAN PLUS
SR PREMIER SOL/SOM PART B
RX UNLM GEN/$2000 BR $7/15
182 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
PSD
PSE
PSF
PSG
PSJ
PSL
PSM
PSN
PSP
PSQ
PSR
PSS
PST
PSV
PSZ
PTA
PTB
PTC
PTE
PTF
PTH
PTI
PTJ
PTN
PTW
PTX
PTY
PTZ
PU2
PU6
PUA
PUB
PUC
PUD
PUE
PUF
PUG
PUH
PUI
PUJ
PUK
PUL
PUM
PUN
PUP
PUQ
PUX
PUY
PUZ
PV2
Plan / Benefit Description
PPO CUSTOM SAN DIEGO
END. RX $9G/$25B $2000 LMT
SV 20/100% POWER 07 AB
$9/$18 GEN ONLY & NO LIMIT
SV $20/$250A PBGH AB
UNLM GNRC/$1500 BRND MAX.
SH $1000 COMB GEN/BR $7/25
$9G/$40B/$65NF-G-UNLM/B350
SV 20/200A PEPSICO
SV 20/200A PEPSICO CB
RX UNLM GEN/$2000 BR $7/20
SR PREMIER SOLANO/SONOMA
PUBLIC SECTOR $10 GRP RET
SH UNLM GEN/$1500 BR $7/25
PPO CUSTOM SAN DIEGO COBRA
SV 25/500A PBGH 08
2003 PART B ONLY PLAN
SV 20-30/250A PETCO 08
SV 25/500A PBGH 08 CB
SV 25/500A PBGH 08 AB
SV 20-30/250A PETCO 08 CB
RSERVED FOR PFFS
SV $25/250A PBGH AB
SVA 20-30/250A PITNEY CB
SV 15/100% PAC LIFE 07 CB
SV 15/100% PAC LIFE 07 AB
SV 20-30/250A PETCO 08 AB
PEP BOTTLING GROUP COBRA
SV 10/100% SC PAINT 06 AB
SV 15/100% SC PAINT 06
SV 10/100% PRVDNCE 06
SV 20-40/500D 07
SV 10/100% SC PAINT 06
MCC PLACER DELUXE SH07
MCC PLACER EP SH07
SV 20-30/250A 07 AB
SV 15/100% SC PAINT 07 CB
SV 15/100% 07 CB
RSERVED FOR PFFS
SV PBGH $5/100% AB
SV 20-40/500D 07 CB
SV 20-30/200A PEPSI 07 AB
SV PBGH $5/100% CB
MC COMP PLACER SH07
MCC PLACER PP SH07
SV 20-40/500D 07 AB
SV 10/100% PRVDNCE 06 AB
SV 10/100% SC PAINT 06 CB
SV 10/100% PRVDNCE 06 CB
VEBA A10 $10/$200/$250
183 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
PV3
PV4
PV5
PV6
PV7
PV8
PV9
PVA
PVB
PVC
PVD
PVE
PVF
PVG
PVH
PVI
PVJ
PVK
PVL
PVN
PVP
PVR
PVS
PVT
PVU
PVV
PVX
PVY
PVZ
PW1
PW2
PW3
PW4
PWA
PWC
PWD
PWE
PWF
PWG
PWH
PWI
PWJ
PWK
PWL
PWM
PWN
PWP
PWU
PWW
PWX
Plan / Benefit Description
VEBA A10 $10/$200/$250 CB
VEBA A15 $15/$200/$500
VEBA A15 $15/$200/$500 CB
VEBA B10 $10/$200/$250
VEBA B10 $10/$200/$250 CB
VEBA B15 $15/$100/$500
VEBA B15 $15/$100/$500 CBR
VEBA TRIPLE OPT 10/100A
VEBA TRIPLE OPT 10/100A CB
SV 20/250A 06
SV 20-30/250A AB
SP 10/200A SCSV B10 06 CB
SV 25/250A PBGH 08
SP 15/200A SCSVEBA 06 CB
SV 10/80% PVH 05
RSERVED FOR PFFS
SV 20/200A PEPSICO AB
SP 10/200A SCSV B10 06 AB
SP 10/200A SCSV A10 06 CB
SV 25/250A PBGH 08 CB
SV 25/250A PBGH 08 AB
$9G/$40B/$65NF-G UNLM-B500
$5G/$20B GEN-UNLIM/B $500
SP 15/200A SCSVEBA 06 CB
SP 10/200A SCSV A10 06 CB
SP 15/200A SCSVEBA 06 AB
SV 20/250A 06 AB
SP 15/200A SCSVEBA 06 AB
SV 20/250A 06 CB
PPO SAN DIEGO RETIREES
PPO SN DIEGO RETIREE COBRA
NATL PPO SAN DIEGO RETIREE
NATL PPO SN DIEGO RET COBR
NATL PPO 80/60-80/70 $250D
SV 15-25/100A 07
SV 15-25/100A 07 CB
PLACER CLASSIC I W/EPO DDS
SVA 20-40/500D 07
SVA 15/250A 07 CB
SV 15-25/100A 07 AB
RSERVED FOR PFFS
SV25-35/250A PBGHMRVYNS AB
SVA 20-40/500D 07 CB
SV 15/100% SC PAINT 07 AB
SV25-35/250A PBGHMRVYNS CB
SVA 20-40/500D 07 AB
PLACER CLASSIC I W/ODP
ARP MCC PLACER PP SH08
ARP MCC PLACER SH08
ARP MCC PLACER DLX SH08
184 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
PWY
PWZ
PX1
PX2
PX3
PX4
PXA
PXC
PXE
PXG
PXH
PXI
PXJ
PXL
PXM
PXP
PXS
PXY
PXZ
PYA
PYB
PYC
PYE
PYH
PYI
PYJ
PYX
PYY
PYZ
PZ1
PZ4
PZ6
PZA
PZB
PZH
PZJ
PZL
PZP
PZS
PZT
PZU
PZX
PZZ
Q1C
Q1I
Q1J
Q1P
Q1Y
Q1Z
Q2B
Plan / Benefit Description
ARP MCC PLACER EP SH08
NA PPO 80/60-80/70 250D CB
NATL PPO CUSTOM S DIEGO
NATL PPO CUSTOM S DIEGO CB
NATL PPO CUSTOM RET S DIEG
NATL PPO CUSTOM RET SD CBR
NATL PPO CUSTOM 500 SERIES
SV 15/100% PAC LIFE 07
SV 25/250A 07 AB
SVA 15/250A 07 AB
SV 15/100% 07 AB
RSERVED FOR PFFS
$5/100% AB
SV 20-40/250A 07 AB
SVA 25/500A PBGH 08 AB
SV 20-30/100D PBG 07 CB
SV $20/$250A PBGH CB
$30/Q PHB CREDIT SH08
NATL PPO CUSTOM 500 CBR
NATL PPO 90/70-90/80 $250D
SV 20/100% SC PAINT 06
SV 20-40/500A 07
SV 20-40/500A 07 CB
SV 20-40/500A 07 AB
RESERVED PFFS
SV 20-30/100D PBG AB
SV 20/100% SC PAINT 06 AB
SV 20/100% SC PAINT 06 CB
NA PPO 90/70-90/80 250D CB
PREFERRED PLAN (COBRA)
SV 10/100% PACIFIC 06 AB
SV 15/100% SC PAINT 06 CB
SV 25-35/250A 06
SV 25-35/250A 06 CB
SV PHS $15-$30/$100A CB
PEPSI BOTTLING GROUP AB
SV 10/100% PACIFIC 06
SV 20-30/100D PBG 07 AB
PERS PLAN PREFERRED/COBRA
SV $25/250A PBGH CB
PEPSI BOTTLING GRP COBRA
SV 25-35/250A 06 AB
SV 10/100% PACIFIC 06 CB
1500 PLAN
II
INDIVIDUAL CONVERSION
1500 PLAN AB
1500 PLAN
1500 PLAN
1500 PLAN COBRA II
SV 20/250A+20% KMSTF 05 CB
185 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
Q2C
Q2J
Q2Z
Q31
Q3C
Q3J
Q3Y
Q3Z
Q4C
Q4J
Q4Z
Q5C
Q5J
Q5Z
Q67
Q6C
Q6J
Q6Z
Q7J
Q7N
Q7Z
Q8J
Q9J
QA4
QA5
QAC
QAH
QAJ
QAQ
QAZ
QBB
QBH
QBJ
QBQ
QCA
QCH
QCJ
QCQ
QDA
QDE
QDG
QDJ
QEA
QEE
QEG
QEJ
QFA
QFB
QFE
QFF
Plan / Benefit Description
MFP 1500 PLAN
SV $20/80% AB
MFP 1500 PLAN (COBRA)
POMONA VLY HOSP 100/80/60
NON-STANDARD 1500 PLAN
SV $10/100% AB
POMONA HOSP 100/80/60 CBR
NON-STANDARD 1500 PLAN CBR
NON STANDARD 20/150
SV $20-$40/$250A AB
NON STANDARD 20/150 CBRA
PBGH $20/$250 $50 ER
SV 20/100% AB
PBGH $20/$250 $50 ER COBRA
SV 20/80% 06 AB
SHEET METAL WORKERS $20
SHEET METAL WORKERS $20 AB
SHEET METAL WORKERS $20 CB
SV 15/250A PORTFOLIO AB
NON-STD $20 HMO
NON-STD $20 HMO COBRA
SV 20/250A+20% KMSTF 05 AB
SV 20-40/250D PORTFOLIO AB
SV $20/$40/$250A
SV $20/$40/$250A CB
$20/$250 HMO 2000 SER
SV 20/100% 07
SV $20/$40/$250A AB
SV 30/500A 07
$20/$250 HMO 2000 SER CBRA
SV 20/250A+20% KMSTF 05
SV 20/100% 07 CB
SV 20/250A AB
SV 30/500A 07 CB
SVA 20/100% 07
SV 20/100% 07 AB
$20/$250 HMO 2000 SER AB
SV 30/500A 07 AB
SVA 20/100% 07 CB
SV 10/100% 07
SPT 10-25/100% SD 07
SV $20-$40/$400D AB
SVA 20/100% 07 AB
SV 10/100% 07 CB
SPT 10-25/100% SD 07 CB
SV 30/500A AB
SVA 30/500A 07
SV 15/250A 07
SV 10/100% 07 AB
SVT 15-35/250A NONSD 07
186 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
QGA
QGB
QGF
QGJ
QHA
QHB
QHF
QHG
QIJ
QJG
QKG
QKH
QLA
QLB
QLH
QLJ
QMA
QMB
QMG
QMH
QNA
QNB
QNJ
QPJ
QPP
QPY
QQ3
QQ4
QQ5
QQ6
QQ7
QQ8
QQ9
QQA
QQB
QQC
QQE
QQF
QQG
QQH
QQI
QQJ
QQK
QQL
QQM
QQN
QQO
QQP
QQR
QQS
Plan / Benefit Description
SVA 30/500A 07 CB
SV 15/250A 07 CB
SVT 15-35/250A NONSD 07 CB
SV 20-40/500D PORTFOLIO AB
SVA 30/500A 07 AB
SV 15/250A 07 AB
SVT 15-35/250A NONSD 07 AB
SVA 10/100% 07
SVA 10/100% AB
SVA 10/100% 07 CB
SVA 10/100% 07 AB
SPT 10-25/100% NONSD 07
SV 20-40/250D 07
SVT 15-35/250A SD 07
SPT 10-25/100% NONSD 07 CB
SVA 20-100% AB
SV 20-40/250D 07 CB
SVT 15-35/250A SD 07 CB
SPT 10-25/100% SD 07 AB
SPT 10-25/100% NONSD 07 AB
SV 20-40/250D 07 AB
SVT 15-35/250A SD 07 AB
SVA 15/250A PORTFOLIO AB
SVA 20-40/250D PORTFOLI AB
PEPSICO CHOICE PLAN
PEPSICO CHOICE COBRA
SV $10/100%
SV $10/100% CB
SV 20/100%
SV 20/100% CB
SV 15/250A PORTFOLIO
SV 15/250A PORTFOLIO CB
SV 20-40/250D PORTFOLIO
SV 20-40/250D PORTFOLIO CB
SV 20-40/400D PRES HOS 05
SV 20-40/400D PRES 05 CB
SV 30/500A
SV 30/500A CB
SV 20-40/500D PORTFOLIO
SV 20-40/500D PORTFOLIO CB
SVA 10/100%
SV 20-40/400D PRES 05 AB
SVA 10/100% CB
SVA 20-100%
SVA 20-100% CB
SVA 15/250A PORTFOLIO
SVA 15/250A PORTFOLIO CB
SVA 20-40/250D PORTFOLI
SVA 30/500A
SVA 30/500A CB
187 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
QQT
QQU
QQV
QRJ
QTJ
QUA
QUJ
QUZ
QV2
QV3
QVA
QVB
QVJ
QVX
QW2
QW3
QW4
QW5
QW6
QW7
QWB
QWC
QWD
QWE
QWF
QWG
QWJ
QYB
QYC
QYJ
QZJ
R01
R02
R03
R04
R05
R06
R07
R08
R09
R0A
R0B
R0C
R0D
R10
R1C
R1J
R1S
R1Z
R23
Plan / Benefit Description
SVA 20-40/500D
SVA 20-40/500D CB
SVA 20-40/250D PORTFOLI CB
SVA 30/500A AB
SVA 20-40/500D AB
SP 15/200A QUIDEL 06
SP 15/200A QUIDEL 06 AB
SP 15/200A QUIDEL 06 CB
SV 20/250A SCS VEBA 06 CB
SP 25/250A SCS VEBA 06 CB
SV 20/250A SCS VEBA 06
SP 25/250A SCS VEBA 06
SV 20/250A SCS VEBA 06 AB
SP 25/250A SCS VEBA 06 AB
SV $20/80%
SV $20/80% CB
SV $20-$40/$250A
SV $20-$40/$250A CB
SV 20/80% 06
SV 20/80% 06 CB
SV 20/250A
SV 20/250A CB
SV $20-$40/$400D
SV $20-$40/$400D CB
SV 20/250A 06
SV 20/250A 06 CB
SV 20/250A 06 AB
SP 10/100% PIH 05
SP 10/100% PIH 05 CB
SP 10/100% PIH 05 AB
MFP 1500 PLAN AB
$5G/$10B/$25NF
$5G/$5B
$5G/$10B/$20NF
$5G/$15B/$25NF
$10G/$10B
$10G/$20B/$40NF
$20G/$30B
20G/35B/100 DED
$20G/$30B/$50NF
20G/35B/50NF/100
$5G/$5B
$10G/$15B
$10G/$25B/$35NF MFP
$10
$10/$100 HMO 2000 SER
$10/$100 HMO 2000 SER AB
RIVERSIDE STANDARD PLAN
$10/$100 HMO 2000 SER CBRA
DUMMY CODE - OK TO USE
188 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
R24
R25
R2C
R2J
R2S
R2Z
R3C
R3J
R3P
R3S
R3U
R4J
R4P
R4S
R5P
R5S
R64
R65
R66
R67
R6E
R6J
R6S
R74
R75
R76
R77
R7E
R7J
R7S
R84
R85
R86
R87
R8D
R8E
R8H
R8J
R8L
R8N
R9D
R9E
R9H
R9L
R9N
RA2
RAD
RAE
RAF
RAG
Plan / Benefit Description
DUMMY - OK TO USE
O/P PRESCRIP DRUGS $2.50
$10/$250 HMO 2000 SER
$10/$250 HMO 2000 SER AB
RIVERSIDE STANDARD - II
$10/$250 HMO 2000 SER CBRA
CALPERS RET$5G/$15B/$30NF
SV 10/100A AB
0/90H 1 YR RESPITE GR07
RIVERSIDE PLUS PLAN
$10G/$20B/$35NF GRP RET
SV 10/250A AB
0/50H 1 YR RESPITE GR07
RIVERSIDE STD. W/OPT DDS
0/40-100H 1YR RESPITE GR07
RIVERSIDE STAND. W/HI DENT
KEC 1 RVERSDE CG GR07
KEC 1 RVERSDE LO CG GR07
KEC 1 RVERSDE HI CG GR07
KEC 1 RVERSDE DX CG GR07
SV 10/100A 06
SV 10/100A 06 AB
RIVERSIDE PLUS W/OPT DENTL
KEC 1 RVERSDE CGII GR07
KEC 1 RVERSDE LO CGII GR07
KEC 1 RVERSDE HI CGII GR07
KEC 1 RVERSDE DX CGII GR07
SV 10/100A 06 CB
SV $10-$20/$100D AB
RIVERSIDE PLUS W/HI DENTAL
KEC 1 RVERSDE CGEH GR07
KEC 1 RVERSDE LO CGEH GR07
KEC 1 RVERSDE HI CGEH GR07
KEC 1 RVERSDE DX CGEH GR07
MCC 2 RIVERSDE DELUXE SH07
SV 10/250A 06
MCC 2 RIVERSDE HIGH SH07
SV 10/250A 06 AB
MCC 2 RIVERSDE LOW SH07
MC COMP 2 RIVERSIDE SH07
MCC 3 RIVERSDE DELUXE SH07
SV 10/250A 06 CB
MCC 3 RIVERSDE HIGH SH07
MCC 3 RIVERSDE LOW SH07
MC COMP 3 RIVERSIDE SH07
$7/$7
SV 20/90% RITE AID 07
SV 20/90% RITE AID 07 CB
SV 15-25/250A ROSS 07
SV 20/90% RITE AID 07 AB
189 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
RBA
RBH
RBJ
RBZ
RC1
RC2
RC3
RC4
RC5
RC7
RCA
RCB
RCC
RCD
RCE
RCF
RCG
RCH
RCI
RCJ
RCK
RCL
RCM
RCN
RCO
RCP
RCQ
RCS
RCT
RCU
RCV
RCW
RCY
RCZ
RDA
RDB
RDD
RDE
RDF
RDG
RDH
RDJ
RDL
RDN
RDZ
RE1
RE2
RE3
RE4
RE5
Plan / Benefit Description
SV 20/100A ROCHE PAL 06
20 ROCHE PA NON-AARP GR08
SV 20/100A ROCHE PAL 06 AB
SV 20/100A ROCHE PAL 06 CB
RETAIL CLERKS PLAN
RETAIL CLERK DRUG PLAN
$5G/$15B/$30NF CALPERS RET
ROSS STORES ADV 15/250A
ROSS STORES ADV 15/250A CB
$7
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
$2 FLAT RX
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
SV 30/500A RESIG 06
20/100A ROCHE PA GR06
MCC ESS RVRSDE DLUXE SH07
SP 10/100% RUSD 07
SV 15-25/250A ROSS 07 CB
SV 25/250A RETA 07
MCC ESS RVRSDE HIGH SH07
SV 15/100% RUSD 05 AB
MCC ESS RVRSDE LOW SH07
MC COMP ESS RVRSDE SH07
SV $15/100% RIVERSIDE CB
RETAIL CLERKS-EXT. OB CARE
SV 10/100A
SV 10/100A CB
SV 10/250A
RETIREE RX 5/10 $1600 BRND
190 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
RE6
RE7
RE8
REA
REC
REF
REK
REP
REV
REX
REZ
RF0
RF1
RF2
RF3
RF4
RF5
RF6
RF7
RFA
RFB
RFC
RFD
RFE
RFF
RFG
RFH
RFL
RFM
RFN
RFS
RFU
RFW
RFX
RFY
RFZ
RG1
RG2
RG3
RG4
RG5
RG6
RG7
RG8
RG9
RGA
RGB
RGC
RGD
RGE
Plan / Benefit Description
SV 10/250A CB
SV $10-$20/$100D
SV $10-$20/$100D CB
SV 30/500A RESIG 06 CB
REED $10
SH RETIREE EDISON FLX CSTM
SP 10/100% RUSD 06
SP 10/100% RUSD 06 CB
SP 10/100% RUSD 06 AB
SH RETIREE EDISON FLEX $5
SV 20/250A RESIG 06
RX RETIREE $0G/$0B UNLM MF
RX RETIREE $1G/1B UNLMD MF
RX RETIREE $2G/2B UNLMD MF
RX RETIREE $3G/3B UNLMD MF
RX RETIREE $4G/4B UNLMD MF
RX RETIREE $5G/5B UNLMD MF
RX RETIREE $6G/6B UNLMD MF
RX RETIREE $7G/7B UNLMD MF
$10G/$20B RET $250 INJ
RET.GOLD TRW EH790
RX RETIREE $5G/$10B UNLMD
$5G/$20B RET $250INJ
RX RETIREE $5G/$10B $1600B
RX RETIREE $7G/10B $1600B
RX RETIREE $7G/10B $2500B
RX $10G/$10B $250 INJ
RX RETIREE $5G/$20B UNLMD
RX RETIREE $5G/10B UNLM MF
RX RETIREE $5G/15B UNLMD
RX RETIREE $7G/$10B $2500B
RX RETIREE $7G/10B UNLIM
RX RETIREE 3G/5B UNLMTD MF
RX RETIREE $10G/10B UNLMD
RX RETIREE $10G/20B UNL MF
SV 20/250A RESIG 06 CB
RETIREE GOLD BAS-PLUS NO C
RETIREE GOLD CUST/DEN N CA
RG PLUS SO CAL
RG PLUS SO CAL NO PAY
RG PLUS SO CA - CUSTOM
RG PLUS SO CA - CUSTOM
RG BASIC PLUS CUSTOM
RG PREMIER CUSTOM
RG PREMIER SO CALIF
RETIREE GOLD CUSTOM
RETIREE GOLD BASIC SO CA
RG CUSTOM
RETIREE GOLD S-DENT SO CA
RETIREE GOLD W/DENT NO CAL
191 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
RGN
RGP
RGT
RGX
RH1
RH2
RHB
RHC
RHD
RHE
RHF
RHG
RHH
RHJ
RHR
RHZ
RIB
RJA
RJB
RJC
RJE
RJF
RJJ
RK1
RK2
RKD
RKH
RKL
RKN
RL2
RLA
RLB
RLE
RLF
RLM
RLR
RLS
RLT
RLU
RM0
RM1
RM2
RM3
RM4
RM5
RM6
RM7
RMA
RMD
RMF
Plan / Benefit Description
RETIREE GOLD BASIC NO CAL
RETIREE GOLD RX SO CA
SH RETIREE GMP $5G/10B CF
$10G/$10B GRP RET
RET.GOLD HRNG A1325
RET.GOLD F2191 HEARING
SV 15/250A RETA 07
ROHR PLAN
ROHR $10
ROHR $10 - COBRA
$5 RX CO-PAY/$1500 AN.MAX.
ROHR $20
ROHR $20 - COBRA
ROHR $10 AB
RX CSTM GMP TRUST 5/10
ROHR PLAN - COBRA
RX RETIREE SO CA IBEW
SV 10/100% CRYROP 06
SV 15/250A RETA 07 CB
KEENAN COMP 1 RVERSDE GR07
SP 10/100% RUSD 07 CB
SV 10/100% CRYROP 06 CB
SV 10/100% CRYROP 06 AB
ROCKWELL PLAN/PREF-50 OPMH
STANDARD 10 - $25 ER
MCC 1 RIVERSDE DELUXE SH07
MCC 1 RIVERSDE HIGH SH07
MCC 1 RIVERSDE LOW SH07
MC COMP 1 RIVERSDE SH07
PLACER II STANDARD PLAN
$5G/$7.50B
SV 15/250A RETA 07 AB
SP 10/100% RUSD 07 AB
SV 15-25/250A ROSS 07 AB
RX RETIREE LORAL CUSTOM
RX RETIREE LACERS 5/10 OPN
RX RETIREE - LORAL SPACE
$5G/$5B GRP RET
$5G/$10B GRP RET
O/P RX $0 SH-RETIREE
O/P PRESCRIP $1 (SH-RET)
O/P PRESCRIP $2 (SH-RET)
O/P PRESCRIP $3 (SH-RET)
O/P PRESCRIP $4 (SH-RET)
O/P PRESCRIP $5 (SH-RET)
O/P PRESCRIP $6 (SH-RET)
O/P PRESCRIP $7 (SH-RETIRE
SV 30/500A RESIG 06 AB
RX CSTM MCDONNELL DOUGLAS
SV 25/70% RESIG 06
192 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
RMG
RMH
RMR
RMS
RN1
RN2
RN3
RN4
RN5
RN6
RNA
RNB
RNC
RND
RNE
RNF
RNG
RNH
RNJ
RNK
RNL
RP1
RP2
RP3
RP4
RP5
RP6
RP7
RP8
RP9
RPB
RPC
RPD
RPE
RPI
RPJ
RPM
RPN
RPO
RPP
RPQ
RPR
RPS
RPT
RPU
RPV
RPX
RPZ
RQC
RQE
Plan / Benefit Description
SV 25/70% RESIG 06 CB
SV 25/70% RESIG 06 AB
$15G/$20B/$30NF
RIVERSIDE MEDICAL
$7G/$14B GRP RET
$10G/$20B GRP RET
$10G/$25 GRP RET
$10G/$20B/$40NF
$10G/$20B/$50NF
$15G/$25B/$40NF
$7G/$14B GRPRET
$10G/$20B GRPRET
$10G/$25B GRPRET
$10G/$20B/$40NF
$10G/$20B/$50NF
$15G/$25B/$40NF
$7G/$14B
$10G/$20B
$10G/$25B
$10G/$20B/$40NF
$15G/$25B/$40NF
RG PREMIER SO CAL CUSTOM
RG PREMIER SO CAL CUSTOM
$3
RETIREE GOLD CUSTOM PLAN
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RG PREMIER SO CALIF CUSTOM
RX RETIREE $5G/15B UNLM MF
THRIFTY PAYLESS PLAN
SV 15-25/250A ROSS 06
RESPITE/PERS CARE SH07
RX RETIREE TPIG $5G/10B UN
SV 15-25/250A ROSS 06 AB
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
SV 15-25/250A ROSS 06 CB
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RESPITE/PERS CARE WL-SH08
THRIFTY PAYLESS PLAN COBRA
$10/$250 HMO MFP PLAN
KEC 1 RVERSDE LOW GR07
193 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
RQH
RQL
RQW
RQX
RQZ
RR7
RRA
RRB
RRC
RRD
RRE
RRF
RRG
RRH
RRI
RRJ
RRK
RRL
RRM
RRN
RRO
RRP
RRQ
RRR
RRS
RRT
RRU
RRV
RRW
RRX
RRZ
RS1
RS2
RS3
RS4
RS5
RS6
RS7
RS8
RSC
RSD
RSE
RSH
RSJ
RSL
RSN
RSU
RSV
RT2
RT6
Plan / Benefit Description
ARP MCC 1 RVSIDE HI SH08
ARP MCC 1 RVSIDE LO SH08
ARP MCC 1 RVSIDE SH08
ARP MCC 1 RVSIDE DLX SH08
$10/$250 HMO MFP PLAN COBR
SH RETIREE STD $7 RX
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
ROHR PLAN
RETIREE GOLD CUSTOM
KEC 1 RVERSDE HIGH GR07
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
ROHR PLAN
COBRA
SH RIVERSIDE STD MED
SH RIVERSIDE STD W/ HI DEN
SH RIVERSIDE PART B STD
RIVERSIDE PART B W/ HI DEN
SH RIVERSIDE PLUS MED
RIVERSIDE PL MED W/ HI DEN
RIVERSIDE PART B PLUS MED
RIVERSIDE PT B PL W/ HI DE
RETIREE SH CUSTOM 5/10
SV 15/100% RUSD 05 CB
END RIVERS BASIC W/ NO DEN
$10G/$15B
CUSTOM RX CITY OF SAN JOSE
RX CSTM SO.CAL.LABORERS
$10G/$20B/$25NF
SV $15/100% RIVERSIDE
RX RETIREE $5G/10B CUSTOM
10/250 PLAN MFP
SV 15/250A RETA 06
194 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
RTA
RTC
RTE
RTG
RTJ
RTP
RTR
RTX
RTZ
RUA
RUC
RUD
RUF
RUG
RUJ
RUL
RUS
RUT
RUZ
RVA
RVC
RVD
RVE
RVF
RVH
RVJ
RVL
RVS
RVT
RVZ
RWA
RWD
RWE
RWH
RX0
RX1
RX2
RX3
RX4
RX5
RX6
RX7
RX8
RX9
RXA
RXB
RXC
RXD
RXE
RXF
Plan / Benefit Description
RETIREE GOLD CUSTOM
RETIREE GOLD CUSTOM
KEC 1 RVERSDE DELUXE GR07
SV 25/250A RETA 07 CB
10/250 PLAN MFP AB
5/10 CLOSED RX/UNLIMITED
SV 15/250A RETA 06 CB
SV 15/250A RETA 06 AB
10/250 PLAN MFP COBRA
RX RETIREE UA LOCAL 447 PT
RX RETIREE UC $5G/10B CL F
$1OG/$20B/$35NF
SP 10/100% RUSD 06
SV 25/250A RETA 07 AB
SV $15/100% RIVERSIDE AB
SP 10/100% RUSD 06 CB
SV 15/100% RUSD 05
SP 10/100% RUSD 06 AB
SV 20/250A RESIG 06 AB
SV 10-20/100D 07
$10/$250 PER ADMIT
RVRSDE CLSC ENHNCD W/OPDDS
RVRSDE CLSC ENHNCD W/EPDDS
SV 10/100% RUSD 06
RVRSDE CLSC ENHNCD W/HIDDS
$10/$250 PER ADMIT AB
SV 10/100% RUSD 06 CB
RIVERSIDE CLSC ENHANCED
SV 10/100% RUSD 06 AB
$10/$250 PER ADMIT COBRA
SV 10-20/100D 07 CB
RIVERSIDE MEDICAL W/OP DDS
RVRSIDE MEDICAL W/EPO DDS
RVRSIDE MEDICAL W/HIOP DDS
$0
$1
$2
$3
$4
$5 GENERIC $10 BRND UNLIM.
$6
$7
$8
$9
RX SO.CAL.MAX
RX SACRAMENTO MAX.
RX NO.CAL.MAX
$1500 ANNUAL MAX
$1400 ANNUAL MAX.
$1200 ANNUAL MAX.
195 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
RXG
RXH
RXI
RXJ
RXK
RXL
RXM
RXN
RXO
RXP
RXR
RXS
RXT
RXU
RXV
RXX
RXY
RXZ
RYA
RYH
RYL
RYW
RYX
RZ1
RZ2
RZC
RZJ
S10
S1A
S1C
S1D
S1E
S1F
S1G
S1J
S1L
S1M
S1P
S1R
S1T
S1U
S1X
S1Y
S1Z
S2B
S2C
S2D
S2E
S2F
S2J
Plan / Benefit Description
$1000 ANNUAL MAX.
$800 ANNUAL MAX.
$5 RX/$1500 ANNUAL MAX.
$5 WALK-IN MANAGED CL RX
$10 WALK-IN MNGD CL RX
S.H. O/P PRESCRIPT DRUGS
S.H. O/P PRESCRIP SAN DIEG
$5G/$10B/$20NF
PRESCRIPTION BENEFIT ONLY
$7/$10 GENERIC/FORMULARY
$5/$5 GENERIC/BRND/FORM.
RETIREE RX $5/$15
SH O/P PRESCRIPT DRUG
$7 GENERIC/UNLIMITED
$10G/$20B GRP RET
SH O/P PRESCRIPT $5/$1500
SH O/P PRESCRIPT $5/$1200
$5 RX CO-PAY/$2500 ANN.MX.
SV 10-20/100D 07 AB
ARP MCC 3 RVSIDE HI SH08
ARP MCC 3 RVSIDE LO SH08
ARP MCC 3 RVSIDE SH08
ARP MCC 3 RVSIDE DLX SH08
RETAIL CLERKS PLAN (COBRA)
RETAIL CLERK DRUG PLAN CBR
REED $10 - COBRA
ROHR PLAN AB
STANDARD 10 PLAN
SANTA CLARA STANDARD PLAN
PBGH 15 PLAN
SAN DIEGO STANDARD - I
SAN BERNARDINO STANDARD
SAN FRANCISCO STANDARD
SAN DIEGO STANDARD-III
SAN JOAQUIN STANDARD PLAN
SAN LUIS OBISPO STANDARD
SACRAMENTO STANDARD PLAN
STANDARD 90%/$15 - POS
SANTA BARBARA STANDARD
SAN MATEO STANDARD PLAN
STANISLAUS STANDARD PLAN
SANTA CRUZ STANDARD PLAN
STANDARD 90%/$15 POS COBRA
PBGH 15 PLAN CBR
BOEING BNA HRLY ERET
STANDARD $15/250 MFP PLAN
KEC S JAQUN CG GR07
KEC S JAQUN CGII GR07
KEC S JAQUN CGEH GR07
SJHS 100/80/50 MFP
196 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
S2M
S2P
S2R
S2S
S2T
S2Y
S2Z
S32
S3A
S3B
S3C
S3D
S3E
S3F
S3G
S3H
S3J
S3M
S3N
S3P
S3Q
S3X
S3Y
S3Z
S42
S48
S4A
S4B
S4C
S4D
S4E
S4F
S4G
S4J
S4L
S4M
S4P
S4X
S4Y
S58
S5A
S5B
S5C
S5D
S5E
S5F
S5G
S5H
S5J
S5K
Plan / Benefit Description
ST MARY MFP 100/80/50
$15 POS PITNEY BOWES
SV 15/200A SKYWEST 07
SV 15/200A SKYWEST 07 CB
SV 15/200A SKYWEST 07 AB
$15 POS PITNEY BOWES COBRA
STANDARD $15/250 MFP CBRA
KEC 1 S BRDO LO CG GR07
SANTA CLARA PLUS PLAN
BOEING BNA HRLY ERET COBRA
SAFEWAY 2000
SAN DIEGO - I PLUS PLAN
SAN BERNARDINO PLUS PLAN
SAN FRANCISCO PLUS PLAN
SAN DIEGO - III PLUS PLAN
KEC S JAQUN EP CG GR07
SJHS 100/80/50 MFP COBRA
SACRAMENTO PLUS PLAN
KEC S JAQUN EP CGII GR07
PITNEY BOWES ENHANCED POS
KEC S JAQUN EP CGEH GR07
SH RETIREE STD 3
PITNEY BOWES ENHAN POS CBR
SAFEWAY 2000 CBRA
KEC 1 S BRDO LO CGII GR07
KEC 1 S BRDO DX CG GR07
SANTA CLARA STD W/OPT DNTL
BSS HOURLY ACTIVES
SV 10/100% 06
SAN DIEGO-I STD W/OPT DDS
S BERNARDINO STD W/OPT DDS
SAN FRANCISCO STD. W/DENTL
S DIEGO III STD W/OPT DDS
ST JOSEPH MFP $5/100%
SV 10/100% 06 CB
SACRAMENTO STD W/OPT DDS
NORDSTROM POS PLAN
SV 10/100% 06 AB
NORDSTROM POS PLAN CBRA
KEC 1 S BRDO DX CGII GR07
SANTA CLARA STD W/HI DENTL
BSS HOURLY ACTIVES COBRA
$15 HMO 2000 SER
SAN DIEGO-I STD. W/HI DENT
SAN BERN STANDARD W/HI DNT
SAN FRANCISCO STD W/HI DEN
STD $5 PLAN GRP RETIREE
MCC SAN MATEO HIGH SH07
SV 15/200A SKYWEST AB
KEC S JAQUN PP CG GR07
197 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
S5L
S5M
S5N
S5P
S5Q
S5R
S5W
S5X
S5Z
S62
S66
S67
S68
S69
S6A
S6B
S6C
S6D
S6E
S6F
S6G
S6H
S6J
S6L
S6M
S6N
S6P
S6Q
S6R
S6Y
S6Z
S7A
S7B
S7C
S7D
S7E
S7F
S7G
S7H
S7J
S7M
S7P
S7Q
S7R
S7S
S7T
S7U
S7W
S7X
S7Y
Plan / Benefit Description
MCC SAN MATEO LOW SH07
KEC S JAQUN PP CGII GR07
MC COMP SAN MATEO SH07
KEC S JAQUN PP CGEH GR07
KEC 1 S DEGO HI CG GR07
KEC 1 S DEGO H-P CG GR07
SH RETIREE STD 5
SH RETIREE STD 5
$15 HMO 2000 SER CBRA
KEC 1 S BRDO LO CGEH GR07
KEC 1 S BRDO CG GR07
KEC 1 S BRDO CGII GR07
KEC 1 S BRDO DX CGEH GR07
KEC 1 S BRDO CGEH GR07
SANTA CLARA PLUS W/OPT DNT
BSS HOURLY ERET
HMO STD $15/100 MFP
SAN DIEGO-I PLUS W/OPT DDS
SAN BERN PLUS W/OPT DDS
SAN FRANCISCO PLUS W/DENTL
S DIEGO III PLUS W/OPT DDS
MCC ESS S MATEO HIGH SH07
ST JOSEPH MFP $5/100% CBRA
MCC ESS S MATEO LOW SH07
SACRAMENTO PLUS W/OPT DDS
MC COMP ESS SAN MATEO SH07
ELGAR 100/80/70
KEC 1 S DEGO HI CGII GR07
KEC 1 S DEGO H-P CGII GR07
ELGAR 100/80/70 COBRA
HMO STD $15/100 MFP COBRA
SANTA CLARA PLUS W/HI DNTL
BSS HOURLY ERET COBRA
COLA 2001 HMO $15/$250
SAN DIEGO-I PLUS W/HI DNTL
SAN BERNARDINO PLS-HI DNTL
SAN FRANCISCO PLUS-HI DNTL
SAN DIEGOIII PLUS W/HI DDS
SH RETIREE STD 7
ST JOSEPH MFP $5/100% AB
ST MARY MFP 100/80/50 CBR
ELGAR 100/80/70
KEC 1 S DEGO HI CGEH GR07
KEC 1 S DEGO H-P CGEH GR07
KEC 1 S BRDO HI CG GR07
KEC 1 S BRDO HI CGII GR07
KEC 1 S BRDO HI CGEH GR07
KEC 1 S DEGO PL CG GR07
SH RETIREE STD 7
ELGAR 100/80/70 - COBRA
198 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
S7Z
S86
S87
S89
S8A
S8C
S8D
S8E
S8G
S8J
S8N
S8P
S8R
S8V
S8W
S8X
S8Y
S8Z
S96
S97
S99
S9E
S9F
S9G
S9J
S9K
S9N
S9P
S9W
S9X
S9Z
SA1
SA2
SA3
SA4
SA5
SA6
SA7
SA8
SA9
SAA
SAB
SAC
SAD
SAE
SAF
SAG
SAH
SAI
SAJ
Plan / Benefit Description
COLA 2001 HMO$15/$250 CBR
MCC S LUIS OBPO PP-PL SH07
MCC S LUIS OBPO EP-PL SH07
MCC S LUIS OBPO PLUS SH07
SV 15-30/100% 06
STD 15 MFP $50ER
SV 15-30/100% 06 CB
MCC S LUIS OBPO EP SH07
STD $10 GRP RETIREE
STD 15 MFP $50ER AB
MC COMP SAN LUIS OBPO SH07
MCC S LUIS OBPO PP SH07
KEC S JAQUN DX CG GR07
KEC S JAQUN DX CGII GR07
KEC 1 S DEGO PL CGII GR07
SV 15-30/100% 06 AB
KEC S JAQUN DX CGEH GR07
STD 15 MFP $50ER COBRA
MCC ESS SL OBPO PP-PL SH07
MCC ESS SL OBPO EP-PL SH07
MCC ESS SL OBPO PLUS SH07
MCC ESS SL OBPO EP SH07
SP 10/100% PBGH 06
STD $15 GRP RETIREE
SV 10/100% ST ANTHONY AB
SP 10/100% PBGH 06 CB
MC COMP ESS SL OBPO SH07
MCC ESS SL OBPO PP SH07
KEC 1 S DEGO PL CGEH GR07
SP 10/100% PBGH 06 AB
AB1401 $15 HMO 2000 SER
SH SACRAM BASIC MED W/ DEN
SH SACRAMENTO STD W/ HI DE
SACRAM PT B BAS MED W/ DEN
SACRAMENTO PT B W/ HI DEN
SH SACRAMENTO PLUS MED
SACRAMENTO PLUS W/ HI DEN
SH SACRAMENTO PART B PLUS
SACRAMENTO PT B PL W/ HI D
SV 10/100% ST ANTHONY CB
DUMMY
SR PLAN PART B ONLY SO CAL
SV $20/100%
SV $20/100%
CB
END SACRAM BASIC W/ NO DEN
SP 10/100A SDSU 06
SR PLAN PART B SO CA GOLD
SV $20/80%
SV 15-30/100% SAIC
SV $20/80%
CB
199 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
SAK
SAL
SAM
SAN
SAP
SAQ
SAR
SAS
SAT
SAU
SAW
SAX
SAY
SAZ
SB3
SB4
SB5
SB6
SB8
SB9
SBA
SBB
SBC
SBD
SBE
SBH
SBJ
SBL
SBM
SBN
SBP
SBS
SBW
SBZ
SC1
SC2
SC3
SC4
SC5
SC6
SC7
SC8
SCA
SCB
SCC
SCD
SCE
SCF
SCG
SCH
Plan / Benefit Description
SP 10/100A SDSU 06 CB
DUMMY
SV $20/100%
AB
SR PLAN PART B SO CA NO DN
SO.CAL.BASIC CHOICE PLAN
SP 15/250A SDSU 08
SV 10/100% ST ANTHONY
SR PLAN PART B SO CA SILVE
KEENAN COMP 1 S BRDO GR07
KEC 1 S BRDO HIGH GR07
KEC 1 S BRDO LOW GR07
SP 10/100A SDSU 06 AB
KEC 1 S BRDO DELUXE GR07
SV 15-30/100% SAIC CB
SH RETIREE STD 3
BAYER CORP $15/$150A
SH RETIREE STD 5
BAYER CORP $15/$150A COBRA
SEC HORIZ. B-ONLY SD&VENT.
SEC HORIZ. B-ONLY PLAN
PART B ONLY-SANTA BARBARA
SH BASIC PLAN-SANTA BARBAR
SV 25/500A SBC COMM
SOUTHERN BASIC DENTAL
SV 20/100% SCL 06
SV 20/100% SCL 06 CB
SR. OPERATIONS $15/$30 AB
SV 20/100% SCL 06 AB
SR PLAN MARIN PART B
KEENAN COMP S BARBARA GR07
SO.CAL.PRT B ONLY-CHOICE
SR PLAN SOLANO/SONOMA PT B
20 SC DRUG NON-AARP GR08
SV 25/500A SBC COMM CB
SH SANTA CLARA STD MED
SANTA CLARA STD W/ HI DEN
SANTA CLARA PART B STD MED
SANTA CLARA PT B W/ HI DEN
SH SANTA CLARA PLUS MED
SANTA CLARA PLUS W/ HI DEN
SANTA CLARA PT B PLUS MED
S CLARA PT B PL W/ HI DEN
SH BSC ALAMEDA PART B ONLY
SH BASIC-SANTA CLARA B ONL
SH-BASIC PLAN-SAN CLARA CO
SO.CALIF.DRUG CUSTOM RX
SO. CAL. EDISON
RETIREE-COUNTY OF FRESNO
SV 10/100 SO CAL GAS
SP 15/250A SCEET 06
200 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
SCJ
SCK
SCL
SCM
SCP
SCQ
SCR
SCS
SCT
SCU
SCV
SCW
SCX
SCY
SCZ
SD1
SD2
SD3
SD4
SD5
SD6
SD7
SD8
SDA
SDB
SDC
SDD
SDE
SDF
SDG
SDH
SDJ
SDK
SDL
SDM
SDN
SDP
SDQ
SDR
SDS
SDU
SDW
SDX
SDY
SDZ
SE1
SE2
SE3
SE4
SE5
Plan / Benefit Description
SV 15-30/100% SAIC AB
SV 20-35/250A SEN OP 06
SH BASIC-SANTA CLARA CO.
20/500A SO CA DRUG GR07
SH RETIREE SO CAL IBEW
$15 IBEW GRP RET
$10G/$15B/$25NF
SV 10/100% SCDS 05
SV 10/100 SO CAL GAS CB
RX RETIREE UFCW SC DRG MF
SV 0/100% S CAL DRUG 06
SV 0/100% S CAL DRUG 06 CB
SV 20-35/250A SEN OP 06 AB
SV 0/100% S CAL DRUG 06 AB
SV 20-35/250A SEN OP 06 CB
SH SAN DIEGO STD MED
SH SAN DIEGO STD W/ HI DEN
SH SAN DIEGO PART B STD ME
SAN DIEGO PT B W/ HI DEN
SH SAN DIEGO PLUS MED
SAN DIEGO PLUS W/ HI DEN
SAN DIEGO PART B PLUS MED
SAN DIEGO PT B PL W/ HI DE
SH PART B ONLY-SAN DIEGO
SAN DIEGO $10/100%
COUNTY OF SAN DIEGO
SV 25/250A SONY ELEC 07
END S DIEGO BASIC W/ NO DE
SV 15/100% 1500D VEBA06
SP 10/100% CTY STAN 07
SP 15/250A SCEET 06 CB
COUNTY OF SAN DIEGO AB
SV 15/100% 1500D VEBA06 CB
SVT 10-25/100% SD 07
SV $10/100% SD CNTY RET
SV $10/100% SD CNTY RET CB
SH-STD S.D. PHAN B ONLY
SV 25/500A S CA DRUG 06
SV 15/100% 1500D VEBA06 AB
SV 10/100% SCDS 05 CB
SP 10/100A SDSU FNDTION
SV 25/500A S CA DRUG 06 CB
SAN DIEGO $10/100% COBRA
SV 25/500A S CA DRUG 06 AB
COUNTY OF SAN DIEGO COBRA
SH SAN BERNARDINO STD MED
S BERNARDINO STD W/ HI DEN
S BERNARDINO PT B STD MED
S BERNARDINO PT B W/ HI DE
SH SAN BERNARDINO PLUS MED
201 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
SE6
SE7
SE8
SE9
SEA
SEB
SEC
SED
SEE
SEF
SEG
SEH
SEJ
SEK
SEL
SEM
SEN
SEO
SEQ
SER
SES
SET
SEU
SEV
SEZ
SF1
SF2
SF3
SF4
SF5
SF6
SF7
SF8
SFA
SFB
SFC
SFD
SFE
SFF
SFG
SFH
SFJ
SFK
SFL
SFM
SFN
SFP
SFQ
SFR
SFT
Plan / Benefit Description
S BERNARDINO PLUS W/ HI DE
SAN BERNARDINO PT B PLUS
S BERNARD B PLUS W/ HI DEN
SV 10/100% SNDIEGO 06 AB
SR PLUS SOLANO/SONOMA PT B
SV 10/100% SNDIEGO 06
SEMPRA ENERGY $10
SV $10/100% SEMPRA
END S BERN BASIC W/ NO DEN
SV 10/100% SNDIEGO 06 CB
SP 10/100% SCCS 07
SP 15/250A SCEET 06 AB
SV 30/500A SEARS AB
SV 15/200A SUREWEST 07
SVT 10-25/100% SD 07 CB
SV $10/100% SEMPRA CB
SV 10/100A CCSF 07
SV 15/30 100% SEN OP
SP 10/100% SN LRNZO 07 CB
SUPP ELIGIBILITY RIDER
SP 10/100% SCCS 07 CB
SV 10/100A SJHS 07
SP 10/100% SCCS 07 AB
S. DIEGO ENHANCED VALUE
SEMPRA ENGERY $10 - COBRA
SH SAN FRANCISCO STD MED
SAN FRANCISCO STD W/ HI DE
SAN FRANCISCO PT B STD MED
SAN FRAN PT B W/ HI DEN
SH SAN FRANCISCO PLUS MED
SAN FRAN PLUS W/ HI DEN
SAN FRANCISCO PART B PLUS
SAN FRAN PT B PL W/ HI DEN
SH SAN FRAN PART B ONLY
SV 5/100% SJHS 07
SPLIT FAMILY COVERAGE
$10/$30/$60 SF
END S FRAN BASIC W/ NO DEN
SV 15/100% SEES 06
SV 15/100% SEES 06 CB
SV 15/100% SEES 06 AB
SV $15/100% AB
SV 10/100% SCBAKERY 06
SVT 10-25/100% SD 07 AB
SV $15/100%
SV 10/100A CCSF 07 CB
SV $15/100% CB
SV 15/100% 06
SV 15/100% 06 CB
SV 10/100A SJHS 07 CB
202 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
SFX
SG1
SG2
SG3
SG4
SG5
SG6
SG7
SG8
SGA
SGB
SGD
SGE
SGF
SGG
SGH
SGJ
SGK
SGM
SGN
SGP
SGQ
SGR
SGS
SGT
SGU
SGV
SGX
SH1
SH2
SH3
SH4
SH5
SH6
SH7
SHA
SHB
SHC
SHD
SHE
SHG
SHH
SHJ
SHL
SHM
SHO
SHP
SHQ
SHU
SHV
Plan / Benefit Description
SPLIT FAMILIY ENROLLMENT
SH SANTA BARBARA STD MED
SANTA BARBARA STD W/ HI DE
SANTA BARBARA PART B STD M
RESERVED
SAN DIEGO-III STD W/HI DDS
SANTA BARB PLUS W/ HI DEN
SANTA BARB PT B PLUS MED
SANTA BARB PT B PL W/ HI D
SR PLAN NCA SAC/EL DO PT B
SV 5/100% SJHS 07 CB
SV 15/100% SCEET 06
SV 0/100% SEIU 07
SV 15/100% SCEET 06 CB
SV 15/100% SCEET 06 AB
SV 10/100% SCFCHW 06
SV 10/100 SO CAL GAS AB
SV 15/200A SUREWEST 07 CB
GM $15 GRP RET SLRY
SV 10/100A CCSF 07 AB
SP10/200A SCSVEBA 06
SP 10/100% SN LRNZO 07 AB
SV 0/100% SEIU 07 CB
SP10/200A SCSVEBA 06 CB
SV 10/100A SJHS 07 AB
SV 0/100% SEIU 07 AB
SP10/200A SCSVEBA 06 AB
SH RETIREE STD 15
RETIREE $1 OV
SH RETIREE STNDRD 2
SH STD 3
SH STD 4
SH STD 5
NO.CALIF.STANDARD 6 PLAN
$7 CLOSED RX-RETIREE
SV 20-40/500A+10% SBC06
HI-OP CHOICE PRT B ONLY SO
SECURE HORIZONS B ONLY HI
SECURE HORIZ. B ONLY PLAN
SV 20-40/500A+10% SBC06 CB
SH RETIREE STD 15
SECURE HORIZONS B ONLY PL
UBS FINANCIAL SERV $20 AB
SECURE HORIZONS PLAN
RETIREE $10 OV
SH PREFERRED $0 ER
SH PREFERRED
SP 15/100A SCEET 07
UFCW
RETIREE $5 OV
203 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
SHX
SI3
SIJ
SJ1
SJ2
SJ3
SJ4
SJ5
SJ6
SJ7
SJ8
SJ9
SJA
SJB
SJC
SJD
SJF
SJH
SJJ
SJK
SJL
SJM
SJO
SJP
SJQ
SJR
SJS
SJT
SJU
SJV
SJW
SJX
SJY
SJZ
SK1
SK2
SK3
SK4
SK5
SK6
SK7
SK8
SKA
SKB
SKD
SKE
SKF
SKG
SKH
SKJ
Plan / Benefit Description
SV 20-40/500A+10% SBC06 AB
SH SAN DIEGO MEDI-MEDI PLN
SONY ELCTRNICS 20/100A AB
SH SAN JOAQUIN STD MED
SAN JOAQUIN STD W/ HI DEN
SAN JOAQUIN PART B STD MED
SAN JOAQUIN PT B W/ HI DEN
SH SAN JOAQUIN PLUS MED
SAN JOAQUIN PLUS W/ HI DEN
SH SAN JOAQUIN PART B PLUS
SAN JOAQUIN B PL W/ HI DEN
SV 10 SJHS MFP 06 AB
SAN JOAQUIN BASIC PLAN
SAN JOAQUIN-PART B ONLY
SV 20-30/250A SR OPS 06
SP 10/100% NTRDAME 06
SP 10/100% NTRDAME 06 CB
SP 15 SJHS MFP 06
SV $20/80%
AB
SP 10/100% NTRDAME 06 AB
SVA 10/100% SCSVEBA 06
ENTERED IN ERROR-SEE OR-43
KEC S JAQUN DELUXE GR07
SV 10 SJHS MFP 06
SP 15/100A SCEET 07 CB
SVA 10/100% SCSVEBA 06 CB
KEENAN COMP S JAQUN GR07
SVA 10/100% SCSVEBA 06 AB
KEC S JAQUN EP GR07
SV 5/100% SCRUZMF 07
KEC S JAQUN PP GR07
SP 15 SJHS MFP 06 AB
SV 10 SJHS MFP 06 CB
SP 15 SJHS MFP 06 CB
SH SANTA CRUZ STD MED
SANTA CRUZ STD W/ HI DEN
SANTA CRUZ PART B STD MED
SANTA CRUZ PT B W/ HI DEN
SH SANTA CRUZ PLUS MED
SANTA CRUZ PLUS W/ HI DEN
SANTA CRUZ PART B PLUS MED
SANTA CRUZ PT B PL W/ HI D
SH PART B ONLY - KERN CO.
SV 15/200A SKYWEST 06
SP 10/100% SCEET 06
SH BASIC PLAN - KERN CO.
SP 10/100% SCEET 06 CB
SP 10/100% SCEET 06 AB
SV 10/100% SCBAKERY 06 CB
SV $10/100% SEMPRA AB
204 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
SKK
SKP
SKQ
SKR
SKV
SKX
SKZ
SL1
SL2
SL3
SL4
SL5
SL6
SL7
SL8
SLA
SLB
SLC
SLD
SLE
SLF
SLG
SLH
SLJ
SLK
SLL
SLM
SLN
SLP
SLS
SLU
SLV
SLX
SM1
SM2
SM3
SM4
SM5
SM6
SM7
SM8
SM9
SMA
SMB
SMC
SMD
SMJ
SMM
SMP
SMS
Plan / Benefit Description
SV 10/100% SCBAKERY 06 AB
SP 10/100% SGVMC 07
SP 15/100A SCEET 07 AB
KEENAN COMP SAN FRAN GR07
SV 5/100% SCRUZMF 07 CB
SV 15/200A SKYWEST 06 AB
SV 15/200A SKYWEST 06 CB
SH SAN LUIS OBISPO STD MED
SH SLO STD MED W/ HI DEN
SH SLO PART B STD MED
SH SLO PT B STD W/ HI DEN
SH SAN LUIS OBISPO PLUS ME
SH SLO PLUS MED W/ HI DEN
SH SLO PART B PLUS MED
SLO PART B PLUS W/ HI DEN
SH STANDARD-RX COUNTIES
SH STD-RX CO. PHAN B ONLY
SAN LUIS OBISPO CLASSIC I
SV 25/250A SONY ELEC 07 CB
S.L. OBSPO CLSC I W/EPODDS
RX SLF SOLUTIONS
SP 10/100% CTY STAN 07 CB
SP 10/100% SN LRNZO 07
SV 10-25/250A SARES AB
SV 25/250A SONY ELEC 06
SV 25/250A SONY ELEC 06 CB
SH RETIREE LOCKHEED MARTIN
KEENAN COMP SL OBSPO GR07
SH STD - RX COUNTIES PHAN
SH BSC PLAN STANISLAUS
S.L. OBSPO CLSC I W/ODPDDS
SV 5/100% SCRUZMF 07 AB
SV 25/250A SONY ELEC 06 AB
SH SAN MATEO STD MED
SH SAN MATEO STD W/ HI DEN
SAN MATEO PART B STD MED
SAN MATEO PT B W/ HI DEN
SH SAN MATEO PLUS MED
SAN MATEO PLUS W/ HI DEN
SAN MATEO PART B PLUS MED
SAN MATEO PT B PL W/ HI DE
NON-STD BASIC 10 PLAN AB
SAN MATEO-BASIC PLAN
SAN MATEO-PART B ONLY
SR PLAN MARIN
SV 20/250A SPHERION 05
ST MARY MFP 100/80/50 AB
SR PLUS MARIN PART B
NON-STD BASIC 10 PLAN
SV 20/250A SPHERION 05 CB
205 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
SMX
SMZ
SN1
SN2
SN3
SN4
SN5
SN6
SN7
SN8
SNA
SNB
SNC
SND
SNE
SNG
SNJ
SNK
SNL
SNP
SNX
SNY
SO1
SO2
SO3
SO4
SO5
SO6
SO7
SO8
SOA
SOB
SOI
SOJ
SOQ
SOU
SOV
SOW
SOY
SOZ
SP1
SP2
SP3
SP4
SP5
SP6
SP7
SP8
SPA
SPB
Plan / Benefit Description
SV 20/250A SPHERION 05 AB
NON-STD BSC 10 PLAN COBRA
SH SONOMA STD MED
SH SONOMA STD MED W/ HI DE
SH SONOMA PART B STD MED
SONOMA PT B STD W/ HI DEN
SH SONOMA PLUS MED
SH SONOMA PLUS W/ HI DEN
SH SONOMA PART B PLUS MED
SONOMA PT B PLUS W/ HI DEN
SR PLAN NO CAL -PART B
SR PLAN -NO CAL
SH STANDARD $10
100/80/60 PLAN
SV 20/100A SONY
SR PLAN NO CAL SACRA/EL DO
SV 20/100A SONY AB
SV 15/200A SUREWEST 07 AB
KEENAN COMP SONOMA GR07
SH RETIREE PREFERRED
SH RETIREE STD 10
100/80/60 PLAN COBRA
SH SOLANO STD MED
SOLANO STD MED W/ HI DEN
SH SOLANO PART B STD MED
SOLANO PT B STD W/ HI DEN
SH SOLANO PLUS MED
SOLANO PLUS MED W/ HI DEN
SH SOLANO PART B PLUS MED
SOLANO PT B PLUS W/ HI DEN
SH BASIC PLAN SONOMA CO
SH BASIC SONOMA CO B ONLY
ARP MCC SLO EP-PL SH08
SV 15/30 100% SEN OP AB
ARP MCC SLO PP-PL SH08
ARP MCC SLO PP SH08
ARP MCC SLO PLUS SH08
ARP MCC SLO SH08
ARP MCC SLO EP SH08
SV 15/30 100% SEN OP CB
SUPPLEMENTAL LIFE BENE
CALPERS CUSTOM PLAN
SH RETIREE STD 3
HEWLETT PACKARD $15/$300
SH RETIREE STD 5
HEWLETT PACKARD 15/300 CBR
UBS FINANCIAL SERV $20
UBS FINANCIAL SERV $20 COB
SO.CAL.POS-BASIC PLAN
SENIOR PLAN - SO CAL
206 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
SPC
SPE
SPF
SPG
SPH
SPJ
SPK
SPL
SPM
SPN
SPO
SPP
SPQ
SPR
SPS
SPX
SPZ
SQA
SQB
SQC
SQD
SQE
SQF
SQG
SQH
SQJ
SQK
SQL
SQM
SQN
SQP
SQT
SQU
SQW
SQX
SQY
SQZ
SR1
SR2
SR3
SR4
SR5
SR6
SR7
SR8
SR9
SRA
SRB
SRC
SRD
Plan / Benefit Description
PBGH $15/100% NON STD PLAN
PERS CUSTOM PLAN
SP 15/200A SCSVEBA 06
SR PLAN SO CAL W/GOLD DENT
SV 10/100% SCFCHW 06 CB
HEWLETT PACKARD 15/300 AB
SP 15/200A SCSVEBA 06 CB
SP 20/100% CTY STAN 08
SR PLUS MARIN
SR PLAN SO CAL NO DENTAL
SECURE PREMIUM OFFSET
SR PLUS SO CAL GOLD DENTAL
SP 15/200A SCSVEBA 06 AB
SR PREMIER
SR PLAN SO CAL W/SILVER DE
SR PLUS SO CAL PART B ONLY
PBGH $15/100% NON STD CBRA
SP 10/200A SCSVEBA 06
SPA 10/200A SCSVEBA 06
PBGH $15/100% NON STD
SP 10/100% SCEET 06
END S CLARA BASIC W/ NO DE
SP 10/100% SCEET 06 CB
SP 10/100% SCEET 06 AB
SP 10/200A SCSVEBA 06 CB
SP 10/100% SND 05 AB
SPA 10/200A SCSVEBA 06 CB
SP 10/200A SCSVEBA 06 AB
SPA 10/200A SCSVEBA 06 AB
SV 20-35/100A STAN UV 08
SP 10/100% SGVMC 07 CB
KEC 1 S DEGO HI GR07
ARP MCC S FRAN PP SH08
ARP MCC S FRAN SH08
SV 15/100% 06 AB
ARP MCC S FRAN EP SH08
PBGH $15/100% NON STD COBR
SEC HORIZ-RETIREE GROUP
SEC HORIZ-RETIREE SD/VENT.
SECURE HORIZ. TELEDYNE PLN
SEARS ROEBUCK 30/500
SEARS ROEBUCK 30/500 COBRA
SR. OPERATIONS $15/$30
SR. OPERATIONS $15/$30 CBR
RETA TRUST $15/$250A
RETA TRUST $15/$250A COBRA
SR PREMIER PART B
SR PLUS NO CA PART B
SV 10/100% SEMPRA 06
SV 30/500A SEARS 06
207 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
SRE
SRF
SRG
SRJ
SRK
SRL
SRM
SRN
SRO
SRP
SRQ
SRR
SRS
SRT
SRV
SRX
SRY
SRZ
SS2
SS3
SS4
SS5
SS7
SS8
SS9
SSA
SSB
SSC
SSD
SSF
SSG
SSH
SSJ
SSK
SSL
SSN
SSP
SSQ
SSR
SSS
SSV
SSX
ST0
ST1
ST8
ST9
STA
STB
STC
STD
Plan / Benefit Description
SV 30/500A SEARS
SV 30/500A SEARS CB
SVT 10-25/100% NONSD 07
RETA TRUST $15/$250A AB
SV 10-25/250A SARES
SV 10-25/250A SARES CB
SV 20-35/250A SEN OP 08
SV 20-35/100A STAN UV 08CB
POS SUPPLEMENTAL BENEFIT
SR PLUS NO CA
SP 15/250A SDSU 08 CB
SV 20-40/250A SARES 06
SR PLUS SOLANO/SONOMA
KEC 1 S DEGO HI-PL GR07
SV 30/500A SEARS 06 AB
SV 10/100% SEMPRA 06 AB
SV 30/500A SEARS 06 CB
SV 10/100% SEMPRA 06 CB
SONY ELCTRNICS 20/100A
SH RETIREE STD 3
SONY ELCTRNICS 20/100A CBR
SH RETIREE STD 5
SH RETIREE STD 7
SECURE HORZ. SD/VENTURA
SECURE HORIZONS-STANDARD
SH PART B ONLY-RX COUNTIES
SECURE HORIZONS B-ONLY
SEC HORIZ. B-ONLY SD&VENT.
SH BASIC PLAN-SAN DIEGO
SH BASIC PLAN- SAN FRAN CO
SH RETIREE STD 15
SV 10/100% SCFCHW 06 AB
SV $10/100% SD CNTY RET AB
SH SILVER SNEAKERS
SECURE HORIZONS-STANDARD
SV 20-35/100A STAN UV 08AB
SH-STD SAN DIEGO PHAN
SP 10/100% SND 05
SLV SNEAK/FITNESS BEN GR06
SR PLAN SOLANO/SONOMA
SECURE HORIZ. SD/VENTURA
SH RETIREE STD 10
STANDARD PLAN INACTIVE
STANDARD PLAN
SV 15/250A RETA 05
SV 15/250A RETA 05 CB
SH BASIC STANISLAUS
SH PART B ONLY STANISLAUS
SUTTER HEALTH $15 HMO
RESERVED FOR PPO LIFE
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Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
STE
STG
STJ
STN
STP
STQ
STR
STS
STT
STU
STV
STX
STZ
SU1
SU2
SU3
SU4
SU5
SU6
SU7
SU8
SUA
SUB
SUC
SUD
SUE
SUF
SUG
SUH
SUJ
SUK
SUL
SUM
SUN
SUP
SUQ
SUR
SUX
SUY
SUZ
SV
SV2
SV3
SV4
SV5
SV6
SV7
SVA
SVB
SVC
Plan / Benefit Description
KEENAN COMP STANSLAUS GR07
SP 10/100% CTY STAN 07 AB
SV 15/250A RETA 05 AB
SVA 15/500A SMW 07
SH RETIREE PREFERRED
SP 10/100% SND 05 CB
SP 15/200A SJHS 07
SVA 15/500A SMW 07 CB
SP 15/200A SJHS 07 CB
SVA 15/500A SMW 07 AB
SP 15/200A SJHS 07 AB
SH RETIREE STD 10
SUTTER HEALTH $15 HMO CBRA
SH STANISLAUS STD MED
STANISLAUS STD W/ HI DEN
STANISLAUS PART B STD MED
STANISLAUS PT B W/ HI DEN
SH STANISLAUS PLUS MED
STANISLAUS PLUS W/ HI DEN
STANISLAUS PART B PLUS MED
STANISLAUS PT B PL W/ HI D
SP 15/100% SCEET 06
INDIV. STANIS B ONLY
UC GRP RET 2002 CST HMO
SP 10/100A SDSU 07
SP 10/100A SDSU 07 CB
SP 15/100% SCEET 06 CB
SP 10/100A SDSU 07 AB
SP 15/100% SCEET 06 AB
SP 10/100A SDSU FNDTION AB
SV 25/250A SEES 07
SP 20/100% CTY STAN 08 CB
SV 20-35/250A SEN OP 08 CB
SV 10/100% SGVMC 07
SV 10/100% SEMPRA 06
SP 15/250A SDSU 08 AB
SV 20-40/250A SARES 06 CB
SV 10/100% SEMPRA 06 AB
SP 10/100A SDSU FNDTION CB
SV 10/100% SEMPRA 06 CB
SV 20-30/250D PETCO 07
KEC 1 S DEGO LO CG GR07
SH STD 3 SAN DIEGO
SH STD 4 SAN DIEGO
SH STD 5 - SAN DIEGO
KEC 1 S DEGO LO CGII GR07
KEC 1 S DEGO LO CGEH GR07
SH PART B ONLY-VENTURA
SV 20-40/250A SARES 05
SP 15/200A SCSVEBA 06
209 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
SVD
SVE
SVF
SVG
SVH
SVJ
SVK
SVL
SVM
SVN
SVP
SVQ
SVR
SVS
SVT
SVU
SVX
SVZ
SW2
SW3
SW4
SW5
SW7
SWA
SWB
SWC
SWD
SWE
SWF
SWG
SWH
SWJ
SWL
SWM
SWN
SWP
SWQ
SWT
SWX
SX2
SX6
SX9
SXA
SXB
SXC
SXD
SXE
SXF
SXG
SXH
Plan / Benefit Description
SVA 5/100% SCSVEBA 06
SH BASIC PLAN-VENTURA
SP 15/200A SCSVEBA 06 CB
SVA 5/100% SCSVEBA 06 CB
SPA 15/200A SCSVEBA 06
SV 10/100% SCDS 05 AB
SP 15/200A SCSVEBA 06 AB
SVA 5/100% SCSVEBA 06 AB
SVA 20/250A SCSVEBA 06
SV 10/100% SGVMC 07 CB
SH PREFERRED SAN DIEGO
SPA 15/200A SCSVEBA 06 CB
SVA 20/250A SCSVEBA 06 CB
SPA 15/200A SCSVEBA 06 AB
KEC 1 S DEGO LO GR07
SVA 20/250A SCSVEBA 06 AB
SV 20-40/250A SARES 05 AB
SV 20-40/250A SARES 05 CB
WILLIAMS-SONOMA 20/100A
WILLIAMS-SONOMA 20/100A CB
SV 20/400A SMW 06
SV 20/400A SMW 06 CB
SV 20/400A SMW 06 AB
SKYWEST AIR $15/$200A
SV 15/200A SKYWEST
SV 15/100% ST MARYS 06
S DGO ENHNCD VALU W/OP DDS
S DGO ENHNCD VALU W/EPODDS
SV 15/100% ST MARYS 06 CB
SVT 10-25/100% NONSD 07 CB
S DGO ENHNCD VALU W/HI DDS
WILLIAMS-SONOMA 20/100A AB
SP 20/100% CTY STAN 08 AB
SV 20-35/250A SEN OP 08 AB
SV 10/100% SGVMC 07 AB
SH RETIREE LADWP CUSTOM
SV 20/200A+10% SRWST 08
KEC 1 S DEGO PLUS GR07
SV 15/100% ST MARYS 06 AB
KEC 1 S DEGO CG GR07
KEC 1 S DEGO CGII GR07
KEC 1 S DEGO CGEH GR07
SV 5/100% SCEET 06
SV 20-35/250A SEN OP 07
SV 20-35/250A SEN OP 07 CB
SV 20-35/250A SEN OP 07 AB
SV 20-40/250A SARES 06 AB
SV 5/100% SCEET 06 CB
STD $10 PLAN GRP RETIREE
SV 5/100% SCEET 06 AB
210 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
SXJ
SXK
SXL
SXM
SXQ
SXT
SXV
SY2
SY6
SY9
SYA
SYB
SYC
SYD
SYE
SYF
SYG
SYH
SYJ
SYK
SYL
SYM
SYP
SYQ
SYT
SYU
SYW
SYX
SYY
SYZ
SZ0
SZ1
SZ2
SZ3
SZ8
SZA
SZB
SZC
SZD
SZE
SZF
SZG
SZH
SZJ
SZK
SZL
SZM
SZP
SZQ
SZT
Plan / Benefit Description
SAN DIEGO $10/100% AB
SV 25/250A SEES 07 CB
SP 10/100% SCRUZ MF 07
SV 15/500A SMW 07
SV 20/200A+10% SRWST 08 CB
KEENAN COMP 1 S DEGO GR07
STD $15 PLAN GRP RETIREE
KEC 1 S DEGO L-P CG GR07
KEC 1 S DEGO L-P CGII GR07
KEC 1 S DEGO L-P CGEH GR07
SP 10/100% SCEET 06
SV 5/100% SJHS 07 AB
NEW YORK COALITION PLAN 2A
SV 25/250A SONY ELEC 07 AB
SV 20/100A SONY CB
SP 10/100% SCEET 06 CB
SVT 10-25/100% NONSD 07 AB
SP 10/100% SCEET 06 AB
SJHS 100/80/50 MFP AB
SV 25/250A SEES 07 AB
SP 10/100% SCRUZ MF 07 CB
SV 15/500A SMW 07 CB
SP 10/100% SGVMC 07 AB
SV 20/200A+10% SRWST 08 AB
KEC 1 S DEGO LO-PL GR07
ARP MCC S JOAQUN PP SH08
ARP MCC S JOAQUN SH08
ARP MCC S JOAQUN DLX SH08
ARP MCC S JOAQUN EP SH08
N.Y. COALITION (2A) COBRA
STANDARD 10 PLAN COBRA
STANDARD PLAN (COBRA)
CALPERS CUSTOM PLAN COBRA
SH RETIREE STD 3 COBRA
STD $10 GRP RETIREE CBRA
SV 10/100% SCEET 06
SV 15/200A SKYWEST CB
SV 10/100% C SN DGO 06
SV 10/100% C SN DGO 06 CB
SP 10/100A SCSVEBA 06
SV 10/100% SCEET 06 CB
SV 10/100% C SN DGO 06 AB
SV 10/100% SCEET 06 AB
SV 25/500A SBC COMM AB
SP 10/100A SCSVEBA 06
SP 10/100% SCRUZ MF 07 AB
SV 15/500A SMW 07 AB
PERS RETIREE CUSTOM COBRA
SP 10/100A SCSVEBA 06 CB
SP 10/100A SCSVEBA 06 AB
211 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
SZW
SZX
SZZ
T1C
T1I
T1P
T1R
T1S
T1T
T1U
T1V
T1W
T1X
T1Y
T1Z
T2I
T2M
T3I
T3J
T3M
T4I
T5I
T6I
TA2
TA3
TA6
TAA
TAB
TAC
TAD
TAE
TAJ
TAK
TAW
TAZ
TBA
TBB
TBD
TBE
TBJ
TBL
TBN
TBP
TBZ
TC2
TCA
TCB
TCC
TCI
TCJ
Plan / Benefit Description
SKYWEST AIR $15/$200A CBRA
SP 10/100A SCSVEBA 06 AB
SP 10/100A SCSVEBA 06 CB
DUMMY PLAN-NOT IN USE
INDIVIDUAL HMO 10 PLAN
STANDARD 10/250
ELITE 100
CAL COBRA
ELITE 100
ELITE 100 FED CBR EXTENDED
ELITE 100 FED CBR DISABLED
ELITE 100 CAL CBR EXTENDED
ELITE 100
COBRA
ELITE 100 CAL CBR DISABLED
STANDARD 10/250
DUMMY PLAN-NOT IN USE
G/I INDIVIDUAL HMO 10 PLAN
SV TRI-CITY $10/100% CB
INDIVIDUAL HMO 10 PLAN
SV TRI-CITY $10/100% AB
SP 10/100% TRICITY MED CB
G/I INDIVIDUAL HMO 10 PLAN
INDIVIDUAL PLAN 10
INDIVIDUAL PLAN 10 HIPAA
SV 15/100% 05 AB
SV 5/100% 05 AB
$0/24 TRPS/YR NON-ERTRNS06
SP 10/100% TRI-CITY 06
SV 20-40/250D NCTILE 07
SV 15/100% 05
SV 15/100% 05 CB
SV 20-35/90% TENET 07
SP 10/100% TRI-CITY 06 AB
SV 5/100% 05
SV 5/100% 05 CB
SP 10/100% TRI-CITY 06 CB
SV 20-30/250A TRBUN 06
SV 20-40/250D NCTILE 07 CB
MCC SACMETO DELUXE SH07
SVA 20-40/400A TMT 07
SV 20-30/250A TRBUN 06 AB
MCC SACMETO LOW SH07
MC COMP SACMENTO SH07
MCC SACMETO PP SH07
SV 20-30/250A TRBUN 06 CB
SV 10/100% 05 AB
SV 5/100% TCUMTA 06
SV 10/100% 05
SV 10/100% 05 CB
IND HMO 10 PLAN (COP)
SP 10/100% TRICITY MED AB
212 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
TCK
TCL
TCM
TCP
TCS
TCU
TCX
TCZ
TD2
TDA
TDC
TDD
TDJ
TDZ
TEA
TEB
TEC
TEE
TEK
TEL
TEP
TEY
TFA
TFE
TFF
TFG
TGK
TH2
THA
THB
THR
THS
THW
TJA
TJC
TJF
TJJ
TJK
TJL
TJM
TJQ
TJZ
TK2
TKA
TKB
TKF
TL3
TL5
TLA
TM3
Plan / Benefit Description
SV TRI-CITY $10/100%
SV 5/100% TEAMSTERS 06
SP 10/100% TRICITY MED
SV 5/100% TCUMTA 06 CB
ADMIN-TOTAL COBRA SERVICES
UC 2002 CUSTOM HMO
SV 5/100% TCUMTA 06 AB
UC 2002 CUSTOM HMO COBRA
SV 0/100% 05 AB
SV 10/100% TOYOTA 06
SV 0/100% 05
SV 0/100% 05 CB
SV 10/100% TOYOTA 06 AB
SV 10/100% TOYOTA 06 CB
TELEPHONIC EAP-PILOT NO CA
SV 20-40/250D NCTILE 07 AB
KEENAN COMP SACMETO GR07
SV 20-35/90% TENET 07 CB
SV 0/100% TEAMSTERS 06
SV 5/100% TEAMSTERS 06 CB
10/100 TAKECARE DISABLED
10/100 TAKECARE DISABLE CB
SV 15/100% TOYOTA 08
SV 0/100% TEAMSTERS 06
SV 0/100% TEAMSTERS 06 CB
SV 0/100% TEAMSTERS 06 AB
SV 0/100% TEAMSTERS 06 CB
SV 10/100% TMT 05 AB
SV 10/100% TMT 05
SV 10/100% TMT 05 CB
PAC ADVAN PLUS PLAN CCOBRA
PAC ADVAN PLUS PLAN
PAC ADVAN PLUS PLAN COBRA
SV 15/100% TEAMSTERS 06
SV 15/100% HRT 06
SV 10/90% TENET 08
SV 15/100% HRT 06 AB
SV 0/100% TEAMSTERS 06 AB
SV 5/100% TEAMSTERS 06 AB
SV 10/90% TENET 08 CB
SV 10/90% TENET 08 AB
SV 15/100% HRT 06 CB
SV 15/100% TMT 05 AB
SV 15/100% TMT 05
SV 15/100% TMT 05 CB
SV 5/100% TRANS CU 07
SV 25/250A FRFLD 06 CB
SV 25/250A FRFLD 06 AB
SV 25/250A FRFLD 06
SP 10/100% FRFLD 06 CB
213 of 640
Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
TM5
TMA
TMC
TME
TMF
TMG
TMJ
TMS
TMT
TMZ
TNA
TNB
TNE
TNF
TO2
TO4
TO5
TO7
TOY
TP1
TP2
TP7
TP8
TPA
TPH
TPJ
TPL
TPR
TPT
TQA
TQC
TQD
TQE
TQF
TQL
TQZ
TRA
TRB
TRC
TRE
TRI
TRJ
TRZ
TS2
TSA
TSB
TSC
TSM
TSZ
TTA
Plan / Benefit Description
SP 10/100% FRFLD 06 AB
SP 10/100% FRFLD 06
10/250 MFP PLAN
SV 5/100% TBTRUST 06
SV 5/100% TBTRUST 06 CB
SV 5/100% TBTRUST 06 AB
SV 10/100% TOYOTA MS AB
SV 10/100% TOYOTA MS
SVA 15/100% TEAMSTRS
10/250 MFP PLAN COBRA
SVA 15/100% TEAMSTRS 07
SV 15/100% TRI CITY 08
SV 20-35/90% TENET 07 AB
SV 5/100% TRANS CU 07 CB
SACRAMENTO II STD PLAN
SACRAMENTO II PLUS PLAN
SACRAMENTO II STD W/OP DDS
SACTO II PLS PLN W/OP DDS
SV 10/100% TOYOTA MS CB
SH PLUS MED TRANSPORTATION
TOWERS PERRIN $15 PLAN
SH CA NON-ER TRANSPRTATION
16R/32ONE WAY NON-ER TRANS
SV 20/100% TEAMSTERS 06
5-10/100% GR06
15-20/100A AARP GR08
15-20/100A GR06
PREMIUM REVERSAL
15-20/100A NON-AARP GR08
SVA 15/100% TEAMSTRS 07 CB
CUSTOM HMO $10/$250
SV 0/100% TM TRUST 06
SVA 20-40/400A TMT 07 CB
SV 0/100% TM TRUST 06 CB
SV 0/100% TM TRUST 06 AB
CUSTOM HMO $10/$250 COBRA
SVA 15/100% TEAMSTRS 07 AB
SV 20-30/250A TRIBUNE
SV 20-30/250A TRIBUNE CB
SVA 20-40/400A TMT 07 AB
$15 100% TRIBUNE GR
SV 20-30/250A TRIBUNE AB
$15 100% TRIBUNE GR CB
SV 20-40/400A TMT 05 AB
SV 20-40/400A TMT 05
SV 20-40/400A TMT 05 CB
STANDARD 10/250 MFP
SACRAMENTO CLASSIC I
STANDARD 10-250 MFP COBRA
SV 10/100% TRI CITY 06
214 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
TTB
TTC
TTE
TTG
TTJ
TTZ
TU1
TU2
TU3
TU4
TU5
TU6
TU7
TU8
TUA
TUB
TUC
TUE
TUG
TUH
TUK
TUL
TUM
TUP
TUY
TUZ
TVA
TVC
TVE
TVF
TVG
TVH
TWA
TWC
TWD
TWE
TWF
TWH
TWJ
TWK
TWT
TWZ
TXA
TXC
TXJ
TYA
TYC
TYD
TYE
TZA
Plan / Benefit Description
SV 15/100% TRI CITY 08 CB
SP 10/100% TRI-CITY 07
SP 10/100% TRI-CITY 07 CB
SP 10/100% TRI-CITY 07 AB
SV 10/100% TRI CITY 06 AB
SV 10/100% TRI CITY 06 CB
SH TULARE STD MED
SH TULARE STD MED W/ HI DE
SH TULARE PART B STD MED
SH TULARE PART B W/ HI DEN
SH TULARE PLUS MED
TULARE PLUS MED W/ HI DEN
SH TULARE PART B PLUS MED
TULARE PT B PLUS W/ HI DEN
SV 25/90% TEAMSTERS 07
SV 15/100% TRI CITY 08 AB
STANDARD 10/250 PLAN
SV 10/100% TBTRUST 06
SV 10/100% TBTRUST 06 CB
SV 10/100% TBTRUST 06 AB
SV 30-45/80% TENET 08
SV 30-45/80% TENET 08 CB
SV 30-45/80% TENET 08 AB
10/250 PLAN (UNISYS)
10/250 PLAN COBRA (UNISYS)
STANDARD 10/250 PLAN COBRA
SV 25/90% TEAMSTERS 07 CB
INDIVIDUAL CONVERSION-FHP
SV 15/100% TBTRUST 06
SV 5/100% TRANS CU 07 AB
SV 15/100% TBTRUST 06 CB
SV 15/100% TBTRUST 06 AB
SV 25/90% TEAMSTERS 07 AB
10/250/50 FHP GUEST PLAN
SACRAMENTO CLSC I W/OP DDS
SACRAMENTO CLSC I W/EPODDS
SP 15/100% TRI CITY 08
SP 15/100% TRI CITY 08 CB
SVA 15/100% TEAMSTRS AB
SP 15/100% TRI CITY 08 AB
SVA 15/100% TEAMSTRS CB
10/250/50 FHP GUEST PLAN
SV 25/500A THMX 06
SV 25/500A THMX 06 CB
SV 25/500A THMX 06 AB
SV 15/100% TOYOTA 08 CB
SV 10/100% TENET 07
SV 10/100% TENET 07 CB
SV 10/100% TENET 07 AB
SV 15/100% TOYOTA 08 AB
215 of 640
Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
TZL
TZU
TZW
TZX
U01
U02
U03
U04
U05
U06
U07
U08
U09
U10
U11
U12
U13
U14
U15
U16
U17
U18
U19
U1R
U1S
U1W
U20
U21
U22
U23
U24
U25
U26
U27
U28
U29
U30
U31
U32
U33
U34
U35
U36
U37
U38
U39
U3J
U40
U41
U42
Plan / Benefit Description
ARP MCC SACMTO LO SH08
ARP MCC SACMTO PP SH08
ARP MCC SACMTO SH08
ARP MCC SACMTO DLX SH08
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSOTMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMAY PPO
BASIC PLAN CAL COBRA
BASIC PLAN
BASIC PLAN
COBRA
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
UFCW $25/$100 AB
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
216 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
U43
U44
U45
U46
U47
U48
U49
U50
U51
U52
U53
U54
U55
U56
U57
U58
U59
U5J
U60
UA2
UA3
UA4
UA5
UA7
UAA
UAJ
UAK
UAZ
UBA
UBB
UBC
UBD
UBJ
UBS
UC2
UC3
UCA
UCB
UCD
UCF
UCJ
UCK
UCM
UCN
UCP
UCW
UCX
UCY
UCZ
UDA
Plan / Benefit Description
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
UFCW $25/$250 AB
USUAL & CUSTOMARY PPO
SV $25/$500A
SV $25/$500A CB
SV $25/70%
SV $25/70%
CB
10/100A UNITED AL GR-07
SV 25/100% GGUSD 05
SV $25/70%
AB
SV $25/$500A AB
SV 25/100% GGUSD 05 CB
SVA 15-30/200A UHG 08
SV 25/70% 07
SV 25/70% 07 CB
SV 25/70% 07 AB
SV 20-30/100A UBS AB
SV 20-30/100A UBS
10/250A UC GR05
SV 20-30/250A UBSFN 06 AB
15/250A UNIV CA GR06
SV 20-30/250A UBSFN 06
SP 35/150A NC UFCW 06
SP 35/150A NC UFCW 06 CB
UNIVERSITY OF CALIF AB
SP 35/150A NC UFCW 06 AB
UNIVERSITY OF CALIF
SV 10/250A UC 05
UTILIZATN CNTRL PRG CHRGS
SP 35/150A NCUFCWW 05
UC SPECIAL ADMIN./SURVEY
SV 20-30/250A UBSFN 06 CB
UNIVERSITY OF CALIF COBRA
SVA 15-30/200A UHG 08 CB
217 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
UDE
UDJ
UE3
UE5
UEA
UEH
UEJ
UEL
UEV
UEW
UEZ
UF1
UF2
UF3
UF6
UFC
UFE
UFF
UFJ
UFL
UFM
UFO
UFR
UFS
UFW
UFX
UFY
UGB
UGD
UGJ
UGZ
UHB
UHC
UHJ
UHZ
UJF
UJJ
UKA
UKF
UKH
UKJ
UKL
UKW
UKZ
ULA
ULD
ULF
ULJ
ULZ
UM1
Plan / Benefit Description
SV 20-40/300A USG 07
SV 25/100% GGUSD 05 AB
ARP MCC 1 SD LO-PL SH08
ARP MCC 1 SD HI-PL SH08
SV 15-25/250A UNTD 06
ARP MCC 1 SD HI SH08
SV 15-25/250A UNTD 06 AB
ARP MCC 1 SD LO SH08
ARP MCC 1 SD PLUS SH08
ARP MCC 1 SD SH08
SV 15-25/250A UNTD 06 CB
UFCW RETIREE RX CODE
UFCW RETIREE $25
UFCW CHIRO 25/12V GR04
SV 25/100A UFCW 06
UFCW
SV 20-40/300A USG 07 CB
SV 25/250A UFCW 06
SV 0/100% UFCW 06 AB
SV 25/100A UFCW 06 CB
SV 25/250A UFCW 06 CB
UFCW
SV 0/100% UFCW 06 CB
SV 20-30/100A UBS CB
SV 0/100% UFCW 06
SV 25/100A UFCW 06 AB
SV 25/250A UFCW 06 AB
SV 20/250A 06
SV 15-25/250A UA 07
SV 20/250A 06 AB
SV 20/250A O6 CB
SVA 20/250A 06
DUAL-OPTION - UHC 06
SVA 20/250A 06 AB
SVA 20/250A 06 CB
SVA 10/100% UFCW 07
SV 10/250A UC 05 AB
SV 10/100% UT 06
SVA 10/100% UFCW 07 CB
NOT USED
SV 10/100% UT 06 AB
NOT USED
ARP MCC ES SD SH08
SV 10/100% UT 06 CB
SV 10/100% UT 06
SV 15-25/250A UA 07 CB
SVA 10/100% UFCW 07 AB
SV 10/100% 06 AB
SV 10/100% 06 CB
UNITED METH/STAND-3-OPMH
218 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
UMA
UMH
UMJ
UML
UMW
UMZ
UNC
UNJ
UNZ
UP1
UP2
UP3
UP4
UPA
UPC
UPJ
UPP
UPX
UPY
UPZ
UQ3
UQ5
UQA
UQH
UQL
UQV
UQW
URE
USB
USF
USJ
USX
USY
USZ
UTC
UUC
UUP
UUY
UVC
UW3
UW4
UW5
UW6
UWC
UWD
UWJ
UWW
UX3
UX5
UXH
Plan / Benefit Description
SV 15/100% UT 06
NOT USED
SV 15/100% UT 06 AB
NOT USED
ARP MCC ES CE/SO SH08
SV 15/100% UT 06 CB
SV 15/250A UC 06
SV 15/250A UC 06 AB
SV 15/250A UC 06 CB
UNION PACIFIC 20/250A
UNION PACIFIC 20/250A CBRA
SV $20/$250A UNION PAC
SV $20/$250A UNION PAC CB
SV 10/100% UTU-MAT 06
UFCW PODIATRY BENEFIT
SV $20/$250A UNION PAC AB
UNION PACIFIC $10
SV 10/100% UTU-MAT 06 AB
SV 10/100% UTU-MAT 06 CB
UNION PACIFIC $10 - COBRA
ARP MCC 3 SD LO-PL SH08
ARP MCC 3 SD HI-PL SH08
SVA 15-30/200A UHG 08 AB
ARP MCC 3 SD HI SH08
ARP MCC 3 SD LO SH08
ARP MCC 3 SD PLUS SH08
ARP MCC 3 SD SH08
SV 20-40/300A USG 07 AB
SVA 20-40/300A USG 06
SV 20-40/300A USG 06
SVA 20-40/300A USG 06 AB
SV 20-40/300A USG 06 AB
SV 20-40/300A USG 06 CB
SVA 20-40/300A USG 06 CB
TAKING CHARGE OF YOU
SV 20-40/200A UHG 08
15/250 PLAN COMM SYS WEST
15/250 PLAN COM SYS W CBRA
SV 20-40/200A UHG 08 CB
UFCW $25/$100
UFCW $25/$100 COBRA
UFCW $25/$250
UFCW $25/$250 COBRA
SV 20-40/200A UHG 08 AB
SV 15-25/250A UA 07 AB
SP 35/150A NCUFCWW 05 AB
SP 35/150A NCUFCWW 05 CB
ARP MCC PRE SD LO-PL SH08
ARP MCC PRE SD HI-PL SH08
ARP MCC PRE SD HI SH08
219 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
UXL
UXV
UXW
UY3
UY5
UYH
UYL
UYV
UYW
UZ1
UZA
UZC
UZF
UZS
V00
V01
V02
V03
V05
V06
V0L
V10
V15
V1J
V1N
V1P
V1T
V1Y
V1Z
V21
V23
V24
V25
V27
V2E
V2F
V2J
V2M
V2N
V2R
V2Z
V30
V3E
V3J
V3M
V3N
V3R
V3Z
V4E
V4J
Plan / Benefit Description
ARP MCC PRE SD LO SH08
ARP MCC PRE SD PLUS SH08
ARP MCC PRE SD SH08
ARP MCC VA SD LO-PL SH08
ARP MCC VA SD HI-PL SH08
ARP MCC VA SD HI SH08
ARP MCC VA SD LO SH08
ARP MCC VA SD PLUS SH08
ARP MMC VA SD SH08
UNITED METH/STAND-3-40OPMH
SV 20/250A UHSD 06
SV 10/250A UC 05 CB
SV 20/250A UHSD 06 CB
SV 20/250A UHSD 06 AB
VISION CARE $0 (VSP)
RETIREE GOLD VISION
RETIREE GOLD VISION
VISION-SO.CAL.RETIREE GOLD
VISION CARE $5 (VSP)
DUMMY
VISION CARE $0 VSP-LA CNTY
$10 VSP-VALUECARE ROLLOVER
VISION CARE $15 (VSP)
STD 10 VALUE NETWORK AB
STD 10 VALUE NETWORK
15/80 MFP POS-D. FREEMAN
VENTURA STANDARD PLAN
15/80 MFP POS COBRA D. FRE
STD 10 VALUE NETWORK COBRA
RET.GOLD $0 EXAM MCD-A1325
RET.GOLD $5 TRW-EH790
RET.GOLD $5 CO-PAY
VISION - THRIFTY/PAYLESS
SC 20 ELIGIBILITY ONLY
SVA $10/$20/$100D
25/70A TOWERS GR-VN06 VSP
SVA $20/80% AB
SVA $25/70%
STD 10/20 VALUE NETWORK
SVA $20/80%
STD 10/20 VALUE NETWRK COB
VISION CARE $30 (VSP)
SVA $10/$20/$100D CB
SVA $10/$20/$100D AB
SVA $25/70% CB
UB STD 10 VALUE NETWORK
SVA $20/80% CB
UB STD 10 VALUE NETWRK COB
SVA $20/100%
SVA $20/100% AB
220 of 640
Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
V4M
V4N
V4R
V4T
V4Z
V5E
V5J
V5M
V5N
V5R
V5S
V5T
V5Z
V6E
V6J
V6M
V6N
V6Z
V7E
V7G
V7H
V7J
V7M
V7N
V7Z
V8E
V8J
V8M
V8N
V8P
V8Q
V8R
V8S
V8T
V8U
V8V
V8W
V8X
V8Z
V9E
V9J
V9M
VA4
VA6
VAJ
VB6
VBA
VBB
VBC
VBE
Plan / Benefit Description
SVA $15/$30/80%
STD 10/20 VALUE SELECT
SVA $20/$40/$250A
VENTURA STANDARD W/OPT DNT
STD 10/20 VALUE SELECT COB
SVA $20/100% CB
SVA $15/$30/80% AB
SVA $15/$30/80% CB
NON-STD 15 VALUE NETWORK
SVA $20/$40/$250A CB
$5/$100 ALLOW S GOLD
VENTURA STANDARD W/HI DNTL
NON-STD 15 VALUE NET-COBRA
SVA $15/$250A
SVA $15/$30/$250D AB
SVA $15/$30/$250D
VALUE NETWK $10-$20/80
VALUE NETWK $10-$20/80 CBR
SVA $15/$250A CB
25/125A 2YRS GR-VN07 VSP
15/75A 2YRS GR-VN07 VSP
SVA $15/$250A AB
SVA $15/$30/$250D CB
VALUE NETWK $15-$30/80
VALUE NETWK $15-$30/80 CBR
SVA $10/100%
SVA $25/$500A AB
SVA $25/$500A
VALUE NETWK $20-$40/$250A
0 REFRAC 1/V YR VN-GR08
5 REFRAC 1/V YR VN-GR08
10 REFRAC 1/V YR VN-GR08
15 REFRAC 1/V YR VN-GR08
20 REFRAC 1/V YR VN-GR08
25 REFRAC 1/V YR VN-GR08
30 REFRAC 1/V YR VN-GR08
35 REFRAC 1/V YR VN-GR08
40 REFRAC 1/V YR VN-GR08
VALUE NETWK 20-40/250A CBR
SVA $10/100% CB
SVA $10/100% AB
SVA $25/$500A CB
30/70A 2YRS GR-VN07
5/100A 2 YRS SH-VN06
SVA 10-20/100D AB
C25/$150A 2YRS VISION 06
SVA 20-40/50% 07
SV 15/150A VERIZON 08
VSP VISION $10 BOEING CUST
10/75A 2YRS GR-VN07
221 of 640
Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
VBJ
VBO
VBP
VBY
VC2
VCA
VCC
VCD
VCE
VCH
VCJ
VCN
VCS
VCX
VDA
VDB
VDE
VDF
VDG
VDH
VDJ
VE3
VE4
VE5
VEA
VEB
VEC
VED
VEJ
VEP
VFI
VFJ
VFP
VFQ
VG6
VGA
VGJ
VGN
VGP
VGQ
VH6
VHA
VHJ
VHM
VHN
VHO
VHP
VHS
VI5
VI6
Plan / Benefit Description
VALUE NETWK 20-40/250A AB
VSP BOEING REP VISION $0
BOEING VISION $10 (VSP)
15/75A BOEING GR-VN07
VSP $5 VISION COUNTY LA
0/75A GR-VN07
PDV PHS VISION PLAN
VENTURA CLASSIC I W/OP DDS
VENTURA CLSC I W/EPO DDS
SVA 20/250A C4H05
UB STD 10 VALUE NETWORK AB
SVA 20/250A C4H05 CB
VENTURA CLASSIC I
SVA 20/250A C4H05 AB
15/70A GR-VN07
SV 15/150A VERIZON 08 CB
SVA 10/100% 06 CB
15/125A 2YRS GR-VN07
SVA 20-40/50%
SVA 20-40/50% CB
SVA $10/100% AB
SH STD 3 VENTURA/KERN
SH STD 4 VENTURA/KERN
SH STD 5 VENTURA/KERN
SVA 20-40/50% 07 CB
SV 15/150A VERIZON 08 AB
KEENAN COMP VENTURA GR07
SVA 10/100% 06
SVA 10/100% 06 AB
SH PREFERRED VENT./KERN
FREEDOM PLAN 168
SVA 10-20/100A AB
0/75A 2YRS VN-GR08
0/125A 2YRS VN-GR08
25/75A VN-GR06
SVA 20-40/50% 07 AB
SVA 20-40/50% AB
SVA 10-20/100A 06
5/75A 2YRS VN-GR08
5/125A 2YRS VN-GR08
10/70A 2YRS VN06 VSP
15/75A 2YRS GR-VN06
SVA $25/70% AB
HI-OPTION VISION $7 COPAY
HI-OPTION VISION $15 COPAY
HI-OPTION VISION $20 COPAY
HI-OPTION VISION $10 COPAY
HI-OPTION VISION $5 COPAY
RETIREE GOLD VISION
RETIREE GOLD VISION
222 of 640
Plan Benefit - CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
VI7
VI8
VJA
VJJ
VJN
VJQ
VKA
VKB
VKE
VKG
VKJ
VKP
VL1
VL2
VL3
VL4
VL5
VLA
VLB
VLC
VLD
VLE
VLJ
VLK
VLX
VM0
VM1
VM2
VM3
VM4
VM5
VMA
VMC
VMD
VME
VMH
VMJ
VMQ
VMR
VMS
VN1
VN2
VN3
VN4
VN5
VN8
VN9
VNA
VNB
VNC
Plan / Benefit Description
RETIREE GOLD VISION
RETIREE GOLD VISION
SVA 10-20/100A 07
SVA 15-30/80% AB
SVA 10-20/100A 06 CB
10/75A 2YRS VN-GR08
SVA 10-20/100A 07 CB
SV 15/100% VERIZON 07
SV 15/100% VERIZON 07 CB
SV 15/100% VERIZON 07 AB
SVA 10-20/80% AB
10/125A 2YRS VN-GR08
W FARGO VALUE NETWORK
XEROX VALUE NETWORK
LOCKHEED VALUE NETWORK
PITNEY BOWES VALUE NETWORK
SVA 20-30/100A LM 06
W FARGO VALUE NETWORK COBR
XEROX VALUE NETWORK COBRA
LOCKHEED VN - COBRA
PITNEY BOWES VN COBRA
0/12V L3/ETI VN05 VSP
XEROX VALUE NETWORK AB
SVA 20-30/100A LM 06 CB
SVA 20-30/100A LM 06 AB
VISON MESC $0 COPAYMENT
MESC VISION - PERS/MEDCARE
MESC/COUNTY OF FRESNO RET
MESC VISION-PERS MEDICARE
MESC VISION - EYEWEAR ONLY
$20/$20 MESC-GOLDEN EAGLE
SVA 10-20/100A 07 AB
SV 20/100A VERIZON 07 CB
VENTURA MEDICAL W/OP DDS
VENTURA MEDICAL W/EPO DDS
VENTURA MEDICAL W/HIOP DDS
SVA 20-40/250A AB
15/125A 2YRS VN-GR08
15-15/75A VN-GR08
VENTURA MEDICAL
5/125A VN-GR06
10/75A 2YRS GR-VN06
RESERVED
SH VENTURA STD-II HI PLAN
20/75A VN-GR06
SH VENTURA STD-II W/OP DNT
SH VENTURA STD-II W/HI DNT
SVA 10-20/100D
SVA 10-20/100D CB
NON STANDARD $15/80%
223 of 640
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
VND
VNE
VNF
VNG
VNH
VNJ
VNK
VNL
VNM
VNN
VNQ
VNZ
VO4
VOC
VOH
VP1
VP6
VPA
VPC
VPD
VPE
VPF
VPH
VPJ
VPL
VPP
VPX
VQ3
VQ5
VQB
VQC
VQD
VQF
VQH
VQJ
VQK
VQL
VQP
VQR
VQV
VQW
VRB
VRJ
VRO
VRP
VRR
VRS
VS0
VS1
VS2
Plan / Benefit Description
SVA $10/100%
SVA $10/100% CB
SVA 10-20/100A
SVA 10-20/100A CB
SVA 15-30/80%
SVA 15-30/80% CB
SVA 10-20/80%
SVA 10-20/80% CB
SVA 20-40/250A
SVA 20-40/250A CB
20/75A 2YRS VN-GR08
NON STANDARD $15/80% COBRA
RETIREE GOLD VISION
VISION CARE $0 VSP-CNTY LA
HI-OPTION VISION
DUMMY
ADVANCE WELLNESS SH-WL06
SVA 20/90% WELLS FARGO
SVA 20/90% WELLS FARGO CB
SP 10/100% VERTEX 06
RESERVED PFFS
SP 10/100% VERTEX 06 CB
VISION $10 VSP
SVA 20/90% WELLS FARGO AB
VISION VSP $15
20/125A 2YRS VN-GR08
SP 10/100% VERTEX 06 AB
ARP MCC VNTRA LO-PL SH08
ARP MCC VNTRA HI-PL SH08
SV 20/100A VERIZON 08
15/130A 1YR DLX VN-SH08
30/70A 2YRS VN-SH08
0/130A 2 YRS VN-SH08
ARP MCC VNTRA HI SH08
5/100A 2YRS VN-SH08
0/75A 2YRS VN-SH08
ARP MCC VNTRA LO SH08
25/70A 2YRS VN-GR08
0/70A 2YRS VN-SH08
ARP MCC VNTRA PLUS SH08
ARP MCC VNTRA SH08
SV 20/100A VERIZON 08 CB
SVA $20/$40/$250A AB
SVA 15/250A ROSS CB
VISION CARE $10 RNP (VSP)
10/75A GR-VN07
SVA 15/250A ROSS
VISION $0 CO-PAY CUSTOM
SR PLAN VISION SO.CAL
SR PLUS VISION-SO.CAL
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
VS3
VS4
VS5
VS6
VS7
VS8
VS9
VSE
VSF
VSH
VSJ
VSK
VSQ
VSX
VT1
VT2
VT3
VT4
VT5
VT6
VT7
VT8
VTA
VTB
VTE
VTJ
VTM
VTO
VTW
VU4
VU6
VUA
VUC
VUT
VVA
VVJ
VVP
VVQ
VWA
VWC
VWM
VWP
VX2
VXA
VXC
VXJ
VYA
VYF
VYG
VYH
Plan / Benefit Description
SR PLAN VISION - NO CAL
SR PLUS VISION - NO CAL
SR PREMIER VISION - NO CAL
RG VISION CUSTOM
RG PREMIER CUSTOM
RETIREE GOLD VISION
RETIREE GOLD VISION
0/75A 2YRS SH-VN07
0/130A 2 YRS SH-VN07
VENTURA CLSC I W/HIOP DDS
SVA 15/250A ROSS AB
5/100A 2YRS SH-VN07
30/70A 2YRS SH-VN07
15/130A 1YR DLX SH-VN07
SH VENTURA STD MED
SH VENTURA STD W/ HI DEN
SH VENTURA PART B STD MED
SH VENTURA PT B W/ HI DEN
SH VENTURA PLUS MED
VENTURA PLUS MED W/ HI DEN
SH VENTURA PART B PLUS MED
VENTURA PT B PLUS W/ HI DE
SVA 15-30/80% 07
SV 20/100A VERIZON 08 AB
END VENTURA BASIC W/ NO DE
SVA 20-40/400A TEAMSTER AB
SVA 20-40/400A TEAMSTER
VISION ONLY
SVA 20-40/400A TEAMSTER CB
15/130A 1YR DLX GR-VN07
15/75A 2YRS VN-GR06
SVA 15-30/80% 07 CB
SV 20/100A VERIZON 07 AB
10/12V VN06 VSP
SVA 15-30/80% 07 AB
SVA 10-20/100A 06 AB
15/75A 2YRS VN-GR08
25/75A 2YRS VN-GR08
SVA 20-40/250A 07
SV 20/100A VERIZON 07
PDV VISION WAL MART
25/125A 2YRS VN-GR08
SVA $15-$30/$250A XEROX CB
SVA 20-40/250A 07 CB
SVA $15-$30/$250A XEROX
SVA $15-$30/$250A XEROX AB
SVA 20-40/250A 07 AB
SVA $25/70% 07
SVA $25/70% 07 CB
SVA $25/70% 07 AB
225 of 640
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
VYZ
VZ2
VZ3
VZ4
VZ5
VZ6
VZ7
VZ8
VZ9
VZA
VZF
VZJ
W1C
W1D
W1E
W1F
W1G
W1I
W1R
W1S
W1W
W1Z
W2C
W2I
W2J
W2Z
W3C
W3D
W3I
W3J
W3U
W3Z
W4C
W4D
W4I
W4J
W4Z
W5C
W5D
W5I
W5J
W5Z
W6D
W6I
W6J
W7C
W7D
W7I
W7J
W7Z
Plan / Benefit Description
10/125A 2YRS GR-VN07
SV 20/1500-DED SG06 CB
SV 20/1500-DED SG06 AB
SV 20/1500-DED SG06 CC
SV 20/1500-DED SG06 CE
SV 20/1500-DED SG06 CD
SV 20/1500-DED SG06 FE
SV 20/1500-DED SG06 FD
SV 20/1500-DED SG06 US
SV 20/1500-DED SG06
15/75A BOEING VN-GR08
0 BOEING VN-GR08
15/250 PLAN
ELITE 15 FED CBR DISABLED
ELITE 15 FED CBR EXTENDED
ELITE 15 CAL CBR EXTENED
ELITE 15 CAL CBR DISABLED
INDIVIDUAL HMO 15 PLAN
ELITE 15 PLAN CCOBRA
ELITE 15 PLAN
ELITE 15 PLAN COBRA
15/250 PLAN COBRA
$15/$250 HMO 2000 SER
INDIVIDUAL HMO 15 7/00
$15/$250 HMO 2000 SER AB
$15/$250 HMO 2000 SER CBRA
PBGH $15/$250 $50 ER
HMO 15 PLAN
G/I INDIVIDUAL HMO 15 7/00
HMO 15 PLAN AB
HMO 15 PLAN USERRA
PBGH $15/$250 $50 ER COBRA
NON STANDARD 15/150
HMO 15 PLAN COBRA
I PLAN HMO $35/30%
MERLE NORMAN $15/250A AB
NON STANDARD 15/150 CBRA
$15/$100 HMO 2000 SER
HMO 15 PLAN CAL COBRA
INDIVIDUAL PLAN 15
$15/$100 HMO 2000 SER AB
$15/$100 HMO 2000 SER CBRA
HMO 15 FED CBR DISABLED
INDIVIDUAL PLAN 15 HIPAA
SV 15/250A AB
BENEFIT ALLIANCE PLAN C
HMO 15 FED CBR EXTENDED
I PLAN $35/30% HIPPA
SV 15/100A AB
BENEFIT ALLIANCE PLAN C CB
226 of 640
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
W8D
W8I
W9D
W9J
WA7
WA8
WAA
WAB
WAC
WAJ
WAK
WAL
WAP
WAX
WB6
WBJ
WC2
WC3
WC5
WC6
WC7
WC8
WCI
WCJ
WD1
WD2
WD3
WD4
WD5
WD6
WD7
WDJ
WDU
WE5
WE6
WE7
WE8
WEJ
WEL
WF2
WFA
WFB
WFC
WFD
WFE
WFF
WFG
WFH
WFJ
WFK
Plan / Benefit Description
HMO 15 CAL CBR EXTENDED
I PLAN $35/30% HIPPA H
HMO 15 CAL CBR DISABLED
SV 15/250A MERLE NORM AB
SV $15/$250A
SV $15/$250A
CB
SV $15/$30/$250D
SV $15/$30/$250D CB
SV 25/100A WACHOVIA 06
SV $15/$250A
AB
SV $15/$30/$250D AB
SV 25/100A WACHOVIA 06 CB
RESERVED WT ALT PROGRAMS
SV 25/100A WACHOVIA 06 AB
HLTH EDUC 12 SESSIONS 06
LOWE ENTERPRISE $20/$30 AB
LOWE ENTERPRISE $20/$30
LOWE ENTERPRISE $20/$3 CBR
SV 15/250A
SV 15/250A CB
SV 15/100A
SV 15/100A CB
IND HMO 15 PLAN (COP)
SV $15-$30/80% AB
SV $15-$30/250A
SV $15-$30/250A CB
SV $15-$30/250A CAL CB
SV $15-$30/250A FED CB DIS
SV $15-$30/250A FED CB EXT
SV $15-$30/250A CAL CB EXT
SV $15-$30/250A CAL CB DIS
SV $15-$30/250A AB
SV $15-$30/250A USERRA
SV 15/250A 05
SV 15/250A 05 CB
SV 15/100A 06
SV 15/100A 06 CB
SV $15-$30/$250D AB
WELLNESS PROGRAM
SV 20/90% WLS FRGO 06 AB
SV 20/90% WLS FRGO 07
SVA 20/90% WLS FRGO 06
SV 20/90% WLS FRGO 06
SV 20/90% WELLS FARGO
SV 20/90% WELLS FARGO CB
SVA 20/90% WLS FRGO 06 CB
SV 20/90% WLS FRGO 06 CB
SV 20/90% WLS FRGO 07 CB
SV 20/90% WELLS FARGO AB
SV 20/90% WLS FRGO 07 AB
227 of 640
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
WFL
WFQ
WFT
WFX
WGJ
WHJ
WHP
WHR
WHS
WHT
WHW
WHX
WHZ
WIR
WJJ
WK1
WK2
WK3
WK4
WK5
WK6
WK7
WKC
WKD
WKE
WKF
WKU
WLA
WLC
WLD
WLE
WLF
WLG
WLJ
WLL
WLZ
WM2
WM3
WM4
WM5
WM6
WM7
WMC
WMJ
WMS
WMZ
WN1
WN2
WN3
WNC
Plan / Benefit Description
SVA 20/90% WLS FRGO 07
SVA 20/90% WLS FRGO 07 CB
SVA 20/90% WLS FRGO 07 AB
SVA 20/90% WLS FRGO 06 AB
SV 15/250A 05 AB
SV 15/100A 06 AB
SV 3/100% WEYERHAEUSER
STANDARD PLAN/HIPC CAL CBR
STANDARD PLAN HIPC
PAC ADVANTAGE STD PLAN
STANDARD PLAN HIPC COBRA
PAC ADVAN STD PLAN COBRA
SV 3/100% WEYERHAEUSER CB
PAC ADVAN STD PLAN CCOBRA
SV 20/100A WM SONOMA 05 AB
HMO 15 PLAN
HMO 15 PLAN COBRA
HMO 15 PLAN CCOBRA
HMO 15 FED CBR DISABLED
HMO 15 FED CBR EXTENDED
HMO 15 CAL CBR EXTENDED
HMO 15 CAL CBR DISABLED
SV $15-$30/80%
SV $15-$30/80% CB
SV $15-$30/$250D
SV $15-$30/$250D CB
HMO 15 PLAN USERRA
SV 20/100A WM SONOMA 05 CB
$15/$250 PLAN COUNTY OF LA
SV 3/100% WRHSR 06
SV 3/100% WRHSR 06 CB
SV 0/100% WALGREEN 06
SV 3/100% WRHSR 06 AB
SV 0/100% WALGREEN 06 AB
SV 0/100% WALGREEN 06 CB
$15/$250 COUNTY OF LA COBR
MARRIOTT ADV 15-25/100A
MARRIOTT ADV 15-25/100A CB
MERLE NORMAN $15/250A
MERLE NORMAN $15/250A CBRA
SV 15/250A MERLE NORM
SV 15/250A MERLE NORM CB
$15/$250 COUNTY OF LA
MARRIOTT ADV 15-25/100A AB
SV 20/100A WM SONOMA 05
$15/$250 COUNTY OF LA CBRA
SV 3/100% LADWP 06
SV 3/100% LADWP 06 CB
SV 3/100% LADWP 06 AB
N.Y. COALITION 15/500
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
WNZ
WOC
WOZ
WPB
WPC
WPD
WPJ
WPP
WPR
WPS
WPT
WPX
WPY
WPZ
WQC
WQP
WQR
WQS
WQT
WQY
WQZ
WRA
WRP
WRR
WRS
WRT
WRY
WRZ
WS2
WS3
WSA
WSP
WSY
WSZ
WV1
WVB
WVG
WVH
WVJ
WVZ
WZ2
WZ3
WZ4
WZ5
WZ6
WZ7
WZ8
WZ9
WZA
X00
Plan / Benefit Description
N.Y.COALITION 15/500 COBRA
15/500 TAKECARE DISABLED
15/500 TAKECARE DIABLE CBR
SV 3/100% WYRHSR 06
CREATED IN ERROR
SV 3/100% WYRHSR 06 CB
SV 3/100% WEYERHAEUSER AB
PAINEWEBBER POS
10-15/50A T1A GR07
5-20/100A T1B GR07
10-20/200A T1C GR07
SV 3/100% WYRHSR 06 AB
PAINEWEBBER POS (COBRA)
CREATED IN ERROR P
DUMMY PLAN-NOT IN USE
$15 POS MFP OPTION 6
10-20/750A T2A GR07
15-25/130D T2B GR07
10-25/150D T2C GR07
$15 POS MFP OPTION 6 COBRA
DUMMY PLAN-NOT IN USE
HMO 15 RAYTHEON
POS 15 RAYTHEON
15-25/200D T3A GR07
15-30/220D T3B GR07
20-35/250D T3C GR07
POS 15 RAYTHEON
HMO 15 RAYTHEON CBRA
STATE FARM 25/250A
STATE FARM 25/250A COBRA
RAYTHEON 15 HMO EA RET
RAYTHEON 15 POS EA RET
RAYTHEON 15 POS EA RET CBR
RAYTHEON 15 HMO EA RET CBR
SV 20/100A WACHOVIA
SV 25/100A WACHOV 07
SV 25/100A WACHOV 07 CB
SV 25/100A WACHOV 07 AB
SV 20/100A WACHOVIA AB
SV 20/100A WACHOVIA CB
SVA 35/600D SG06 CB
SVA 35/600D SG06 AB
SVA 35/600D SG06 CC
SVA 35/600D SG06 CE
SVA 35/600D SG06 CD
SVA 35/600D SG06 FE
SVA 35/600D SG06 FD
SVA 35/600D SG06 US
SVA 35/600D SG06
NO RX-CARVE OUT RXSOL 100I
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
X0A
X1N
X2N
X50
XA0
XA1
XA2
XA3
XA4
XA5
XA6
XA7
XA8
XA9
XAA
XAB
XAC
XAD
XAE
XAF
XAG
XAH
XAI
XAJ
XAK
XAL
XAM
XAN
XAP
XAQ
XAR
XAS
XAT
XAU
XAV
XAW
XAX
XAY
XAZ
XB0
XB1
XB2
XB3
XB4
XB5
XB6
XB7
XB8
XB9
XBA
Plan / Benefit Description
NORX-CO RXSO 100%I
$10G/$25B
$10G/$25B
NO RX-CARVE OUT RX SOL 50I
$0
$1
$2
$3
$4
$5
$6
$7
$8
$9
$10
$5G/$10B
$5G/$5+30%B
$10
$5/$7/70%
$5G/$15B
$10G/$15B
$5
$5G/$10B
$5
$5
$10
$5G/$10B
$10
$5G/$10B
$10G/$15B
$5G/$25B
$10G/$30B
$15G/$35B
$10
$5
$10G/$30B
$10
$5G/$10B
$5G/$20B
$0
$1
$2
$3
$4
$5
$6
$7
$8
$9
$10
230 of 640
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
XBB
XBC
XBD
XBE
XBF
XBG
XBJ
XBK
XBL
XBM
XBN
XBP
XBR
XBS
XBZ
XC1
XC2
XC3
XC5
XCA
XCB
XCC
XCD
XCE
XCH
XCJ
XCM
XCN
XCO
XCP
XD4
XD5
XDA
XDB
XDC
XE5
XEF
XEL
XEO
XF3
XF5
XF6
XFA
XFE
XFF
XG7
XGA
XGB
XGC
XGD
Plan / Benefit Description
$5G/$10B
$5G/$5+30%B
$6G/$12B
$2.50
SVA 15-30/250A XEROX 06
SVA 15-30/250A XEROX 06 CB
$5
$5G/$10B
$5
$10
$5G/$10B
$10G/$20B
$5G/$25B
$10G/$30B
$5G/$20B
$5G/$10B
$10
SV 35/600D 05 USERRA
$5
$10
$10
$5G/$7B
$3
INDEMNITY PHARMACY
$5G/$10B
SVA 15-30/250A XEROX 06 AB
$4G/$7B CAREMARK
$0
$0/90%
$5G/$20B
SV 35/600D 05 CAL CB
$5G/$15B
$5G/$10B
$10G/$20B
$5G/$10B
$5
SVA 15-30/250A SG07 FD
$5/$7/90%
$0/80%
$3
$5
SV 35/600D 05 FED CB DIS
SVA 20-40/500D SG 07 FE
CUSTOM RX FOOD EMP.BENEFIT
SVA 15-30/250A SG07 FE
SV 35/600D 05 FED CB EXT
SVA 20-40/500D SG 07 CD
SVA 15-30/250A XEROX 07
SVA 10-30/100% SG07
SVA 15-30/250A XEROX 07 CB
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
XGF
XGG
XGH
XH8
XHA
XIH
XJ9
XJD
XKE
XKF
XKG
XKH
XMA
XMB
XMI
XMP
XNG
XQD
XQG
XRD
XRG
XSD
XSG
XTA
XTE
XUA
XUE
XVA
XVC
XVD
XVE
XXA
XXB
XXJ
XXX
XYE
XYF
XYG
XZ1
XZ2
XZ3
XZ4
XZ5
XZ6
XZ7
XZ8
XZ9
XZA
Y00
Y0A
Plan / Benefit Description
SVA 10-30/100% SG07 CB
SVA 15-30/250A XEROX 07 AB
SVA 10-30/100% SG07 AB
SV 35/600D 05 CAL CB EXT
SVA 20-40/500D SG 07 CE
0%G/20%B
SV 35/600D 05 CAL CB DIS
$10G/$15B
SVA 15-30/250A SG07
SVA 15-30/250A SG07 CD
SVA 10-30/100% SG07 US
SVA 15-30/250A SG07 CE
$10G/$15B
$10 OR 50%/$100 DEDUCTIBLE
$10G/$15B
$10G/50%B $100 DED
SVA 10-30/100% SG07 CC
SVA 20-40/500D SG 07 US
SVA 10-30/100% SG07 FD
SVA 20-40/500D SG 07 CC
SVA 10-30/100% SG07 FE
SVA 20-40/500D SG 07 FD
SVA 10-30/100% SG07 CD
SV 20-40/250A XANTRX 08
SVA 15-30/250A SG07 CB
SV 20-40/250A XANTRX 08 CB
SVA 10-30/100% SG07 CE
SV 20-40/250A XANTRX 08 AB
SVA 15-30/250A SG07 CC
SVA 15-30/250A SG07 US
SVA 15-30/250A SG07 AB
SV 35/600D 05
SV 35/600D 05 CB
SV 35/600D 05 AB
NO BENEFIT
SVA 20-40/500D SG 07
SVA 20-40/500D SG 07 CB
SVA 20-40/500D SG 07 AB
BAXTER PLAN (COBRA)
SVA 20/1500-DED SG06 CB
SVA 20/1500-DED SG06 AB
SVA 20/1500-DED SG06 CC
SVA 20/1500-DED SG06 CE
SVA 20/1500-DED SG06 CD
SVA 20/1500-DED SG06 FE
SVA 20/1500-DED SG06 FD
SVA 20/1500-DED SG06 US
SVA 20/1500-DED SG06
NO RX-CARVE OUT OTHER 100I
NORX-CO OTHR 100%I
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CA
CA
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
Y1K
Y1P
Y1V
Y1Y
Y2P
Y2Y
Y3A
Y3B
Y3R
Y50
Y5A
Y5B
Y5R
YA5
YAA
YAB
YAM
YAN
YB5
YBA
YBB
YC3
YCE
YCP
YCS
YCT
YD4
YE5
YEA
YED
YEE
YEN
YEP
YF6
YFA
YG7
YGA
YH8
YJU
YJW
YJX
YJY
YLA
YLO
YOR
YRR
YSB
YSG
YSI
YSM
Plan / Benefit Description
DUMMY
STANDARD 90%/$10 - POS
DUMMY
STANDARD 90%/$10-POS COBRA
$10/90% MFP - POS
$10/90% MFP - POS COBRA
90/80/70 $300 DED
90/80/70 $300 DED
90/80/70 $300 DED CAL CBRA
NO RX-CARVE OUT OTHER 50I
90/80/70 $500 DED
90/80/70 $500 DED
90/80/70 $500 DED CAL CBRA
$5G/$5B/$20NF
$10G/$10B/$20NF
$5/$10/$20
SH ALAMEDA PLUS W/OPT DNTL
$10G/$10B/$20NF
$5G/$5B/$20NF
$10G/$10B/$20NF
$5/$10/$20
SV 10/500D 05 USERRA
YOLO CLASSIC I W/EPO DDS
YOLO CLASSIC I W/ODP DDS
YOLO CLASSIC I
SH CONTRA COSTA PLS-LO DNT
SV 10/500D 05 CAL CB
SV 10/500D 05 FED CB DIS
SVA 15/250A YUM 08
MCC YOLO DELUXE SH07
MCC YOLO EP SH07
MC COMP YOLO SH07
MCC YOLO PP SH07
SV 10/500D 05 FED CB EXT
SVA 15/250A YUM 08 CB
SV 10/500D 05 CAL CB EXT
SVA 15/250A YUM 08 AB
SV 10/500D 05 CAL CB DIS
ARP MCC YOLO PP SH08
ARP MCC YOLO SH08
ARP MCC YOLO DLX SH08
ARP MCC YOLO EP SH08
KEENAN COMP YOLO GR07
RESERVED
RESERVED
SH RIVERSIDE PLUS W/OP DNT
SH SAN BERN PLUS W/OPT DNT
SH SAN DIEGO PLUS W/OP DNT
RESERVED
SH SACRAMENTO PLS W/OP DNT
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
YSN
YSO
YSX
YUA
YUB
YUC
YVN
YXA
YXJ
YXZ
YYA
YYB
YYJ
YYX
YZ2
YZ3
YZ4
YZ5
YZ6
YZ7
YZ8
YZ9
YZA
YZC
YZZ
Z2P
Z2R
Z2T
Z5R
Z8P
ZA2
ZA3
ZA4
ZA5
ZA6
ZA7
ZA8
ZA9
ZAA
ZAB
ZAC
ZAD
ZAE
ZAF
ZAG
ZAH
ZAJ
ZAK
ZAL
ZAM
Plan / Benefit Description
SH SAN FRAN PLUS W/OPT DNT
RESERVED
SH SANTA CLARA PLUS-LO DNT
$5G/$10B/$25NF
$5G/$15B/$25NF
$10G/$10B/$25NF
RESERVED
SVA 15/250A YUM 06
SVA 15/250A YUM 06 AB
SVA 15/250A YUM 06 CB
SV 10/500D 05
SV 10/500D 05 CB
SV 10/500D 05 AB
SV 20-40/400D NAT'L 06 AB
SVA 40-60/2000-DED SG06 CB
SVA 40-60/2000-DED SG06 AB
SVA 40-60/2000-DED SG06 CC
SVA 40-60/2000-DED SG06 CE
SVA 40-60/2000-DED SG06 CD
SVA 40-60/2000-DED SG06 FE
SVA 40-60/2000-DED SG06 FD
SVA 40-60/2000-DED SG06 US
SVA 40-60/2000-DED SG06
NON STD $5/80 PLAN
NON STD $5/80 PLAN CBRA
10-15/50A T1A NON-AARP GR8
10-20/750A T2A NO-AARP GR8
15-25/200D T3A NO-AARP GR8
15-25/130D T2B NO-AARP GR8
10-20/200A T1C NO-AARP GR8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 10/100% SCEET 05
SV 10/100% SCEET 05 CB
SP 10/100% SCEET 05
SP 10/100% SCEET 05 CB
SV 5/100% SCEET 05
SV 5/100% SCEET 05 CB
SV 15/100% SCEET 05
SV 15/100% SCEET 05 CB
SV 10/100% SCEET 05 AB
SP 10/100% SCEET 05
SP 10/100% SCEET 05 CB
SH ALAMEDA PLUS W/HI DNTL
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CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
ZAN
ZAP
ZAQ
ZAR
ZB2
ZB3
ZB4
ZB5
ZB6
ZB7
ZB8
ZB9
ZC2
ZC3
ZC4
ZC5
ZC6
ZC7
ZC8
ZC9
ZCJ
ZCT
ZD2
ZD3
ZD4
ZD5
ZD6
ZD7
ZD8
ZD9
ZDE
ZDN
ZDP
ZE2
ZE3
ZE4
ZE5
ZE6
ZE7
ZE8
ZE9
ZEJ
ZF2
ZF3
ZF4
ZF5
ZF6
ZF7
ZF8
ZF9
Plan / Benefit Description
SP 10/100% SCEET 05
SP 10/100% SCEET 05 CB
SP 15/100% SCEET 05
SP 15/100% SCEET 05 CB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SP 10/100% SCEET 05 AB
SH CONTRA COSTA PLS-HI DDS
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
MCC SANTA CRUZ EP SH07
MC COMP SANTA CRUZ SH07
MCC SANTA CRUZ PP SH07
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 5/100% SCEET 05 AB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
235 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
ZG2
ZG3
ZG4
ZG5
ZG6
ZG7
ZG8
ZG9
ZGJ
ZH2
ZH3
ZH4
ZH5
ZH6
ZH7
ZH8
ZH9
ZJ2
ZJ3
ZJ4
ZJ5
ZJ6
ZJ7
ZJ8
ZJ9
ZK2
ZK3
ZK4
ZK5
ZK6
ZK7
ZK8
ZK9
ZKJ
ZLO
ZLS
ZM2
ZM3
ZM4
ZM5
ZM6
ZM7
ZM8
ZM9
ZN2
ZN3
ZN4
ZN5
ZN6
ZN7
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 15/100% SCEET 05 AB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SP 10/100% SCEET 05 AB
RESERVED
SH LA PLUS W/HI OPT DENTAL
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
236 of 640
Plan Benefit - CA
State
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
CA
Plan / Benefit
ZN8
ZN9
ZNJ
ZOR
ZP2
ZP3
ZP4
ZP5
ZP6
ZP7
ZP8
ZP9
ZPR
ZQJ
ZR2
ZR3
ZR4
ZR5
ZR6
ZR7
ZR8
ZR9
ZRR
ZSB
ZSG
ZSI
ZSN
ZSO
ZSX
ZUC
ZUE
ZUP
ZVN
ZZ2
ZZ3
ZZ4
ZZ5
ZZ6
ZZ7
ZZ8
ZZ9
ZZA
ZZZ
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
SP 10/100% SCEET 05 AB
SH ORANGE PLUS W/HI OP DNT
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10-15/50A T1A GR08
SP 15/100% SCEET 05 AB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SH RIVERSIDE PLS W/HI DNTL
SH SAN BERN PLUS W/HI DNTL
SH SAN DIEGO PLS W/HI DNTL
RESERVED
SH SAN FRAN PLUS W/HI DNTL
RESERVED
SH SANTA CLARA PLUS-HI DNT
SANTA CRUZ CLASSIC I
S CRUZ CLSC I W/EPO DDS
S CRUZ CLSC I W/ODP DDS
RESERVED
SV 35/600D SG06 CB
SV 35/600D SG06 AB
SV 35/600D SG06 CC
SV 35/600D SG06 CE
SV 35/600D SG06 CD
SV 35/600D SG06 FE
SV 35/600D SG06 FD
SV 35/600D SG06 US
SV 35/600D SG06
HISTORICAL PLAN
237 of 640
Plan Benefit - CO
Cap/Eligibility CP7810
Assigned Plan Benefit Codes & Descriptions
State
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
Plan / Benefit
0AA
1AA
1AB
1AC
2AB
2AC
2AD
2AE
2AF
2AG
2AH
2AJ
2AK
2AN
2AY
2BF
2BG
2BH
2BL
2CF
2CG
2CH
2DF
2DG
2DH
2FH
2FL
2GH
2HH
2JH
2KH
2MH
2NH
2PH
2PT
2QH
2UH
2VH
2WH
2XH
2YH
2ZA
Plan / Benefit Description
SV 30/250D 05
15 SH-RX05
7.50 SH-RX05
10 SH-RX05
7.5/15 SH-RX05
7/14 GR-RX05
10/20 GR-RX05
10/25L GR-RX05
7/14 I GR-RX05
10/20 I GR-RX05
10/25L I GR-RX05
15/15L SH-RX05
12/12 SH-RX05
4/20/40 LO GR-RX07
4/25/50 HI GR-RX07
7/14 IM GR RX05
10/20 IM GR-RX05
10/25L IM GR-RX5
10/25/50 RX-GR08
7/14 I+ GR-RX05
10/20 I+ GR-RX05
10/25L I+ GR-RX05
7/14 II GR-RX05
10/20 II GR-RX05
10/25L II GR-RX5
4/15/30 RX-GR08
5/20/45 RX-GR08
4/20/40 RX-GR08
4/15/30 RX-GR08
4/20/40 RX-GR08
4/25/50 RX-GR08
4/25/45 RX-GR08
4/28/55 RX-GR08
4/28/58 RX-GR08
15/45/60 GR-RX07
4/25/50 RX-GR08
10/25/50 RX-GR08
10/25/50 RX-GR08
5/20/45 RX-GR08
5/20/45 RX-GR08
4/10/20 RX-GR08
0/0 GR-RX07
238 of 640
Plan Benefit - CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
2ZB
2ZC
2ZD
2ZE
2ZF
3AC
3AD
3AE
3AG
3AH
3AJ
3BG
3BH
3BJ
3CG
3CH
3CJ
3DG
3DH
3DJ
3HP
3ZE
3ZF
3ZG
3ZH
3ZJ
3ZK
3ZL
3ZM
42A
6AH
6AL
6BD
6BH
6BI
6BL
6DH
6DL
6EH
6EL
6FH
6FL
6GP
6GR
6HH
6HL
6HP
6JH
6JL
6KH
6KL
2/40 GR-RX07
5/25 GR-RX07
5/65 GR-RX07
5/10 GR-RX07
10/20 GR-RX07
10/20/40 GR-RX05
15/25/40L GR-RX05
15/25/40 GR-RX05
10/20/40 I GR-RX05
15/25/40L I GR-X05
15/25/40 I GR-RX05
10/20/40 IM GR-RX5
15/25/40L IM GRRX5
15/25/40 IM GRRX5
10/20/40 I+ GR-RX5
15/25/40L I+ GRRX5
15/25/40 I+ GR-RX5
10/20/40 II GR-RX5
15/25/40L II GR-X5
15/25/40 II GR-RX5
5/30/45 GR-RX07
5/10/20 GR-RX07
10/20/35 GR-RX07
10/20/35 GR-RX07
10/25/55 GR-RX07
10/40/75 GR-RX07
7/20/50% GR-RX07
2/30/60 GR-RX07
10/25/50 GR-RX07
MCC 3 DEN/SPRINGS GR08
0/0 HI GR-RX07
0/0 LO GR-RX07
7/14 GR-RX06
2/30/60 HI GR-RX07
7/14 I GR-RX06
2/30/60 LO GR-RX07
2/40 HI GR-RX07
2/40 LO GR-RX07
5/25 HI GR-RX07
5/25 LO GR-RX07
5/65 HI GR-RX07
5/65 LO GR-RX07
8.50/26.45/50% SH6
10/20 GR-RX06
5/10 HI GR-RX07
5/10 LO GR-RX07
8.50/26.45/50% SH6
5/10/20 HI GR-RX07
5/10/20 LO GR-RX07
7/14 HI GR-RX07
7/14 LO GR-RX07
239 of 640
Plan Benefit - CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
6LH
6LL
6MA
6MH
6ML
6NH
6NL
6NM
6PH
6PL
6PP
6QH
6QI
6QL
6QR
6RH
6RL
6RP
6SH
6SL
6TH
6TL
6TP
6UH
6UL
6VM
6WH
6YI
6YR
7AA
7AB
7AC
7AD
7AQ
7AR
7BD
7BH
7BI
7BL
7BR
7CD
7CI
7CM
7DD
7DH
7DL
7DM
7DR
7ED
7EH
7EL
7/20/50% HI GR-RX7
7/20/50% LO GR-RX7
10/25%/40% RX-GR06
10/20 HI GR-RX07
10/20 LO GR-RX07
10/20/40 HI GR-RX7
10/20/40 LO GR-RX7
5/15/30 GR-RX06
10/20 HI GR-RX07
10/20 LO GR-RX07
8.50/26.85/50% SH6
10/20/35 HI GR-RX7
10/20/40 I GR-RX06
10/20/35 LO GR-RX7
10/20/40 GR-RX06
10/20/35 HI GR-RX7
10/20/35 LO GR-RX7
8.50/27.05/50% SH6
10/25/55 HI GR-RX7
10/25/55 LO GR-RX7
10/40/75 HI GR-RX7
10/40/75 LO GR-RX7
4.50/14.50/50% SH6
15/25/40 HI GR-RX7
15/25/40 LO GR-RX7
5/5 GR-RX06
10/25/50 HI GR-RX7
15/25/40 I GR-RX06
15/25/40 GR-RX06
SV 15/30/300A 05
SV 15/100A IP05
SV 15/30/300A C/C DEN 05
SP 15/200A 05
7/20 GR-RX07
0/0 GR-RX07
7/14 GR-RX07
4/10/20 T1A H GRX7
7/14 I GR-RX07
4/10/20 T1A L GRX7
0/0 FLAT GR-RX07
7/14 GR-RX07
7/14 I GR-RX07
15/25/40 GR-RX07
7/20/30 GR-RX07
4/15/30 T1B H GRX7
4/15/30 T1B L GRX7
15/25/40 GR-RX07
10/10 FLAT GR-RX07
7/7 GR-RX07
4/20/40 T1C H GRX7
4/20/40 T1C L GRX7
240 of 640
Plan Benefit - CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
7EM
7ER
7FD
7FH
7FL
7FM
7FR
7GD
7GM
7GR
7HH
7HI
7HL
7HR
7JH
7JL
7JM
7JR
7KH
7KI
7KL
7KM
7KR
7LH
7LL
7LM
7LR
7MA
7MH
7MI
7ML
7MR
7NH
7NL
7NM
7PH
7PI
7PL
7PM
7PR
7QH
7QI
7QL
7QM
7QR
7RA
7RB
7RC
7RD
7RH
7RL
3/3 FLAT GR-RX07
10/20 GR-RX07
7/7 C GR-RX07
4/25/50 T1D H GRX7
4/25/50 T1D L GRX7
3/3/3 GR-RX07
10/20 GR-RX07
10/20/30 GR-RX07
5/10 GR-RX07
10/20 GR-RX07
4/15/30 T2A H GRX7
10/20 I GR-RX07
4/15/30 T2A L GRX7
10/20 GR-RX07
4/28/58 T3C H GRX7
4/28/58 T3C L GRX7
5/10 GR-RX07
10/10 GR-RX07
4/28/55 T3B H GRX7
10/20/35 I GR-RX07
4/28/55 T3B L GRX7
5/10/20 GR-RX07
10/20/35 GR-RX07
4/25/45 T3A H GRX7
4/25/45 T3A L GRX7
5/15 GR-RX07
15/25/40 GR-RX07
10/25%/40% GR-RX07
4/20/40 T2B H GRX7
10/20/40 I GR-RX07
4/20/40 T2B L GRX7
10/20/40 GR-RX07
4/25/50 T2C H GRX7
4/25/50 T2C L GRX7
5/15/30 GR-RX07
4/25/50 T2C H GRX7
10/20/40 I GR-RX07
4/25/50 T2C L GRX7
5/15/30 GR-RX07
10/20/40 GR-RX07
4/20/40 T2B H GRX7
10/20/40 I GR-RX07
4/20/40 T2B L GRX7
5/15/30 GR-RX07
10/20/40 GR-RX07
10/20/35 RDS GRX7
10/20 RDS GR-RX07
10/20/35 RDS GRX7
10/20 RDS GR-RX07
4/15/30 T2A H GRX7
4/15/30 T2A L GRX7
241 of 640
Plan Benefit - CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
7RM
7SB
7SI
7SR
7TH
7TL
7TM
7TR
7UH
7UL
7UM
7UR
7VH
7VL
7VM
7WH
7WI
7WL
7WM
7WR
7XA
7XB
7XC
7XD
7XE
7XF
7XG
7XH
7XJ
7XL
7XM
7XP
7XQ
7YH
7YI
7YL
7YM
7YR
7ZH
7ZL
7ZM
7ZR
82A
82B
82C
82D
82E
82F
82G
82H
82J
5/15/30 GR-RX07
10/25%/40% GR-RX07
10/20/40 I GR-RX07
10/20/40 GR-RX07
4/28/55 T3B H GRX7
4/28/55 T3B L GRX7
5/5 GR-RX07
10/25/40 GR-RX07
4/28/58 T3C H GRX7
4/28/58 T3C L GRX7
5/5 GR-RX07
15/25/40 GR-RX07
4/25/50 T1D H GRX7
4/25/50 T1D L GRX7
5/5 GR-RX07
4/20/40 T1C H GRX7
15/25/40 I GR-RX07
4/20/40 T1C L GRX7
5/7.50 GR-RX07
15/25/40 GR-RX07
4/10/20 RDS GR-RX7
4/15/30 RDS GR-RX7
4/20/40 RDS GR-RX7
4/25/50 RDS GR-RX7
4/10/20 RDS GR-RX7
4/15/30 RDS GR-RX7
4/20/40 RDS GR-RX7
4/15/30 T1B H GRX7
4/25/50 RDS GR-RX7
4/15/30 T1B L GRX7
7/14 GR-RX07
5/29/60 N/G SH-RX7
5/29/60 N/G SH-RX7
4/10/20 T1A H GRX7
15/25/40 I GR-RX07
4/10/20 T1A L GRX7
7/14 GR-RX07
15/25/40 GR-RX07
4/25/45 T3A H GRX7
4/25/45 T3A L GRX7
7/14 GR-RX07
15/25/40 GR-RX07
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
10-20/200A T1C AARP GR08
242 of 640
Plan Benefit - CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
82K
82L
82M
82N
82P
82Q
82R
82S
82T
82U
82V
82W
82X
82Y
82Z
83A
83B
83C
83D
83E
83F
83G
83H
83J
83K
83L
83M
8AA
8AH
8AR
8B8
8BH
8CH
8DD
8DH
8DR
8ED
8EH
8EM
8ER
8FD
8FH
8GH
8GM
8HD
8HH
8KM
8LH
8LM
8MA
8N8
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
SV 20/35/150D SG 05
0/0 HI C GR-RX07
0/0 C GR-RX07
5/29/60NG RX-SH08
DO NOT USE
2/30/60 HI C GRX07
7/20/30 C GR-RX07
2/40 HI C GR-RX07
10/10 FLAT C GRX07
7/7 C GR-RX07
5/25 HI C GR-RX07
3/3 FLAT C GR-RX07
10/20 C GR-RX07
7/7 C GR-RX07
5/65 HI C GR-RX07
5/10 HI C GR-RX07
5/10 C GR-RX07
10/20/30 C GR-RX07
DO NOT USE
5/10/20 C GR-RX07
7/20/50% HI C GRX7
5/15 C GR-RX07
10/25%/40% C GRX07
5/29/60G RX-SH08
243 of 640
Plan Benefit - CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
8NM
8PH
8PM
8RH
8RM
8SH
8TH
8TM
8TR
8UM
8UR
8VM
8WH
91H
92H
93H
94H
95H
9AN
9AQ
9AR
9AY
9BE
9BH
9BL
9CM
9DH
9DL
9DR
9EH
9EL
9ER
9FD
9FH
9FL
9GE
9GM
9HD
9HH
9HK
9HL
9HN
9HP
9JH
9JL
9KH
9KL
9KS
9LH
9LL
9LM
5/15/30 C GR-RX07
10/20 HI C GR-RX07
5/15/30 C GR-RX07
10/20/35 HI C GRX7
5/15/30 C GR-RX07
10/25/55 HI C GRX7
10/40/75 HI C GRX7
5/5 C GR-RX07
10/25/40 C GR-RX07
5/5 C GR-RX07
15/25/40 C GR-RX07
5/7.50 C GR-RX07
10/25/50 HI C GRX7
15/25/40 HI RX-GR8
10/25/50 HI RX-GR8
10/20/40 HI RX-GR8
10/20 HI RX-GR08
10/40/75 HI C XGR8
4/20/40 LO RX-GR08
7/20 RX-GR08
0/0 RX-GR08
4/25/50 HI RX-GR08
7/14 RX-GR08
4/10/20 T1A H XGR8
4/10/20 T1A L XGR8
15/25/40 RX-GR08
4/15/30 T1B H XGR8
4/15/30 T1B L XGR8
10/10 FLAT C XGR08
4/20/40 T1C H XGR8
4/20/40 T1C L XGR8
10/20 RX-GR08
7/7 C RX-GR08
4/25/50 T1D H XGR8
4/25/50 T1D L XGR8
10/20/30 RX-GR08
5/10 RX-GR08
10/20/30 C RX-GR08
4/15/30 T2A H XGR8
4/10/20 RX-GR08
4/15/30 T2A L XGR8
4/15/30 RX-GR08
5/30/45 RX-GR08
4/28/58 T3C H XGR8
4/28/58 T3C L XGR8
4/28/55 T3B H XGR8
4/28/55 T3B L XGR8
10/20/35 RX-GR08
4/25/45 T3A H XGR8
4/25/45 T3A L XGR8
5/15 C RX-GR08
244 of 640
Plan Benefit - CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
9LP
9LV
9MA
9MH
9MI
9ML
9MR
9NH
9NL
9NM
9PH
9PL
9PT
9PX
9QH
9QL
9RH
9RL
9RP
9RX
9TH
9TL
9UH
9UL
9VH
9VM
9WH
9WI
9WL
9WM
9XH
9XL
9YH
9YL
9ZH
9ZL
APF
APN
AT7
ATP
ATQ
ATU
ATV
B6P
BAK
BAM
BVE
BVL
C27
C7A
C7E
5/15 RX-GR08
10/20/35 RX-GR08
10/25%/40% RX-GR08
4/20/40 T2B H XGR8
10/20/40 I RX-GR08
4/20/40 T2B L XGR8
10/20/40 RX-GR08
4/25/50 T2C H XGR8
4/25/50 T2C L XGR8
5/15/30 RX-GR08
4/25/50 T2C H XGR8
4/25/50 T2C L XGR8
15/45/60 RX-GR08
5/29/60 P RX-GR08
4/20/40 T2B H XGR8
4/20/40 T2B L XGR8
4/15/30 T2A H XGR8
4/15/30 T2A L XGR8
5/15/30 RX-GR08
NO RX
4/28/55 T3B H XGR8
4/28/55 T3B L XGR8
4/28/58 T3C H XGR8
4/28/58 T3C L XGR8
4/25/50 T1D H XGR8
5/5 RX-GR08
4/20/40 T1C H XGR8
15/25/40 I RX-GR08
4/20/40 T1C L XGR8
5/7.50 RX-GR08
4/15/30 T1B H XGR8
4/15/30 T1B L XGR8
4/10/20 T1A H XGR8
4/10/20 T1A L XGR8
4/25/45 T3A H XGR8
4/25/45 T3A L XGR8
10/12V 1YR ACU SH07
10/12V 1YR ACU SH08
ATW-STD SH-WL07
ATW-PLUS SH-WL07
ATW ENHANCED SH08
ATW-PLUS WL-SH07
ATW-STD WL-SH08
15/100% BP AMOCO GR06
20 BP AMOCO NON-AARP GR08
20/100% BP AMOCO GR07
15/100A BOEING VEBA GR07
15 BO-VEBA NON-AARP GR08
SC 90 ELIGIBILITY ONLY
5/12V 1YR GR-CH07
10/12V 1YR GR-CH07
245 of 640
Plan Benefit - CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
C7F
C7G
C7H
C7J
C7K
C7L
C7M
C7P
C7S
C7U
C7W
C7Y
C9A
CAB
CAC
CAD
CAE
CAF
CGL
CGS
CGV
CGX
CHU
CHW
CPA
CRR
D6V
D8B
D8E
D8J
DA7
DA8
DAD
DAI
DAV
DAW
DAY
DB7
DB8
DBA
DBI
DBV
DBW
DBY
DF6
DF7
DF8
DFI
DFV
DFW
DFY
10/20V 1YR GR-CH07
10/30V 1YR GR-CH07
15/12V 1YR GR-CH07
15/20V 1YR GR-CH07
0/20V 1YR GR-CH07
15/30V 1YR GR-CH07
20/12V 1YR GR-CH07
5/10V 1YR GR-CH07
30/12V 1YR GR-CH07
5/20V 1YR GR-CH07
5/30V 1YR GR-CH07
5/40 1YR GR-CH07
CHIRO SC90
5/12V GR-CH05
15/12V GR-CH05
20/12V GR-CH05
10/12V GR-CH05
10/20V GR-CH05
CAREGIVER LITE SH06
CAREGIVER GR05
CAREGIVER CG-GR08
CAREGIVER ENHANCED
10/12V 1YR SH-CH07
10/12V 1YR CH-SH08
RESERVED PFFS
10/12V GR-CH07
DENTAL - VISION GR06
PREVENTIVE DN-SH08
$20 469 DN-SH08
$5 260 DN-SH08
ARP MCC 3 DEN 260 SH08
ARP MCC 3 DEN 260-PL SH08
OPTIONAL SH-DN05
ARP MCC 3 DEN EP-PL SH08
ARP MCC 3 DEN PLUS SH08
ARP MCC 3 DEN SH08
ARP MCC 3 DEN EP SH08
ARP MCC 1 DEN 260 SH08
ARP MCC 1 DEN 260-PL SH08
100%/70% DISCOUNT GR-DN07
ARP MCC 1 DEN EP-PL SH08
ARP MCC 1 DEN PLUS SH08
ARP MCC 1 DEN SH08
ARP MCC 1 DEN EP SH08
$0 466 SH-DN06
ARP MCC ES DEN 260 SH08
ARP MCC ES DEN 260-PL SH08
ARP MCC ES DEN EP-PL SH08
ARP MCC ES DEN PLUS SH08
ARP MCC ES DEN SH08
ARP MCC ES DEN EP SH08
246 of 640
Plan Benefit - CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
DG7
DG8
DGI
DGV
DGW
DGY
DMA
DMG
DMQ
DN2
DN3
DN6
DN7
DN8
DNA
DQ6
DRR
FC2
FCE
FCN
FSL
FT2
FTE
FTL
FTN
FZ7
FZW
FZY
GD7
GDW
GK7
GK8
GKI
GKV
GKW
GKY
GZ7
GZ8
GZI
GZV
GZW
GZY
H6P
H8A
H8G
HAA
HAB
HAC
HAD
HAN
HBJ
ARP MCC 2 DEN 260 SH08
ARP MCC 2 DEN 260-PL SH08
ARP MCC 2 DEN EP-PL SH08
ARP MCC 2 DEN PLUS SH08
ARP MCC 2 DEN SH08
ARP MCC 2 DEN EP SH08
20% SH-DM05
10/100% GR06
10/100% NON-AARP GR08
SO 460 GRP BILLED - GR
SO 462 INDIV BILLED - GR
$6 260 SH-DN06
$5 260 SH-DN07
SO 460 GRP BILLED DN-GR08
PREVENTIVE SH-DN07
$20 469 SH-DN06
10-20/200A DERP GR07
15/30 FREMONT C SH06 D260
15/30 FREMONT C SH06 EPO
15/30 FREMONT C SH06
SILVER SNEAKER SH/GR-WL07
MCC FREMONT 260 SH07
MCC FREMONT EP SH07
SILVER SNEAKER SH/GR-WL08
MC COMP FREMONT SH07
ARP MCC FREMONT 260 SH08
ARP MCC FREMONT SH08
ARP MCC FREMONT EP SH08
ARP MCC ES C SP 260 SH08
ARP MCC ES C SP SH08
ARP MCC 1 C SP 260 SH08
ARP MCC 1 C SP 260-PL SH08
ARP MCC 1 C SP EP-PL SH08
ARP MCC 1 C SP PLUS SH08
ARP MCC 1 C SP SH08
ARP MCC 1 C SP EP SH08
ARP MCC 3 C SP 260 SH08
ARP MCC 3 C SP 260-PL SH08
ARP MCC 3 C SP EP-PL SH08
ARP MCC 3 C SP PLUS SH08
ARP MCC 3 C SP SH08
ARP MCC 3 C SP EP SH08
15-25/100A GR06
0/500A 3YRS PL HA-SH08
0/800A 3YRS HA-SH08
0/400A 3YR SH-HA05
0/300A 2YR GR-HA05
0/500A 2YR GR-HA05
0/500A 3YR GR-HA05
300A/24M GR-HA07
HEARING AID $500 EVERY 3YR
247 of 640
Plan Benefit - CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
HD6
HDE
HF6
HHE
HK8
HOA
HOE
HOI
HPE
HPG
HRJ
HRP
HRR
HTC
IAA
JAN
JCE
JCN
JCP
JDN
JEE
JEN
JEP
JME
JMN
JMP
LAD
LOK
LOL
MTK
MTM
NL8
O1Q
O1R
O1W
O2Q
O2R
O2W
O33
O3G
O3Q
O3R
O3W
O4Q
O4R
O4W
O5Q
O5R
O5W
O6Q
O6R
RESERVED HEARING SH06
300A 2YRS HA-GR08
25/400A 3 YRS SH-HA06
500A 3YRS HA-GR08
500A 3YRS 0PREM HA-GR08
RESERVED HEARING PFFS
RESERVED HEARING PFFS
RESERVED HEARING PFFS
RESERVED PFFS
20-40/500A HP GR07
0/800A 3YRS SH-HA07
0/500A 3YRS PL SH-HA07
300A GR-HA07
500A 2YRS HA-GR08
INFERTILITY SH05
MC COMP MESA SH07
10/25 MESA C SH06 EPO
10/25 MESA C SH06
10/25 MESA C SH06 ODP
MC COMP ESS MESA SH07
5/10 MESA CE SH06 EPO
5/10 MESA CE SH06
5/10 MESA CE SH06 ODP
5/10 MESA M SH06 EPO
5/10 MESA M SH06
5/10 MESA M SH06 ODP
20-30/250A LOKHEED GR06
20-30/250A LOKHEED GR07
20-30 LOKHEED NON-AARP GR8
10/5V 1YR MSG THRPY SH07
10/5V 1YR MSG THRPY SH08
24HR NURSLINE WL-SH/GR08
10-20/750A T2A GR07
15-25/200D T3A GR07
10-15/50A T1A GR07
10-20/750A T2A GR07
15-25/200D T3A GR07
10-15/50A T1A GR07
10/100% NAT'L-GR06
15/250A NAT'L-GR06
10-20/750A T2A GR07
15-25/200D T3A GR07
10-15/50A T1A GR07
15-25/130D T2B GR07
15-30/220D T3B GR07
5-20/100A T1B GR07
15-25/130D T2B GR07
15-30/220D T3B GR07
5-20/100A T1B GR07
15-25/130D T2B GR07
15-30/220D T3B GR07
248 of 640
Plan Benefit - CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
O6W
O7Q
O7R
O7W
O8Q
O8R
O8W
O9Q
O9R
O9W
OC1
OC3
OC5
OD1
OD3
ODE
ODF
ODG
ODK
OE1
OE3
OE5
OE8
OF1
OF3
OF5
OG3
OG5
OH1
OH3
OH5
OP3
OP4
OP5
OR1
OR3
OR5
ORX
OTZ
OVW
OY8
OYY
P8B
PAA
PAB
PAD
PAE
PAF
PAG
PAH
PAK
5-20/100A T1B GR07
10-25/150D T2C GR07
20-35/250D T3C GR07
10-20/200A T1C GR07
10-25/150D T2C GR07
20-35/250D T3C GR07
10-20/200A T1C GR07
10-25/150D T2C GR07
20-35/250D T3C GR07
10-20/200A T1C GR07
5/100% NAT'L GR 06
5/100% NAT'L GR 06
5/100% NAT'L GR 06
10/100% NAT'L-GR06
10/100% NAT'L GR 06
5/100% AARP GR086
10/100% AARP GR08
15/250A AARP GR08
20/100% NON-AARP GR08
10-20/250A NAT'L GR 06
10-20/250A NAT'L GR 06
10-20/250A NAT'L GR 06
10-20/250A AARP GR08
10-20/500A NAT'L GR 06
10-20/500A NAT'L GR 06
10-20/500A NAT'L GR 06
15/250A NAT'L GR 06
15/250A NAT'L GR 06
15-25/500A NAT'L GR 06
15-25/500A NAT'L GR 06
15-25/500A NAT'L GR 06
20-40/250A NAT'L GR 06
20-40/250A NAT'L GR 06
20-40/250A NAT'L GR 06
20/100% NAT'L GR 06
20/100% NAT'L GR 06
20/100% NAT'L GR 06
OTHR RX-NOT PS GR06
20-40/250A AARP GR08
10/100% NON-AARP GR08
10-20/250A NON-AARP GR08
15/250A NON-AARP GR08
20-30 PERA NON-AARP GR08
PPO - PFFS
PPO - PFFS
PPO - PFFS
PPO - PFFS
RESERVED PFFS
RESERVED PFFS
RESERVED PFFS
RESERVED PFFS
249 of 640
Plan Benefit - CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
PET
PEW
PIE
PIF
PIG
PIH
PII
PIK
PIL
PIN
PIO
PLP
PN7
PNW
PNY
PYI
QA2
QAN
QB1
QB2
QB7
QB9
QBE
QBN
QC2
QCE
QCN
QL1
QL2
QL7
QL9
QLE
QLJ
QLN
QM2
QME
QMN
RPE
RPX
S25
S2C
S2D
S2E
S2F
S2G
S2H
S2J
S2P
S2R
S2W
S34
20-30/500A PERA GR07
20-30 PERA NON-AARP GR08
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
PAYMENT LAG PREMIUM ALLOC
ARP MCC PUEBLO 260 SH08
ARP MCC PUEBLO SH08
ARP MCC PUEBLO EP SH08
RESERVED PFFS
MCC ESS C SPRING 260 SH07
MC COMP ESS C SPRING SH07
MCC 1 C SPRING 260-PL SH07
MCC 1 C SPRING 260 SH07
MCC 1 C SPRING EP-PL SH07
MCC 1 C SPRING PLUS SH07
MCC 1 C SPRING EP SH07
MC COMP 1 C SPRING SH07
10/30 COLSPR C SH06 D260
10/30 COLSPR C SH06 EPO
10/30 COLSPR C SH06
MCC 3 C SPRING 260-PL SH07
MCC 3 C SPRING 260 SH07
MCC 3 C SPRING EP-PL SH07
MCC 3 C SPRING PLUS SH07
MCC 3 C SPRING EP SH07
QUEST DIAGNOSTICS
MC COMP 3 C SPRING SH07
0 COLSPR M SH06 D260
0 COLSPR M SH06 EPO
0 COLSPR M SH06
RESPITE/PERS CARE SH07
RESPITE/PERS CARE WL-SH08
10-20/250A NON-AARP GR08
5/100% NAT'L-GR05
10/100% NAT'L-GR05
10-20/250A NAT'L-GR05
10-20/500A NAT'L-GR05
15/250A NAT'L-GR05
15-25/500A NAT'L-GR05
15-20/100A TOWERS PER-GR05
20-40/250A NAT'L-GR05
20/100% NAT'L-GR05
10/100% REGIONAL-GR05
10-20/250A AARP GR08
250 of 640
Plan Benefit - CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
S3C
S3D
S3E
S3F
S3G
S3H
S3P
S3R
S3W
S4H
SBA
SC2
SCA
SD2
SD3
SDA
SDB
SF2
SFC
SL2
SLA
SMA
SP2
SPA
SSP
SSR
SV2
SVA
TA6
TAX
TP1
TPH
TPL
UB2
UBE
UBN
UC2
UCE
UCN
V27
V2F
V8P
V8Q
V8R
V8S
V8T
V8U
V8V
V8W
V8X
VAA
5/100% NAT'L-GR06
10/100% NAT'L-GR06
10-20/250A NAT'L-GR06
10-20/500A NAT'L-GR06
15/250A NAT'L-GR06
15-25/500A NAT'L-GR06
20-40/250A NAT'L-GR06
20/100% NAT'L-GR06
15-25/500A AARP GR08
20-40/250A NON-AARP GR08
20-30 PART B-SH05
15/500A CO SPRG I WD-SH05
15/500A CO SPRG I-SH05
15-30/500A I W/D-SH05
10-25/400A II W/D-05
15-30/500A PLAN I-SH05
10-25/400A PLAN II-SHO5
FREMONT CO W/D-SH05
FREMONT COUNTY I-SH05
15/300A LARIMER I WD-SH05
15/300A LARIMER I-SH05
15-25/200A MESA-SH05
15-40/750A PUEBLO W/D-SH05
15-40/750A PUEBLO-SH05
SILVER SNEAKERS SH05
SLV SNEAK/FITNESS BEN GR06
15-30/700 VALUE W/D-SH05
15-30/700 VALUE PLAN-SHO5
RESERVED TRANS SH06
PCCO PREMIUM TAX
THERAPHYSICS
5-10/100% GR06
15-20/100A GR06
MCC PUEBLO 260 SH07
MCC PUEBLO EP SH07
MC COMP PUEBLO SH07
15/30 PUEBLO C SH06 D260
15/30 PUEBLO C SH06 EPO
15/30 PUEBLO C SH06
SC 20 ELIGIBILITY ONLY
0/70A TOWERS GR-VN05 VSP
0 REFRAC 1/V YR VN-GR08
5 REFRAC 1/V YR VN-GR08
10 REFRAC 1/V YR VN-GR08
15 REFRAC 1/V YR VN-GR08
20 REFRAC 1/V YR VN-GR08
25 REFRAC 1/V YR VN-GR08
30 REFRAC 1/V YR VN-GR08
35 REFRAC 1/V YR VN-GR08
40 REFRAC 1/V YR VN-GR08
0/150A SH-VN05 VSP
251 of 640
Plan Benefit - CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
VAC
VAD
VAE
VAF
VAG
VAH
VAJ
VAK
VAM
VB6
VC2
VCE
VCN
VDA
VE2
VEE
VEN
VFP
VFQ
VG6
VGP
VGQ
VJQ
VKP
VM2
VME
VMN
VMQ
VN2
VNQ
VP6
VPE
VPP
VQ1
VQ2
VQ7
VQ9
VQD
VQE
VQF
VQN
VQP
VRR
VSF
VSQ
VU1
VU2
VU7
VU9
VUE
VUN
0/125A GR-VN05 VSP
0/75A GR-VN05 VSP
25/150A SH-VN05
0/150A GR-VN05
25 EXAM ONLY SH-VN05 VSP
30 EXAM ONLY SH-VN05
40 EXAM ONLY SH-VN05
15/150A SH-VN05 VSP
10 EXAM ONLY SH-VN05
25/150A 2 YRS SH-VN06
10/30 DV CLSC SH06 D260
10/30 DENVER C SH06 EPO
10/30 DENVER C SH06
15/70A GR-VN07
5/10 DENVER CE SH06 D260
5/10 DENVER CE SH06 EPO
5/10 DENVER CE SH06
0/75A 2YRS VN-GR08
0/125A 2YRS VN-GR08
25/75A VN-GR06
5/75A 2YRS VN-GR08
5/125A 2YRS VN-GR08
10/75A 2YRS VN-GR08
10/125A 2YRS VN-GR08
10/20 DENVER M SH06 D260
10/20 DENVER M SH06 EPO
10/20 DENVER M SH06
15/125A 2YRS VN-GR08
10/75A 2YRS GR-VN07
20/75A 2YRS VN-GR08
ADVANCE WELLNESS SH-WL06
RESERVED PFFS
20/125A 2YRS VN-GR08
MCC 1 DENVER 260-PL SH07
MCC 1 DENVER 260 SH07
MCC 1 DENVER EP-PL SH07
MCC 1 DENVER PLUS SH07
30/70A 2YRS VN-SH08
MCC 1 DENVER EP SH07
0/130A 2YRS VN-SH08
MC COMP 1 DENVER SH07
25/70A 2YRS VN-GR08
10/75A GR-VN07
0/130A 2YRS SH-VN07
30/70A 2YRS SH-VN07
MCC ESS DENVER 260-PL SH07
MCC ESS DENVER 260 SH07
MCC ESS DENVER PP-PL SH07
MCC ESS DENVER PLUS SH07
MCC ESS DENVER EP SH07
MC COMP ESS DENVER SH07
252 of 640
Plan Benefit - CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
CO
VV2
VVE
VVN
VVP
VVQ
VW1
VW2
VW7
VW9
VWE
VWN
VWP
VWQ
VY1
VY2
VY7
VY9
VYE
VYN
WB6
WPR
WPS
WPT
WQR
WQS
WQT
WRR
WRS
WRT
XAA
YC2
YCE
YCN
YK2
YKE
YKN
Z2P
Z2T
Z5R
Z8P
15/30 DENVER V SH06 D260
15/30 DENVER V SH06 EPO
15/30 DENVER V SH06
15/75A 2YRS VN-GR08
25/75A 2YRS VN-GR08
MCC 2 DENVER 260-PL SH07
MCC 2 DENVER 260 SH07
MCC 2 DENVER EP-PL SH07
MCC 2 DENVER PLUS SH07
MCC 2 DENVER EP SH07
MC COMP 2 DENVER SH07
25/125A 2YRS VN-GR08
25/70 2YRS VN-GR08
MCC 3 DENVER 260-PL SH07
MCC 3 DENVER 260 SH07
MCC 3 DENVER EP-PL SH07
MCC 3 DENVER PLUS SH07
MCC 3 DENVER EP SH07
MC COMP 3 DENVER SH07
RESERVED HLTH ED SH06
10-15/50A T1A GR07
5-20/100A T1B GR07
10-20/200A T1C GR07
10-20/750A T2A GR07
15-25/130D T2B GR07
10-25/150D T2C GR07
15-25/200D T3A GR07
15-30/220D T3B GR07
20-35/250D T3C GR07
NO RX GR05
15/30 LARIMER C SH06 D260
15/30 LARIMER C SH06 EPO
15/30 LARIMER C SH06
MCC LARIMER 260 SH07
MCC LARIMER EP SH07
MC COMP LARIMER SH07
10-15/50A T1A NON-AARP GR8
15-25/200D T3A NO-AARP GR8
15-25/130D T2B NO-AARP GR8
10-20/200A T1C NO-AARP GR8
253 of 640
Plan Benefit - NV
Cap/Eligibility CP7810
Assigned Plan Benefit Codes & Descriptions
State
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
Plan / Benefit
22B
22C
22H
2AC
2AD
2AE
2AF
2AG
2AH
2AN
2AY
2BL
2FH
2FL
2GH
2HH
2JH
2KH
2MH
2NH
2PH
2QH
2UH
2VH
2WH
2XH
2YH
2ZA
2ZB
2ZC
2ZD
2ZE
2ZF
32A
32B
32C
33B
3AC
3AD
3AE
3AF
3AG
Plan / Benefit Description
3/3 BOEING GR-RX05
5/5 EDISON GR-RX05
5/5 BOEING GR-RX05
7/14 GR-RX05
10/20 GR-RX05
10/25L GR-RX05
7/14 I GR-RX05
10/20 I GR-RX05
10/25L I GR-RX05
4/20/40 LO GR-RX07
4/25/50 HI GR-RX07
10/25/50 RX-GR08
4/15/30 RX-GR08
5/20/45 RX-GR08
4/20/40 RX-GR08
4/15/30 RX-GR08
4/20/40 RX-GR08
4/25/50 RX-GR08
4/25/45 RX-GR08
4/28/55 RX-GR08
4/28/58 RX-GR08
4/25/50 RX-GR08
10/25/50 RX-GR08
10/25/50 RX-GR08
5/20/45 RX-GR08
5/20/45 RX-GR08
4/10/20 RX-GR08
0/0 GR-RX07
2/40 GR-RX07
5/25 GR-RX07
5/65 GR-RX07
5/10 GR-RX07
10/20 GR-RX07
10/20/35L GR-RX05
5/15/30 BO GR-RX05
5/15 B-148 GR-RX05
5/15/30 BO RX-GR08
10/20/40 GR-RX05
15/25/40L GR-RX05
15/25/40 GR-RX05
10/20/40 SH-RX05
10/20/40 I GR-RX05
254 of 640
Plan Benefit - NV
State
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
Plan / Benefit
3AH
3AJ
3AL
3AM
3LL
3ZE
3ZF
3ZG
3ZH
3ZJ
3ZK
3ZL
3ZM
44E
44F
47D
47H
6AH
6AL
6AR
6BH
6BL
6CM
6DH
6DL
6EH
6EL
6ER
6FH
6FL
6GM
6HH
6HL
6JH
6JL
6JP
6KH
6KI
6KL
6KP
6KR
6LH
6LL
6LR
6MA
6MH
6ML
6MR
6NH
6NL
Plan / Benefit Description
15/25/40L I GR-X05
15/25/40 I GR-RX05
10/20/40PA SH-RX05
10/25/50P L SH-X05
10/20/50 GR-RX07
5/10/20 GR-RX07
10/20/35 GR-RX07
10/20/35 GR-RX07
10/25/55 GR-RX07
10/40/75 GR-RX07
7/20/50% GR-RX07
2/30/60 GR-RX07
10/25/50 GR-RX07
MCC CLARK GR08
MCC CLARK DLX GR08
MCC NYE GR08
MCC NYE DLX GR08
0/0 HI GR-RX07
0/0 LO GR-RX07
0/0 GR-RX06
2/30/60 HI GR-RX07
2/30/60 LO GR-RX07
15/25/40 GR-RX06
2/40 HI GR-RX07
2/40 LO GR-RX07
5/25 HI GR-RX07
5/25 LO GR-RX07
10/20 GR-RX06
5/65 HI GR-RX07
5/65 LO GR-RX07
5/10 GR-RX06
5/10 HI GR-RX07
5/10 LO GR-RX07
5/10/20 HI GR-RX07
5/10/20 LO GR-RX07
8.50/26.70/50% SH6
7/14 HI GR-RX07
10/20/35 I GR-RX06
7/14 LO GR-RX07
8.50/26.70/50% SH6
10/20/35 GR-RX06
7/20/50% HI GR-RX7
7/20/50% LO GR-RX7
10/20/35 GR-RX06
10/25%/40% RX-GR06
10/20 HI GR-RX07
10/20 LO GR-RX07
10/20/40 GR-RX06
10/20/40 HI GR-RX7
10/20/40 LO GR-RX7
255 of 640
Plan Benefit - NV
State
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
Plan / Benefit
6PH
6PL
6PM
6QH
6QL
6RH
6RL
6SH
6SL
6TH
6TL
6UC
6UH
6UL
6UM
6VM
6WH
6YM
7AQ
7AR
7BD
7BH
7BI
7BL
7BR
7CD
7CI
7CM
7DD
7DH
7DL
7DM
7DR
7ED
7EH
7EL
7EM
7ER
7FD
7FH
7FL
7FM
7FR
7GD
7GM
7GR
7HH
7HI
7HL
7HR
Plan / Benefit Description
10/20 HI GR-RX07
10/20 LO GR-RX07
5/15/30 GR-RX06
10/20/35 HI GR-RX7
10/20/35 LO GR-RX7
10/20/35 HI GR-RX7
10/20/35 LO GR-RX7
10/25/55 HI GR-RX7
10/25/55 LO GR-RX7
10/40/75 HI GR-RX7
10/40/75 LO GR-RX7
10/20/35 GR-RX06
15/25/40 HI GR-RX7
15/25/40 LO GR-RX7
5/5 GR-RX06
5/5 GR-RX06
10/25/50 HI GR-RX7
7/14 GR-RX06
7/20 GR-RX07
0/0 GR-RX07
7/14 GR-RX07
4/10/20 T1A H GRX7
7/14 I GR-RX07
4/10/20 T1A L GRX7
0/0 FLAT GR-RX07
7/14 GR-RX07
7/14 I GR-RX07
15/25/40 GR-RX07
7/20/30 GR-RX07
4/15/30 T1B H GRX7
4/15/30 T1B L GRX7
15/25/40 GR-RX07
10/10 FLAT GR-RX07
7/7 GR-RX07
4/20/40 T1C H GRX7
4/20/40 T1C L GRX7
3/3 FLAT GR-RX07
10/20 GR-RX07
7/7 C GR-RX07
4/25/50 T1D H GRX7
4/25/50 T1D L GRX7
3/3/3 GR-RX07
10/20 GR-RX07
10/20/30 GR-RX07
5/10 GR-RX07
10/20 GR-RX07
4/15/30 T2A H GRX7
10/20 I GR-RX07
4/15/30 T2A L GRX7
10/20 GR-RX07
256 of 640
Plan Benefit - NV
State
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
Plan / Benefit
7JH
7JL
7JM
7JR
7KH
7KI
7KL
7KM
7KR
7LH
7LL
7LM
7LR
7MA
7MH
7MI
7ML
7MR
7NH
7NL
7NM
7PH
7PI
7PL
7PM
7PR
7QH
7QI
7QL
7QM
7QR
7RA
7RB
7RC
7RD
7RH
7RL
7RM
7SB
7SI
7SR
7TH
7TL
7TM
7TR
7UC
7UH
7UL
7UM
7UR
Plan / Benefit Description
4/28/58 T3C H GRX7
4/28/58 T3C L GRX7
5/10 GR-RX07
10/10 GR-RX07
4/28/55 T3B H GRX7
10/20/35 I GR-RX07
4/28/55 T3B L GRX7
5/10/20 GR-RX07
10/20/35 GR-RX07
4/25/45 T3A H GRX7
4/25/45 T3A L GRX7
5/15 GR-RX07
15/25/40 GR-RX07
10/25%/40% GR-RX07
4/20/40 T2B H GRX7
10/20/40 I GR-RX07
4/20/40 T2B L GRX7
10/20/40 GR-RX07
4/25/50 T2C H GRX7
4/25/50 T2C L GRX7
5/15/30 GR-RX07
4/25/50 T2C H GRX7
10/20/40 I GR-RX07
4/25/50 T2C L GRX7
5/15/30 GR-RX07
10/20/40 GR-RX07
4/20/40 T2B H GRX7
10/20/40 I GR-RX07
4/20/40 T2B L GRX7
5/15/30 GR-RX07
10/20/40 GR-RX07
10/20/35 RDS GRX7
10/20 RDS GR-RX07
10/20/35 RDS GRX7
10/20 RDS GR-RX07
4/15/30 T2A H GRX7
4/15/30 T2A L GRX7
5/15/30 GR-RX07
10/25%/40% GR-RX07
10/20/40 I GR-RX07
10/20/40 GR-RX07
4/28/55 T3B H GRX7
4/28/55 T3B L GRX7
5/5 GR-RX07
10/25/40 GR-RX07
10/20/35 GR-RX07
4/28/58 T3C H GRX7
4/28/58 T3C L GRX7
5/5 GR-RX07
15/25/40 GR-RX07
257 of 640
Plan Benefit - NV
State
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
Plan / Benefit
7VH
7VL
7VM
7WH
7WI
7WL
7WM
7WR
7XA
7XB
7XC
7XD
7XE
7XF
7XG
7XH
7XJ
7XL
7XM
7XP
7YH
7YI
7YL
7YM
7YR
7ZH
7ZL
7ZM
7ZR
82A
82B
82C
82D
82E
82F
82G
82H
82J
82K
82L
82M
82N
82P
82Q
82R
82S
82T
82U
82V
82W
Plan / Benefit Description
4/25/50 T1D H GRX7
4/25/50 T1D L GRX7
5/5 GR-RX07
4/20/40 T1C H GRX7
15/25/40 I GR-RX07
4/20/40 T1C L GRX7
5/7.50 GR-RX07
15/25/40 GR-RX07
4/10/20 RDS GR-RX7
4/15/30 RDS GR-RX7
4/20/40 RDS GR-RX7
4/25/50 RDS GR-RX7
4/10/20 RDS GR-RX7
4/15/30 RDS GR-RX7
4/20/40 RDS GR-RX7
4/15/30 T1B H GRX7
4/25/50 RDS GR-RX7
4/15/30 T1B L GRX7
7/14 GR-RX07
5/29/60 N/G SH-RX7
4/10/20 T1A H GRX7
15/25/40 I GR-RX07
4/10/20 T1A L GRX7
7/14 GR-RX07
15/25/40 GR-RX07
4/25/45 T3A H GRX7
4/25/45 T3A L GRX7
7/14 GR-RX07
15/25/40 GR-RX07
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
10-25/150D T2C AARP GR08
258 of 640
Plan Benefit - NV
State
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
Plan / Benefit
82X
82Y
82Z
83A
83B
83C
83D
83E
83F
83G
83H
83J
83K
83L
83M
8AH
8AR
8B8
8BH
8CH
8DD
8DH
8DR
8ED
8EH
8EM
8ER
8FD
8FH
8GH
8GM
8HD
8HH
8KM
8LH
8LM
8MA
8NM
8PH
8PM
8RH
8RM
8SH
8TH
8TM
8TR
8UM
8UR
8VM
8WH
Plan / Benefit Description
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
0/0 HI C GR-RX07
0/0 C GR-RX07
5/29/60NG RX-SH08
DO NOT USE
2/30/60 HI C GRX07
7/20/30 C GR-RX07
2/40 HI C GR-RX07
10/10 FLAT C GRX07
7/7 C GR-RX07
5/25 HI C GR-RX07
3/3 FLAT C GR-RX07
10/20 C GR-RX07
7/7 C GR-RX07
5/65 HI C GR-RX07
5/10 HI C GR-RX07
5/10 C GR-RX07
10/20/30 C GR-RX07
DO NOT USE
5/10/20 C GR-RX07
7/20/50% HI C GRX7
5/15 C GR-RX07
10/25%/40% C GRX07
5/15/30 C GR-RX07
10/20 HI C GR-RX07
5/15/30 C GR-RX07
10/20/35 HI C GRX7
5/15/30 C GR-RX07
10/25/55 HI C GRX7
10/40/75 HI C GRX7
5/5 C GR-RX07
10/25/40 C GR-RX07
5/5 C GR-RX07
15/25/40 C GR-RX07
5/7.50 C GR-RX07
10/25/50 HI C GRX7
259 of 640
Plan Benefit - NV
State
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
Plan / Benefit
91H
92H
93H
94H
95H
9AN
9AQ
9AR
9AY
9BE
9BH
9BL
9CM
9DH
9DL
9DR
9EH
9EL
9ER
9FD
9FH
9FL
9GE
9GM
9HD
9HH
9HK
9HL
9HN
9JH
9JL
9KH
9KL
9KS
9LH
9LL
9LM
9LP
9LR
9LV
9MA
9MH
9MI
9ML
9MR
9NH
9NL
9NM
9PH
9PL
Plan / Benefit Description
15/25/40 HI GR-RX8
10/25/50 HI GR-RX8
10/20/40 HI GR-RX8
10/20 HI GR-RX08
10/40/75 HI C XGR8
4/20/40 LO RX-GR08
7/20 RX-GR08
0/0 RX-GR08
4/25/50 HI RX-GR08
7/14 RX-GR08
4/10/20 T1A H XGR8
4/10/20 T1A L XGR8
15/25/40 RX-GR08
4/15/30 T1B H XGR8
4/15/30 T1B L XGR8
10/10 FLAT C XGR08
4/20/40 T1C H XGR8
4/20/40 T1C L XGR8
10/20 RX-GR08
7/7 C RX-GR08
4/25/50 T1D H XGR8
4/25/50 T1D L XGR8
10/20/30 RX-GR08
5/10 RX-GR08
10/20/30 C RX-GR08
4/15/30 T2A H XGR8
4/10/20 RX-GR08
4/15/30 T2A L XGR8
4/15/30 RX-GR08
4/28/58 T3C H XGR8
4/28/58 T3C L XGR8
4/28/55 T3B H XGR8
4/28/55 T3B L XGR8
10/20/35 RX-GR08
4/25/45 T3A H XGR8
4/25/45 T3A L XGR8
5/15 C RX-GR08
5/15 RX-GR08
10/20/50 RX-GR08
10/20/35 RX-GR08
10/25%/40% RX-GR08
4/20/40 T2B H CGR8
10/20/40 I RX-GR08
4/20/40 T2B L XGR8
10/20/40 RX-GR08
4/25/50 T2C H XGR8
4/25/50 T2C L XGR8
5/15/30 RX-GR08
4/25/50 T2C H XGR8
4/25/50 T2C L XGR8
260 of 640
Plan Benefit - NV
State
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
Plan / Benefit
9PX
9QH
9QL
9RH
9RL
9RP
9RX
9TH
9TL
9UC
9UH
9UL
9VH
9VL
9VM
9WH
9WI
9WL
9WM
9XH
9XL
9YH
9YL
9ZH
9ZL
APF
APN
AT7
ATP
ATQ
ATU
ATV
BDA
BDL
BOQ
BVE
BVL
C27
C2E
C7A
C7E
C7F
C7G
C7H
C7J
C7K
C7L
C7M
C7P
C7S
Plan / Benefit Description
5/29/60 P RX-GR08
4/20/40 T2B H XGR8
4/20/40 T2B L XGR8
4/15/30 T2A H XGR8
4/15/30 T2A L XGR8
5/15/30 RX-GR08
NO RX
4/28/55 T3B H XGR8
4/28/55 T3B L XGR8
10/20/35 RX-GR08
4/28/58 T3C H XGR8
4/28/58 T3C L XGR8
4/25/50 T1D H XGR8
4/25/50 T1D L XGR8
5/5 RX-GR08
4/20/40 T1C H XGR8
15/25/40 I RX-GR08
4/20/40 T1C L XGR8
5/7.50 RX-GR08
4/15/30 T1B H XGR8
4/15/30 T1B L XGR8
4/10/20 T1A H XGR8
4/10/20 T1A L XGR8
4/25/45 T3A H XGR8
4/25/45 T3A L XGR8
10/12V 1YR ACU SH07
10/12V 1YR ACU SH08
ATW-STD SH-WL07
ATW-PLUS SH-WL07
ATW ENHANCED SH08
ATW-PLUS WL-SH08
ATW-STD WL-SH08
0/250A BOEING IAM725 GR 06
0 BO IAM 725 NO-AARP GR08
15 BO 148 NO-AARP GR08
15/100A BOEING VEBA GR07
15 BO-VEBA NON-AARP GR08
SC 90 ELIGIBILITY ONLY
15/30V GR-CH06
5/12V 1YR GR-CH07
10/12V 1YR GR-CH07
10/20V 1YR GR-CH07
10/30V 1YR GR-CH07
15/12V 1YR GR-CH07
15/20V 1YR GR-CH07
0/20V 1YR GR-CH07
15/30V 1YR GR-CH07
20/12V 1YR GR-CH07
5/10V 1YR GR-CH07
30/12V 1YR GR-CH07
261 of 640
Plan Benefit - NV
State
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
Plan / Benefit
C7U
C7W
C7Y
CAB
CAC
CAD
CAE
CAG
CAH
CBO
CFP
CFV
CGL
CGR
CGS
CGU
CGV
CGX
CHU
CHW
CPA
CRR
CZC
CZD
CZF
CZG
CZH
CZJ
D6V
D8A
D8B
D8E
D8K
DAD
DBA
DL6
DMA
DN2
DN3
DNA
DNY
DQ6
DRR
ECP
EZC
FBB
FFS
FFV
FSL
FTL
Plan / Benefit Description
5/20V 1YR GR-CH07
5/30V 1YR GR-CH07
5/40 1YR GR-CH07
5/12V GR-CH05
15/12V GR-CH05
20/12V GR-CH05
10/12V GR-CH05
15/12V SH-CH05
20/12V SH-CH05
0/20V BOEING IAM GR-CH06
10/CFI-VEBA NON-AARP GR08
10/100% CFI VEBA GR07
CAREGIVER LITE SH06
CAREGIVER - RESPITE SH05
CAREGIVER GR05
CAREGIVER-RESPITE CG-SH08
CAREGIVER CG-GR08
CAREGIVER ENHANCED
10/12V 1YR SH-CH07
10/12V 1YR CH-SH08
RESERVED PFFS
10/12V GR-CH07
10/12V BO HRLY GR-CH05
15/12V BO-HRLY-F GR-CH05
5/10V EDISON GR-CH05
5/10V UC GR-CH05
15/20V B-148 GR-CH05
5/4V BOEING GR-CH05
DENTAL - VISION GR06
DELUXE OPTION DN-SH08
PREVENTIVE DN-SH08
$20 469 DN-SH08
$0 466 DN-SH08
OPTIONAL SH-DN05
100%/70% DISCOUNT GR-DN07
$0 466 SH-DN06
20% SH-DM05
SO 460 GRP BILLED - GR
SO 462 INDIV BILLED - GR
PREVENTIVE SH-DN07
DELUXE OPTION SH-DN07
$20 469 SH-DN06
10-20/200A DERP GR07
10/100% EDISON FLEX GR06
10/100% EDISON-F AARP GR08
FITNESS BENEFIT SH06
FITNESS SH/GR-WL07
FITNESS SH/GR-WL08
SILVER SNEAKER SH/GR-WL07
SILVER SNEAKER SH/GR-WL08
262 of 640
Plan Benefit - NV
State
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
Plan / Benefit
H6P
H8A
H8B
H8D
H8G
H8H
HAA
HAB
HAC
HAD
HAE
HAF
HAH
HAJ
HAN
HBJ
HDE
HF6
HHE
HL8
HOA
HOE
HOI
HPE
HRD
HRJ
HRP
HRR
HRX
HRY
HTC
HXD
KDO
KDQ
KDU
KDV
KDW
KDX
KEO
KEQ
KEU
KEV
KEW
KEX
KFU
KFW
KFX
LAD
LAL
LJ8
Plan / Benefit Description
15-25/100A GR06
0/500A 3YRS PL HA-SH08
0/1300A 3YRS DX HA-SH08
0/800A 3YRS DX HA-SH08
0/800A 3YRS HA-SH08
0/1600A 3YRS DX HA-SH08
0/400A 3YR SH-HA05
0/300A 2YR GR-HA05
0/500A 2YR GR-HA05
0/500A 3YR GR-HA05
15/400A GR-HA05
35%D GR-HA05
1 EAR 3YR GR-HA05
1PR 3YR GR-HA05
300A/24M GR-HA07
HEARING AID $500 EVERY 3YR
300A 2YRS HA-GR08
25/400A 3 YRS SH-HA06
500A 3YRS HA-GR08
400A 3YRS 0PREM HA-GR08
RESERVED HEARING PFFS
RESERVED HEARING PFFS
RESERVED HEARING PFFS
RESERVED PFFS
0/800A 3YRS DX SH-HA07
0/800A 3YRS SH-HA07
0/500A 3YRS PL SH-HA07
300A GR-HA07
0/1600A 3YRS DX SH-HA07
0/1300A 3YRS DX SH-HA07
500A 2YRS HA-GR08
1 EAR 3YR HA-GR08
ARP MCC CLK PL-DLX SH08
ARP MCC CLK PP-PL SH08
ARP MCC CLK PP SH08
ARP MCC CLK PLUS SH08
ARP MCC CLK SH08
ARP MCC CLK DLX SH08
ARP MCC VA CLK PL-DLX SH08
ARP MCC VA CLK PP-PL SH08
ARP MCC VA CLK PP SH08
ARP MCC VA CLK PLUS SH08
ARP MCC VA CLK SH08
ARP MCC VA CLK DLX SH08
ARP MCC ES CLK PP SH08
ARP MCC ES CLK SH08
ARP MCC ES CLK DLX SH08
20-30/250A LOKHEED GR06
15/100% LACERS GR07
15 LACERS NON-AARP GR08
263 of 640
Plan Benefit - NV
State
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
Plan / Benefit
LOC
LOK
LOL
LRI
MTK
MTM
NAU
NAW
NAX
NBU
NBW
NBX
NCE
NCN
NCS
NEE
NEN
NES
NL8
NME
NMN
NMS
NTB
NTL
O1Q
O1R
O1W
O2A
O2K
O2M
O2Q
O2R
O2S
O2W
O3D
O3E
O3Q
O3R
O3W
O4Q
O4R
O4W
O5Q
O5R
O5W
O6Q
O6R
O6W
O7Q
O7R
Plan / Benefit Description
DO NOT USE
20-30/250A LOKHEED GR07
20-30 LOKHEED NON-AARP GR8
LIABILITY/RECOVERY INFO
10/5V 1YR MSG THRPY SH07
10/5V 1YR MSG THRPY SH08
ARP MCC NYE PP SH08
ARP MCC NYE SH08
ARP MCC NYE DLX SH08
ARP MCC ES NYE PP SH08
ARP MCC ES NYE SH08
ARP MCC ES NYE DLX SH08
5/10 NYE C SH06 EPO
5/10 NYE C SH06
5/10 NYE C SH06 ODP
0 NYE CE SH06 EPO
0 NYE CE SH06
0 NYE CE SH06 ODP
24HR NURSLINE WL-SH/GR08
0 NYE M SH06 EPO
0 NYE M SH06
0 NYE M SH06 ODP
0/24-1W NON-ER TRANS SH07
0/24-1W NON-ER TRANS SH08
10-20/750A T2A GR07
15-25/200D T3A GR07
10-15/50A T1A GR07
0/100% BOEING-GR05
10/100% BOEING HRLY-GR05
15/100% BOEING HRLY-F-GR05
10-20/750A T2A GR07
15-25/200D T3A GR07
15/200A BOEING 148-GR05
10-15/50A T1A GR07
10/100% NAT'L-GR06
10-20/250A NAT'L-GR06
10-20/750A T2A GR07
15-25/200D T3A GR07
10-15/50A T1A GR07
15-25/130D T2B GR07
15-30/220D T3B GR07
5-20/100A T1B GR07
15-25/130D T2B GR07
15-30/220D T3B GR07
5-20/100A T1B GR07
15-25/130D T2B GR07
15-30/220D T3B GR07
5-20/100A T1B GR07
10-25/150D T2C GR07
20-35/250D T3C GR07
264 of 640
Plan Benefit - NV
State
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
Plan / Benefit
O7W
O8E
O8K
O8Q
O8R
O8W
O9Q
O9R
O9W
OBC
OBL
OC1
OC2
OC3
OC4
OD2
ODF
ODG
OE2
OE3
OEB
OEC
OF1
OF2
OF4
OG1
OG2
OG4
OH1
OH2
OH3
OLV
OP1
OP2
OP3
OP4
OR1
OR2
OR3
OR4
ORX
OS3
OTZ
OU8
OVW
OYS
OYY
PAA
PAB
PAD
Plan / Benefit Description
10-20/200A T1C GR07
10-20/250A NON-AARP GR08
10 BO HRLY NO-AARP GR08
10-25/150D T2C GR07
20-35/250D T3C GR07
10-20/200A T1C GR07
10-25/150D T2C GR07
20-35/250D T3C GR07
10-20/200A T1C GR07
10/100% NON-AARP GR08
10 SDCERA NON-AARP GR08
5/100% NAT'L GR 06
5/100% NAT'L GR 06
5/100% NAT'L GR 06
5/100% NAT'L GR 06
10/100% NAT'L GR 06
10/100% AARP GR08
15/250A AARP GR08
10-20/250A NAT'L GR 06
10-20/250A NAT'L-GR06
15 BO HRLY-F NO-AARP GR08
15 BO SCPEA NO-AARP GR08
10-20/500A NAT'L GR 06
10-20/500A NAT'L GR 06
10-20/500A NAT'L GR 06
15/250A NAT'L GR 06
15/250A NAT'L GR 06
15/250A NAT'L GR 06
15-25/500A NAT'L GR 06
15-25/500A NAT'L GR 06
15-25/500A NAT'L GR 06
5/100% NON-AARP GR08
20-40/250A NAT'L GR 06
20-40/250A NAT'L GR 06
20-40/250A NAT'L GR 06
20-40/250A NAT'L GR 06
20/100% NAT'L GR 06
20/100% NAT'L GR 06
20/100% NAT'L GR 06
20/100% NAT'L GR 06
OTHR RX-NOT PS GR06
10/100% NAT'L-GR06
20-40/250A AARP GR08
10-20/250A NON-AARP GR08
10/100% NON-AARP GR08
15-25/500A AARP GR08
15/250A NON-AARP GR08
RESERVED PFFS
RESERVED PFFS
RESERVED PFFS
265 of 640
Plan Benefit - NV
State
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
Plan / Benefit
PAE
PAF
PAG
PAH
PAK
PCJ
PCL
PIE
PIF
PIG
PIH
PII
PIK
PIL
PIN
PIO
PLP
PYI
RCE
RCN
RCS
REE
REN
RES
RLD
RLN
RLP
RME
RMN
RMS
RPE
RPL
RPX
RQ6
RQ9
RQD
RQN
RQO
RQP
RY6
RY9
RYD
RYN
RYO
RYP
S25
S2A
S2C
S2D
S2E
Plan / Benefit Description
RESERVED PFFS
RESERVED PFFS
RESERVED PFFS
RESERVED PFFS
RESERVED PFFS
SV $20-$40/$200A PHS 06
SV $20-$40/$200A PHS 06
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
PAYMENT LAG PREMIUM ALLOC
RESERVED PFFS
5/10 CLARK C SH06 EPO
5/10 CLARK C SH06
5/10 CLARK C SH06 ODP
0 CLARK CE SH06 EPO
0 CLARK CE SH06
0 CLARK CE SH06 ODP
MCC ESS CLARK DELUXE SH07
MC COMP ESS CLARK SH07
MCC ESS CLARK PP SH07
0 CLARK M SH06 EPO
0 CLARK M SH06
0 CLARK M SH06 ODP
RESPITE/PERS CARE SH07
ALREADY USED
RESPITE/PERS CARE WL-SH08
MCC CLARK PP-PL SH07
MCC CLARK PLUS SH07
MCC CLARK DELUXE SH07
MC COMP CLARK SH07
MCC CLARK PL-DLX SH07
MCC CLARK PP SH07
MCC VALUE CLARK PP-PL SH07
MCC VALUE CLARK PLUS SH07
MCC VALUE CLARK DELUX SH07
MC COMP VALUE CLARK SH07
MCC VALU CLARK PP-DLX SH07
MCC VALUE CLARK PP SH07
10-20/250A NON-AARP GR08
0/100% BOEING-GR05
5/100% NAT'L-GR05
10/100% NAT'L-GR05
10-20/250A NAT'L-GR05
266 of 640
Plan Benefit - NV
State
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
Plan / Benefit
S2F
S2G
S2H
S2J
S2K
S2M
S2P
S2R
S2S
S2U
S2V
S34
S3C
S3D
S3E
S3F
S3G
S3H
S3P
S3R
SC2
SCA
SN2
SNC
SSP
SSR
TA6
TAA
TAX
TPH
TPJ
TPL
UA7
UCA
V27
V2A
V2F
V2H
V2J
V2K
V2L
V4P
V8P
V8Q
V8R
V8S
V8T
V8U
V8V
V8W
Plan / Benefit Description
10-20/500A NAT'L-GR05
15/250A NAT'L-GR05
15-25/500A NAT'L-GR05
15-20/100A TOWERS PER-GR05
10/100% BOEING HRLY-GR05
15/100% BOEING HRLY-F-GR05
20-40/250A NAT'L-GR05
20/100% NAT'L-GR05
15/200A BOEING 148-GR05
15/100% UNIV CAL-GR05
5/100% EDISON INT-GR05
10-20/250A AARP GR08
5/100% NAT'L-GR06
10/100% NAT'L-GR06
10-20/250A NAT'L-GR06
10-20/500A NAT'L-GRO6
15/250A NAT'L-GR06
15-25/500A NAT'L-GR06
20-40/250A NAT'L-GR06
20/100% NAT'L-GR06
5-15/100A CLASSIC W/D-SH05
5-15/100A CLASSIC-SH05
5-20/100A NYE W/D-SH05
5-20/100A NYE-SH05
SILVER SNEAKERS SH05
SLV SNEAK/FITNESS BEN GR06
0/24T NON-ER TRANS SH06
NON-EMERGENCY TRANS SH05
PCNV PREMIUM TAX
5-10/100% GR06
15-20/100A AARP GR08
15-20/100A GR06
10/100A UNITED AL GR-07
20/250A UNIV CA GR06
SC 20 ELIGIBILITY ONLY
0/75A BOHRLY GR-VN05 NEP
0/70A TOWERS GR-VN05 NEP
0 BOEING GR-VN05 NEP
20%D UC GR-VN05 NEP
0/60A B-148 GR-VN05 NEP
0/75A BOHRLY-F GR-VN05 NEP
FITNESS BENEFIT 06
0 REFRAC 1/V YR VN-GR08
5 REFRAC 1/V YR VN-GR08
10 REFRAC 1/V YR VN-GR08
15 REFRAC 1/V YR VN-GR08
20 REFRAC 1/V YR VN-GR08
25 REFRAC 1/V YR VN-GR08
30 REFRAC 1/V YR VN-GR08
35 REFRAC 1/V YR VN-GR08
267 of 640
Plan Benefit - NV
State
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
NV
Plan / Benefit
V8X
VAA
VAC
VAD
VAK
VAN
VAP
VB6
VDA
VDF
VFP
VFQ
VG6
VGP
VGQ
VJQ
VKP
VMQ
VN2
VNQ
VP6
VPE
VPK
VPP
VQC
VQD
VQF
VQP
VRR
VSF
VSQ
VSX
VU6
VVP
VVQ
VWP
VWQ
VZG
WPR
WPS
WPT
WQR
WQS
WQT
WRR
WRS
WRT
XAA
YBD
YBN
Plan / Benefit Description
40 REFRAC 1/V YR VN-GR08
0/150A SH-VN05 NEP
0/125A GR-VN05 NEP
0/75A GR-VN05 NEP
15/150A SH-VN05 NEP
20/75A GR-VN05 NEP
1PR 1YR GR-VN05
25/150A 2 YRS SH-VN06
15/70A GR-VN07
15/125A 2YRS GR-VN07
0/75A 2YRS VN-GR08
0/125A 2YRS VN-GR08
25/75A VN-GR06
5/75A 2YRS VN-GR08
5/125A 2YRS VN-GR08
10/75A 2YRS VN-GR08
10/125A 2YRS VN-GR08
15/125A 2YRS VN-GR08
10/75A 2YRS GR-VN07
20/75A 2YRS VN-GR08
ADVANCE WELLNESS SH-WL06
RESERVED PFFS
0 BOEING VN-GR08
20/125A 2YRS VN-GR08
15/130A 1YR DLX VN-SH08
30/70A 2YRS VN-SH08
0/130A 2YRS VN-SH08
25/70A 2YRS VN-GR08
10/75A GR-VN07
0/130A 2YRS SH-VN07
30/70A 2YRS SH-VN07
15/130A 1YR DLX SH-VN07
15/75A 2YRS VN-GR06
15/75A 2YRS VN-GR08
25/75A 2YRS VN-GR08
25/125A 2YRS VN-GR08
25/70 2YRS VN-GR08
0/60A B-148 VN-GR08
10-15/50A T1A GR07
5-20/100A T1B GR07
10-20/200A T1C GR07
10-20/750A T2A GR07
15-25/130D T2B GR07
10-25/150D T2C GR07
15-25/200D T3A GR07
15-30/220D T3B GR07
20-35/250D T3C GR07
NO RX GR05
MCC NYE DELUXE SH07
MC COMP NYE SH07
268 of 640
Plan Benefit - NV
State
NV
NV
NV
NV
NV
NV
NV
Plan / Benefit
YBP
YFD
YFN
YFP
Z2P
Z2T
Z8P
Plan / Benefit Description
MCC NYE PP SH07
MCC ESS NYE DELUXE SH07
MC COMP ESS NYE SH07
MCC ESS NYE PP SH07
10-15/50A T1A NON-AARP GR8
15-25/200D T3A NO-AARP GR8
10-20/200A T1C NO-AARP GR8
269 of 640
Plan Benefit - OK
Cap/Eligibility CP7810
Assigned Plan Benefit Codes & Descriptions
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
0AZ
0BZ
1AZ
1BZ
1EZ
1JZ
1S2
1SA
1U5
1UA
1UB
201
271
2AN
2AY
2AZ
2BL
2BZ
2C1
2C2
2C3
2CF
2CG
2CH
2CJ
2CK
2CL
2CM
2CN
2CP
2FB
2FH
2FL
2G1
2G2
2G3
2G4
2GH
2HH
2JH
2KH
2MH
Plan / Benefit Description
PPO PLAN10 15 80/60 250 CB
PPO PLAN10 15 80/60 250 CB
PPO PLAN1 15 90/70 250 CBR
PPO PLAN1 15 90/70 250 CBR
PPO PLAN11 20 80/60 250 CB
PPO PLAN11 20 80/60 250 CB
$10G SH
$5
$5
$10
$5
2070 PLAN
2070 PLAN
4/20/40 LO GR-RX07
4/25/50 HI GR-RX07
PPO PLAN2 20 90/70 250 CBR
10/25/50 RX-GR08
PPO PLAN2 20 90/70 250 CBR
$5G/$10B
$10G/$15B
$7G/$15B
$5G/$5B
$5G/$5B
$7G/$15
$5G/$15B FEDS RX
$10G/$20B
$5G/$10B
$5G/$5B
$5G/$10B
7/20 GEN MOTORS
5/10 RX06
4/15/30 RX-GR08
5/20/45 RX-GR08
$7G/$14B
$10G/$20B
$10G/$25B
$10G/$20B
4/20/40 RX-GR08
4/15/30 RX-GR08
4/20/40 RX-GR08
4/25/50 RX-GR08
4/25/45 RX-GR08
270 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
2NH
2PH
2QH
2S1
2S4
2SA
2U1
2U2
2U5
2U6
2U7
2UB
2UF
2UH
2UJ
2VH
2WH
2XH
2YH
2Z1
2Z7
2ZA
2ZB
2ZC
2ZD
2ZE
2ZF
33B
3AC
3AZ
3B4
3BD
3BZ
3C1
3C2
3C3
3CF
3CH
3CL
3CM
3CT
3CU
3E1
3E2
3E3
3E4
3E5
3FA
3FC
3FD
Plan / Benefit Description
4/28/55 RX-GR08
4/28/58 RX-GR08
4/25/50 RX-GR08
$10G/$30B SH
$10G/$30B SH
$5G/$15B
$5G/$10B
$5G/$15B
$10G/$20B
$10G/$25B
$10G/$30B
$5G/$15B
$10G/$25B
10/25/50 RX-GR08
$5G/$15B
10/25/50 RX-GR08
5/20/45 RX-GR08
5/20/45 RX-GR08
4/10/20 RX-GR08
2070 PLAN (COBRA)
2070 PLAN (COBRA)
0/0 GR-RX07
2/40 GR-RX07
5/25 GR-RX07
5/65 GR-RX07
5/10 GR-RX07
10/20 GR-RX07
5/15/30 BO RX-GR08
15/30/45 RX06
PPO PLAN3 10 90/70 250 CBR
5G/15B/30NF GRP RT
5/20/45 RX06
PPO PLAN3 10 90/70 250 CBR
$10/$15/$25
$15/$20/$30
$10/$20/$30
$20G/$40B/$50NF
$10G/$25B/$45NF
$10G/$35B/$60NF
$10/$35/$60 200D
$10G/$20B/$40NF
$10G/$25B/$40NF
10/20/45 E
10/30/50 E
15/25/50 E
15/30/50E 1HD
15/35/60E 2HD
10/30/50 RX06
10/40/50 RX05
15/30/60 RX06
271 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
3G1
3G2
3G3
3GA
3GB
3JP
3MR
3OA
3PB
3PC
3PH
3QT
3U5
3U7
3U8
3U9
3UG
3UI
3UL
3XB
3ZE
3ZF
3ZG
3ZH
3ZJ
3ZK
3ZL
3ZM
400
401
402
403
404
405
406
407
408
409
40A
40B
40C
40D
40E
40F
40G
40H
40I
40J
40K
40L
Plan / Benefit Description
$15G/$25B/$40NF
$10G/$20B/$50NF
$10G/$20B/$40NF
$15G/$25B/$40NF
15G/25B/40NF W/INJ
10/25/40 JPMRGN
10/30/60 RX 08
$10G/$30B/$55NF
10/20/40 RX06
$10/$30/$40 PHS
10/30/50 RX06
10/20/35 RX 08
$5/$10/$25
$5/$15/$30
$5/$15/$35
$10/$20/$35
$5/$15/$30
$10/$20/$35
$10G/$15B/$25NF
5/20/35 RX 08
5/10/20 GR-RX07
10/20/35 GR-RX07
10/20/35 GR-RX07
10/25/55 GR-RX07
10/40/75 GR-RX07
7/20/50% GR-RX07
2/30/60 GR-RX07
10/25/50 GR-RX07
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
272 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
40M
40N
40O
40P
40Q
40R
40S
40T
40U
40V
40W
40X
40Y
40Z
410
411
412
413
414
415
416
417
418
419
41A
41B
41C
41D
41E
41F
41G
41H
41I
41J
41K
41L
41M
41N
41O
41P
41Q
41R
41S
41T
41U
41V
41W
41X
41Y
41Z
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
273 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
420
421
422
423
424
425
426
427
428
429
42I
430
43I
440
44I
45I
46H
46I
46M
47I
48I
49I
4A0
4A1
4AI
4AO
4AZ
4B0
4B1
4BI
4BO
4BZ
4C0
4C1
4CI
4CO
4D0
4D1
4E0
4E1
4EI
4EO
4F0
4F1
4FI
4FO
4G0
4G1
4GI
4H0
Plan / Benefit Description
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
RESERVED RX PPO
MANDATED OFFER RIDER PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
MCC OKCTY GR08
RESERVED RX PPO
MCC OKCTY DLX GR08
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
PPO PLAN4 20 90/70 500 CBR
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
PPO PLAN4 20 90/70 500 CBR
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
274 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
4H1
4HI
4HO
4I0
4I1
4IA
4IB
4IC
4ID
4IE
4IF
4IG
4IH
4II
4IJ
4IK
4IL
4IN
4IO
4IP
4IQ
4IR
4IS
4IT
4IU
4IV
4IW
4IX
4IY
4IZ
4J0
4J1
4JI
4JO
4K0
4K1
4KI
4KO
4L0
4L1
4LI
4M0
4M1
4MI
4MO
4N0
4N1
4NI
4NO
4O0
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
275 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
4O1
4OA
4OB
4OC
4OD
4OF
4OH
4OI
4OJ
4OK
4OL
4OM
4OO
4OP
4OQ
4OS
4OT
4OU
4OV
4OW
4OX
4OY
4OZ
4P0
4P1
4PI
4PO
4Q0
4Q1
4QI
4QO
4R0
4R1
4RO
4S0
4S1
4T0
4T1
4TI
4U0
4U1
4UI
4UO
4V0
4V1
4VI
4VO
4W0
4W1
4WI
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
276 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
4WO
4X0
4X1
4XI
4XO
4Y0
4Y1
4YI
4YO
4Z0
4Z1
4ZI
4ZO
50A
50B
50C
50D
50E
50F
50G
50H
50I
50J
50K
50L
50M
50N
50O
50P
50Q
50R
50S
50T
50U
50V
50W
50X
50Y
50Z
51A
51B
51C
51D
51E
51F
51G
51H
51I
51J
51K
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
277 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
51L
51M
51N
51O
51P
51Q
51R
51S
51T
51U
51V
51W
51X
51Y
51Z
52I
535
536
537
538
539
53I
540
541
542
543
544
545
546
547
548
549
54I
550
551
552
553
554
555
556
557
558
559
55I
560
561
562
563
564
565
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
278 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
566
567
568
569
56I
570
571
572
573
574
575
576
577
578
579
57I
580
581
582
583
584
585
586
587
588
589
58I
590
591
592
593
594
59I
5A0
5A1
5AA
5AI
5AO
5AX
5AZ
5B0
5BA
5BI
5BO
5BX
5BZ
5C0
5C1
5CA
5CI
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
HMO 5
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
PPO PLAN5 15 80/60 500 CBR
HMO 5 COBRA
RESERVED BENEFIT PPO
HMO 5
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
PPO PLAN5 15 80/60 500 CBR
HMO 5 COBRA
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
HMO 5
RESERVED BENEFIT PPO
279 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
5CO
5CZ
5D0
5D1
5E0
5E1
5EI
5F0
5F1
5FI
5FO
5G0
5G1
5GI
5H0
5H1
5HI
5HO
5I0
5I1
5IA
5IB
5IC
5ID
5IE
5IF
5IG
5IH
5II
5IJ
5IK
5IL
5IN
5IO
5IP
5IQ
5IR
5IS
5IU
5IV
5IW
5IX
5IY
5IZ
5J0
5J1
5JI
5JO
5K0
5K1
Plan / Benefit Description
RESERVED BENEFIT PPO
HMO 5 COBRA
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
280 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
5KI
5KO
5L0
5L1
5LI
5M0
5M1
5MI
5N0
5N1
5NI
5NO
5O0
5O1
5O2
5O3
5O4
5O5
5O6
5O7
5O8
5O9
5OA
5OB
5OD
5OF
5OH
5OI
5OJ
5OK
5OL
5OM
5ON
5OO
5OQ
5OS
5OT
5OU
5OV
5OW
5OX
5OY
5OZ
5P0
5P1
5PI
5PO
5Q0
5Q1
5QI
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
281 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
5QO
5R0
5RO
5S0
5S1
5S2
5S3
5SA
5SB
5SC
5T0
5T1
5TI
5U0
5U1
5UI
5UO
5V0
5V1
5VI
5VO
5W0
5W1
5WI
5WO
5X0
5X1
5XI
5XO
5Y0
5Y1
5YI
5YO
5Z0
5Z1
5ZI
5ZO
635
636
637
638
639
640
641
642
643
644
645
646
647
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
HMO 5 SMALL GROUP COBRA
HMO 5 SMALL GROUP COBRA
HMO 5 SMALL GROUP COBRA
HMO 5 SMALL GROUP
HMO 5 SMALL GROUP
HMO 5 SMALL GROUP
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
282 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
648
649
650
651
652
653
654
655
656
657
658
659
660
661
662
663
664
665
666
667
668
669
670
671
672
673
674
675
676
677
678
679
680
681
682
683
684
685
686
687
688
689
690
691
692
693
694
6AH
6AL
6AP
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
0/0 HI GR-RX07
0/0 LO GR-RX07
8.50/25.90/50% SH6
283 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
6AZ
6BH
6BL
6BP
6BZ
6DH
6DL
6EH
6EL
6EM
6FH
6FL
6FM
6FR
6HH
6HL
6JH
6JL
6KH
6KL
6LH
6LL
6MA
6MH
6ML
6NH
6NL
6PH
6PI
6PL
6PR
6QH
6QL
6QM
6RH
6RL
6SH
6SL
6SP
6TH
6TL
6UH
6UL
6VM
6WH
6ZM
6ZR
710
711
712
Plan / Benefit Description
PPO PLAN6 20 90/70 500 CBR
2/30/60 HI GR-RX07
2/30/60 LO GR-RX07
8.50/25.90/50% SH6
PPO PLAN6 20 90/70 500 CBR
2/40 HI GR-RX07
2/40 LO GR-RX07
5/25 HI GR-RX07
5/25 LO GR-RX07
3/3 FLAT GR-RX06
5/65 HI GR-RX07
5/65 LO GR-RX07
3/3/3 GR-RX06
10/20 GR-RX06
5/10 HI GR-RX07
5/10 LO GR-RX07
5/10/20 HI GR-RX07
5/10/20 LO GR-RX07
7/14 HI GR-RX07
7/14 LO GR-RX07
7/20/50% HI GR-RX7
7/20/50% LO GR-RX7
10/25%/40% RX-GR06
10/20 HI GR-RX07
10/20 LO GR-RX07
10/20/40 HI GR-RX7
10/20/40 LO GR-RX7
10/20 HI GR-RX07
10/20/40 I GR-RX06
10/20 LO GR-RX07
10/20/40 GR-RX06
10/20/35 HI GR-RX7
10/20/35 LO GR-RX7
5/15/30 GR-RX06
10/20/35 HI GR-RX7
10/20/35 LO GR-RX7
10/25/55 HI GR-RX7
10/25/55 LO GR-RX7
4.45/14.50/50% SH6
10/40/75 HI GR-RX7
10/40/75 LO GR-RX7
15/25/40 HI GR-RX7
15/25/40 LO GR-RX7
5/5 GR-RX06
10/25/50 HI GR-RX7
7/14 GR-RX06
15/25/40 GR-RX06
RESERVED PPO
RESERVED PPO
RESERVED PPO
284 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
713
714
715
716
717
718
719
71A
71B
71C
71D
71E
71F
71G
71H
71I
71J
71K
71L
71M
71N
71O
71P
71Q
71R
71S
71T
71U
71V
71W
71X
71Y
71Z
720
721
722
723
724
725
726
727
728
729
72A
72B
72C
72D
72E
72F
72G
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
285 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
72H
72I
72J
72K
72L
72M
72N
72O
72P
72Q
72R
72S
72T
72U
72V
72W
72X
730
731
732
733
734
735
736
737
738
739
73A
73B
73C
73D
73E
73F
73G
73H
73I
73J
73K
73L
73M
73N
73O
73P
73Q
73R
73S
73T
73U
73V
73W
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
286 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
73X
73Y
73Z
740
741
742
743
744
745
746
747
748
749
74A
74B
74C
74D
74E
74F
74G
74H
74I
74J
74K
74L
74M
74N
74O
74P
74Q
74R
74S
74T
74U
74V
74W
74X
74Y
74Z
750
751
752
753
754
755
756
757
758
759
75A
Plan / Benefit Description
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PLAN PPO
287 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
75B
75C
75D
75E
75F
75G
75H
75I
75J
75K
75L
75M
75N
75O
75P
75Q
75R
75S
75T
75U
75V
75W
75X
75Y
75Z
760
761
762
763
764
765
766
767
768
769
76A
76B
76C
76D
76E
76F
76G
76H
76I
76J
76K
76L
76M
76N
76O
Plan / Benefit Description
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
288 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
76P
76Q
76R
76S
76T
76U
76V
7AQ
7AR
7AZ
7BD
7BH
7BI
7BL
7BR
7BZ
7CD
7CI
7CM
7DD
7DH
7DL
7DM
7DR
7ED
7EH
7EL
7EM
7ER
7FD
7FH
7FL
7FM
7FR
7GD
7GM
7GR
7HH
7HI
7HL
7HR
7JH
7JL
7JM
7JR
7KH
7KI
7KL
7KM
7KR
Plan / Benefit Description
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
7/20 GR-RX07
0/0 GR-RX07
PPO PLAN7 10 80/60 500 CBR
7/14 GR-RX07
4/10/20 T1A H GRX7
7/14 I GR-RX07
4/10/20 T1A L GRX7
0/0 FLAT GR-RX07
PPO PLAN7 10 80/60 500 CBR
7/14 GR-RX07
7/14 I GR-RX07
15/25/40 GR-RX07
7/20/30 GR-RX07
4/15/30 T1B H GRX7
4/15/30 T1B L GRX7
15/25/40 GR-RX07
10/10 FLAT GR-RX07
7/7 GR-RX07
4/20/40 T1C H GRX7
4/20/40 T1C L GRX7
3/3 FLAT GR-RX07
10/20 GR-RX07
7/7 C GR-RX07
4/25/50 T1D H GRX7
4/25/50 T1D L GRX7
3/3/3 GR-RX07
10/20 GR-RX07
10/20/30 GR-RX07
5/10 GR-RX07
10/20 GR-RX07
4/15/30 T2A H GRX7
10/20 I GR-RX07
4/15/30 T2A L GRX7
10/20 GR-RX07
4/28/58 T3C H GRX7
4/28/58 T3C L GRX7
5/10 GR-RX07
10/10 GR-RX07
4/28/55 T3B H GRX7
10/20/35 I GR-RX07
4/28/55 T3B L GRX7
5/10/20 GR-RX07
10/20/35 GR-RX07
289 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
7LH
7LL
7LM
7LR
7MA
7MH
7MI
7ML
7MR
7NH
7NL
7NM
7PH
7PI
7PL
7PM
7PR
7QH
7QI
7QL
7QM
7QR
7RA
7RB
7RC
7RD
7RH
7RL
7RM
7SB
7SI
7SR
7TH
7TL
7TM
7TR
7UH
7UL
7UM
7UR
7VH
7VL
7VM
7WH
7WI
7WL
7WM
7WR
7XA
7XB
Plan / Benefit Description
4/25/45 T3A H GRX7
4/25/45 T3A L GRX7
5/15 GR-RX07
15/25/40 GR-RX07
10/25%/40% GR-RX07
4/20/40 T2B H GRX7
10/20/40 I GR-RX07
4/20/40 T2B L GRX7
10/20/40 GR-RX07
4/25/50 T2C H GRX7
4/25/50 T2C L GRX7
5/15/30 GR-RX07
4/25/50 T2C H GRX7
10/20/40 I GR-RX07
4/25/50 T2C L GRX7
5/15/30 GR-RX07
10/20/40 GR-RX07
4/20/40 T2B H GRX7
10/20/40 I GR-RX07
4/20/40 T2B L GRX7
5/15/30 GR-RX07
10/20/40 GR-RX07
10/20/35 RDS GRX7
10/20 RDS GR-RX07
10/20/35 RDS GRX7
10/20 RDS GR-RX07
4/15/30 T2A H GRX7
4/15/30 T2A L GRX7
5/15/30 GR-RX07
10/25%/40% GR-RX07
10/20/40 I GR-RX07
10/20/40 GR-RX07
4/28/55 T3B H GRX7
4/28/55 T3B L GRX7
5/5 GR-RX07
10/25/40 GR-RX07
4/28/58 T3C H GRX7
4/28/58 T3C L GRX7
5/5 GR-RX07
15/25/40 GR-RX07
4/25/50 T1D H GRX7
4/25/50 T1D L GRX7
5/5 GR-RX07
4/20/40 T1C H GRX7
15/25/40 I GR-RX07
4/20/40 T1C L GRX7
5/7.50 GR-RX07
15/25/40 GR-RX07
4/10/20 RDS GR-RX7
4/15/30 RDS GR-RX7
290 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
7XC
7XD
7XE
7XF
7XG
7XH
7XJ
7XL
7XM
7XP
7XV
7YH
7YI
7YL
7YM
7YR
7ZH
7ZL
7ZM
7ZR
810
811
812
813
814
815
816
817
818
819
820
821
822
823
824
825
826
827
828
829
82A
82B
82C
82D
82E
82F
82G
82H
82J
82K
Plan / Benefit Description
4/20/40 RDS GR-RX7
4/25/50 RDS GR-RX7
4/10/20 RDS GR-RX7
4/15/30 RDS GR-RX7
4/20/40 RDS GR-RX7
4/15/30 T1B H GRX7
4/25/50 RDS GR-RX7
4/15/30 T1B L GRX7
7/14 GR-RX07
5/29/60 N/G SH-RX7
5/35/65 NGB SH-RX7
4/10/20 T1A H GRX7
15/25/40 I GR-RX07
4/10/20 T1A L GRX7
7/14 GR-RX07
15/25/40 GR-RX07
4/25/45 T3A H GRX7
4/25/45 T3A L GRX7
7/14 GR-RX07
15/25/40 GR-RX07
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
291 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
82L
82M
82N
82P
82Q
82R
82S
82T
82U
82V
82W
82X
82Y
82Z
830
831
832
833
834
835
836
837
838
839
83A
83B
83C
83D
83E
83F
83G
83H
83J
83K
83L
83M
840
841
842
843
844
845
846
847
848
849
84A
84B
84C
84D
Plan / Benefit Description
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
292 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
84E
84F
84G
84H
84J
84K
84L
84M
84N
84P
84Q
84R
84S
84T
84U
84V
84W
84X
84Y
84Z
850
851
852
853
854
855
856
857
858
859
85A
85B
85C
85D
85E
85F
85G
85H
85J
85K
85L
85M
860
861
862
863
864
865
866
867
Plan / Benefit Description
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
293 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
868
869
870
881
882
88F
8AH
8AR
8AZ
8B8
8BH
8BZ
8CH
8DD
8DH
8DR
8ED
8EH
8EM
8ER
8FD
8FH
8GH
8GM
8HD
8HH
8K8
8KM
8LH
8LM
8M8
8MA
8NM
8PH
8PM
8R8
8RH
8RM
8SH
8TH
8TM
8TR
8UM
8UR
8VM
8WH
8Z1
8Z2
8ZF
910
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED FOR PPO
880 PLAN
880 PLAN
OPT PLAN 880
0/0 HI C GR-RX07
0/0 C GR-RX07
PPO PLAN8 20 80/60 500 CBR
5/29/60NG RX-SH08
DO NOT USE
PPO PLAN8 20 80/60 500 CBR
2/30/60 HI C GRX07
7/20/30 C GR-RX07
2/40 HI C GR-RX07
10/10 FLAT C GRX07
7/7 C GR-RX07
5/25 HI C GR-RX07
3/3 FLAT C GR-RX07
10/20 C GR-RX07
7/7 C GR-RX07
5/65 HI C GR-RX07
5/10 HI C GR-RX07
5/10 C GR-RX07
10/20/30 C GR-RX07
DO NOT USE
5/34/79NG RX-SH08
5/10/20 C GR-RX07
7/20/50% HI C GRX7
5/15 C GR-RX07
5/36/82NG RX-SH08
10/25%/40% C GRX07
5/15/30 C GR-RX07
10/20 HI C GR-RX07
5/15/30 C GR-RX07
5/37/71G RX-SH08
10/20/35 HI C GRX7
5/15/30 C GR-RX07
10/25/55 HI C GRX7
10/40/75 HI C GRX7
5/5 C GR-RX07
10/25/40 C GR-RX07
5/5 C GR-RX07
15/25/40 C GR-RX07
5/7.50 C GR-RX07
10/25/50 HI C GRX7
880 PLAN (COBRA)
880 PLAN
OPT PLAN 880 (COBRA)
RESERVED PPO
294 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
911
912
913
914
915
916
917
918
919
91H
920
921
922
923
924
925
926
927
928
929
92H
930
931
932
933
934
935
936
937
938
939
93H
940
941
942
943
944
945
946
947
948
949
94H
950
951
952
953
954
955
956
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
15/25/40 HI RX-GR8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/25/50 HI RX-GR8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/20/40 HI RX-GR8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/20 HI RX-GR08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
295 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
957
958
959
95H
960
961
962
963
964
965
966
967
968
969
970
971
972
973
974
975
976
977
978
979
980
981
982
983
984
985
986
987
988
989
990
991
992
993
994
9AN
9AQ
9AR
9AY
9AZ
9BE
9BH
9BL
9BZ
9CM
9DH
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/40/75 HI C XGR8
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
4/20/40 LO RX-GR08
7/20 RX-GR08
0/0 RX-GR08
4/25/50 HI RX-GR08
PPO PLAN9 25 80/60 500 CBR
7/14 RX-GR08
4/10/20 T1A H XGR8
4/10/20 T1A L XGR8
PPO PLAN9 25 80/60 500 CBR
15/25/40 RX-GR08
4/15/30 T1B H XGR8
296 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
9DL
9DR
9EH
9EL
9ER
9FD
9FH
9FL
9GE
9GM
9HD
9HH
9HK
9HL
9HN
9JH
9JL
9KH
9KL
9KS
9LH
9LL
9LM
9LP
9LV
9MA
9MH
9MI
9ML
9MR
9NH
9NL
9NM
9PH
9PL
9PX
9QH
9QL
9RH
9RL
9RP
9RX
9TH
9TL
9UH
9UL
9VH
9VL
9VM
9WH
Plan / Benefit Description
4/15/30 T1B L XGR8
10/10 FLAT C XGR08
4/20/40 T1C H XGR8
4/20/40 T1C L XGR8
10/20 RX-GR08
7/7 C RX-GR08
4/25/50 T1D H XGR8
4/25/50 T1D L XGR8
10/20/30 RX-GR08
5/10 RX-GR08
10/20/30 C RX-GR08
4/15/30 T2A H XGR8
4/10/20 RX-GR08
4/15/30 T2A L XGR8
4/15/30 RX-GR08
4/28/58 T3C H XGR8
4/28/58 T3C L XGR8
4/28/55 T3B H XGR8
4/28/55 T3B L XGR8
10/20/35 RX-GR08
4/25/45 T3A H XGR8
4/25/45 T3A L XGR8
5/15 C RX-GR08
5/15 RX-GR08
10/20/35 RX-GR08
10/25%/40% RX-GR08
4/20/40 T2B H XGR8
10/20/40 I RX-GR08
4/20/40 T2B L XGR8
10/20/40 RX-GR08
4/25/50 T2C H XGR8
4/25/50 T2C L XGR8
5/15/30 RX-GR08
4/25/50 T2C H XGR8
4/25/50 T2C L XGR8
5/29/60 P RX-GR08
4/20/40 T2B H XGR8
4/20/40 T2B L XGR8
4/15/30 T2A H XGR8
4/15/30 T2A L XGR8
5/15/30 RX-GR08
NO RX
4/28/55 T3B H XGR8
4/28/55 T3B L XGR8
4/28/58 T3C H XGR8
4/28/58 T3C L XGR8
4/25/50 T1D H XGR8
4/25/50 T1D L XGR8
5/5 RX-GR08
4/20/40 T1C H XGR8
297 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
9WI
9WL
9WM
9XH
9XL
9YH
9YL
9ZH
9ZL
A1C
A1H
A1L
A1M
A1X
A1Z
A38
AA1
AA2
AA3
AA4
AA5
AA6
AA7
AA8
AAA
AAC
AAF
AAH
AAJ
AAZ
AB1
ABA
ABC
ABZ
ACA
ACF
ACZ
AD0
AD1
AD2
AD3
AD4
AD5
AD8
ADA
ADC
ADH
ADL
ADM
ADN
Plan / Benefit Description
15/25/40 I RX-GR08
4/20/40 T1C L XGR8
5/7.50 RX-GR08
4/15/30 T1B H XGR8
4/15/30 T1B L XGR8
4/10/20 T1A H XGR8
4/10/20 T1A L XGR8
4/25/45 T3A H XGR8
4/25/45 T3A L XGR8
PREFERRED PLAN
PREFERRED PLAN COBRA
PREFERRED PLAN
PREFERRED PLAN
PREFERRED PLAN
COBRA
PREFERRED PLAN COBRA
C80 PLAN
AA $15-$20/$250
AA $15-$20/$250 COBRA
AA $15-$20/$250
AA $15-$20/$250 COBRA
AA 20-40/250A
AA 20-40/250A COBRA
AA 20-40/250A
AA 20-40/250A COBRA
HMO 10
SV 20-40/350A 06
SV 20-40/350A 06 CB
SV 20-40/350A 06
SV 20-40/350A 06 CB
HMO 10 COBRA
ANHEUSER-BUSCH $8/80 CBRA
HMO 10
ANHEUSER-BUSCH $8/80
HMO 10 COBRA
HMO 10
BROKER/CONSULTANT FEE
HMO 10 COBRA
ALCOHOL/DRUG ABUSE (100%)
INP CHEM DEP-HIGH (STATE)
INP CHEM DEP-LOW OK STATE
INP CHEM DEP-LOW OK STATE
INP CHEM DEP-HIGH OK STATE
ALCOHOL/DRUG REHAB 50/50
ALCOHOL/DRUG ABUSE (80%)
CHEMICAL DEPENDENCY (AAON)
HMO 10 HILLCREST
ALCOHOL/DRUG REHAB-HIGH
ALCOHOL / DRUG REHAB -LOW
ALCOH/DRUG REHAB - MC DOUG
ADMINISTRATION FEE
298 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
ADS
ADZ
AEC
AEZ
AFM
AFS
AFX
AL1
AL2
ALA
ALB
AMC
AMH
AML
AMZ
AN1
AN2
AN6
AN7
ANA
ANB
ANC
AND
ANE
APF
APN
ART
AS0
AS1
AS2
AS3
ASA
ASB
ASC
ASD
ASE
AT7
ATP
ATU
ATV
B2A
B2B
B2C
B2D
B2E
B2F
B2G
B2H
B2J
B2P
Plan / Benefit Description
ALCOHOL/DRUG REHAB
HMO 10 HILLCREST
HMO 10 HILLCREST
HMO 10 HILLCREST
FORD MOTOR COMPANY
ADMINISTRATIVE SERVICE FEE
FORD MOTOR COMPANY - COBRA
HMO LARGE GRP $15/90% CBR
HMO LARGE GRP $15/90% CBR
HMO LARGE GROUP $15/90%
HMO LARGE GROUP $15/90%
FORD MOTOR COMPANY
MCDONNEL DOUGLAS PLAN
MCDONNELL DOUGLAS PLAN
FORD MOTOR COMPANY-(COBRA)
AMERICAN AIR $10/$100 CBRA
AMERICAN AIR $10/$100 CBRA
SV $20-$40/$250A AM AIR CB
SV $20-$40/$250A AM AIR CB
AMERICAN AIRLINES $10/$100
AMERICAN AIRLINES $10/$100
SV $20-$40/$250A AM AIR
ADMINISTRATION FEE
SV $20-$40/$250A AM AIR
10/12V 1YR ACU SH07
10/12V 1YR ACU SH08
RESERVED
ALLERGY SERUM
ALLERGY SERUM (50%)
ALLERGY SERUM
ALLERGY SERUM
ALLERGY SERUM
ALLERGY SERUM
ALLERGY SERUM $12/6 WEEKS
ALLERGY SERUM $26/6WEEKS
ALLERGY SERUM $12/6WEEKS
ATW-STD SH-WL07
ATW-PLUS SH-WL07
ATW-PLUS WL-SH08
ATW-STD WL-SH08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
299 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
B2R
B3A
B3B
B3C
B3D
B3E
B3F
B3G
B3H
B3J
B3P
B3R
B4A
B4B
B4C
B4D
B4E
B4F
B4G
B4H
B4J
B4P
B4R
B5A
B5B
B5C
B5D
B5E
B5F
B5G
B5H
B5J
B5P
B5R
B62
B6A
B6B
B6C
B6D
B6E
B6F
B6G
B6H
B6J
B6R
B7A
B7B
B7C
B7D
B7E
Plan / Benefit Description
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
20-30/100% BH06
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
300 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
B7F
B7G
B7H
B7J
B7P
B7R
B8A
B8B
B8C
B8D
B8E
B8F
B8G
B8H
B8J
B8P
B8R
B9A
B9B
B9C
B9D
B9E
B9F
B9G
B9H
B9J
B9P
B9R
BA1
BA2
BA3
BAC
BAF
BAH
BBP
BC0
BC1
BC2
BC3
BC4
BC5
BC6
BC7
BC8
BC9
BCA
BCB
BCC
BCD
BCE
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
BASIC PLAN
BASIC PLAN
RESERVED
RESERVED
OPT BASIC PLAN
25/250A BH 08
20/100D BH06
AMERICAN AIR SMI/MH/CD
BOEING HOURLY SMI/MH/CD
BOEING NUS SMI/MH/CD
WILLIAM SONOMA SMI/MH/CD
7-ELEVEN SMI/MH/CD
PACIFICARE SMI/MH/CD
SMI/CHEM/MEN HLTH - MCKSN
SMI/CHEM/MEN HLTH - PBG
SMI/CD/MH BOEING VEBA
SMI/MH/CD GM SALARIED
STATE OK HIGH SMI/MH/CD
STATE OK LOW SMI/MH/CD
SEARS SMI/MH/CD $250
OK AA $15-$20/$250
OK MARRIOTT $15-$25/$100
301 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
BCF
BCG
BCH
BCI
BCJ
BCK
BCL
BCM
BCN
BCO
BCP
BCQ
BCR
BCS
BCT
BCU
BCV
BCW
BCX
BCY
BCZ
BD2
BDA
BDF
BDK
BDL
BDN
BE1
BE2
BEA
BEB
BEF
BEK
BFC
BFD
BFK
BG6
BGF
BGK
BGR
BH2
BH3
BH4
BH5
BH6
BH7
BH8
BH9
BHA
BHB
Plan / Benefit Description
PEPSI BOTTLING $20/$200
LOCKHEED $20/100%
CHEVRON TEXACO $20/100%
FARMERS $15-$30/$250
GM SALARIED $15/100%
AT&T $10-$15/$100
GM HOURLY 2003 $10/100%
BOEING $10/100% HOURLY
BOEING $10/100% IAM
ORAL ROBERTS $20/NC
FORD $0/100%
FORD SALARY $0/100%
BOEING $15/100%
NORTHROP GRUMMAN 100%/$20
OK SMI/MH/CD HI OPTION
STATE FARM SMI/MH/CD
BANK ONE SMI/MH/CD
PBG SMI/MH/CD
SMI/CD/MH BOEING IAM
OK SMI/MH/CD LOW OPTION
OK SMI/MH/CD ALT OPTION
15-20/100A BH06
0/250A BOEING IAM725 GR 06
0/250A BOEING IAM725 GR 06
SV 15/250A BOEING 08
0 BO IAM 725 NO-AARP GR08
0 BO IAM 725 NO-AARP GR08
SV 15/200A BOEING UAW CB
SV 15/200A BOEING UAW CB
SV 15/200A BOEING UAW
SV 15/200A BOEING UAW
15/250A BH 08
SV 15/250A BOEING 08 CB
SV 15/250A BOEING 08
SV 15/250A BOEING 08 CB
SV 15/250A BOEING 08
20-50/500D OK MH06
20-40/250D BH 06
SV 15/250A BOEING 08 CB
25-40/500A BH 08
BOEING NA-HRLY $10 GRP RET
BOEING NA-HRLY $10 GRP RET
BOEING HOURLY $15 GRP RET
BOEING HOURLY $15 GRP RET
20-35/200A OK MH06
$15/$200 BOEING GR
$15/$200 BOEING GR
35/240A MH06
NA SMI/CD/MH $10/$20/$100D
NA SMI/CD/MH $15/$30/$250D
302 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
BHC
BHD
BHE
BHG
BHH
BHJ
BHK
BHL
BHM
BHN
BHP
BHQ
BHR
BHS
BHT
BHU
BHV
BHW
BHX
BHY
BHZ
BIE
BIF
BIG
BIH
BJC
BJP
BKP
BKR
BL1
BL2
BLA
BLB
BNE
BNF
BNG
BNH
BO1
BO2
BO3
BO4
BO5
BO6
BO7
BO8
BOA
BOB
BOC
BOD
BOE
Plan / Benefit Description
NA SIM/CD/MH $15/$30/$400D
NA SMI/CD/MH $20/$40/$250D
NA SMI/CD/MH $20/$40/$400D
RE SMI/CD/MH $20/$40/$250D
20-40/200A BH 06
NA SMI/CD/MH $5/100%
NA SMI/CD/MH $10/100%
NA SMI/CD/MH $10/$100
NA SMI/CD/MH $10/$250
NA SMI/CD/MH $15/$100
NA SMI/CD/MH $15/$250
RE SMI/CD/MH $5/100%
RE SMI/CD/MH $10/100%
RE SMI/CD/MH $15/10%
RE SMI/CD/MH $20/100%
RE SMI/CD/MH $20/$400
RE SMI/CD/MH $20/20%
RE SMI/CD/MH $25/$600
NA SMI/CD/MH $15/100%
NA SMI/CD/MH $10/$15/$250
20-40/350A BH 06
SV 15/200A BOEING IAM
SV 15/200A BOEING IAM CB
SV 15/200A BOEING IAM
SV 15/200A BOEING IAM CB
20-40/250A BH 07
SV 15/250A BOEING 08
SV 15/250A BOEING 08 CB
15/250A BH06
HMO LARGE GRP $20/$400 CBR
HMO LARGE GRP $20/$400 CBR
HMO LARGE GROUP $20/$400
HMO LARGE GROUP $20/$400
SV 10/100% BOEING NUS
SV 10/100% BOEING NUS CB
SV 10/100% BOEING NUS
SV 10/100% BOEING NUS CB
BOEING HRLY $10/100%
BOEING HRLY $10/100% COBRA
BOEING HRLY $10/100%
BOEING HRLY $10/100% COBRA
BOEING HRLY $15/100%
BOEING HRLY $15/100% COBRA
BOEING HRLY $15/100%
BOEING HRLY $15/100% COBRA
BOEING ERET $15/100%
BOEING ERET $15/100% COBRA
BOEING ERET $15/100%
BOEING ERET $15/100% COBRA
SV 15-25/250A BOEING
303 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
BOF
BOG
BOH
BOR
BOS
BP2
BP3
BP4
BP5
BP6
BP7
BP8
BP9
BPA
BPC
BPD
BPE
BPF
BPG
BPH
BPJ
BPK
BPL
BPM
BPN
BPP
BPQ
BPR
BPS
BPU
BPV
BPW
BPX
BPY
BPZ
BQ1
BQ2
BQ3
BQ4
BQ5
BQ6
BQ7
BQ8
BQA
BQB
BQC
BQD
BQE
BQF
BQG
Plan / Benefit Description
SV 15-25/250A BOEING CB
SV 15-25/250A BOEING
SV 15-25/250A BOEING CB
15 BO 148 NO-AARP GR08
15 BO 148 NO-AARP GR08
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 20/40/250D SG
SV 20/40/250D SG CB
SV 25/600A SG
SV 25/600A SG CB
SV 20/400A SG
SV 20/400A SG CB
SV 10/200A SG
SV 10/200A SG CB
SV 20/40/250D SG
SV 20/40/250D SG CB
SV 25/600A SG
SV 25/600A SG CB
SV 20/400A SG
SV 20/400A SG CB
SV 10/200A SG
304 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
BQH
BQI
BQJ
BQK
BQL
BQM
BQN
BQP
BQQ
BR2
BR3
BR4
BR5
BR6
BR7
BR8
BR9
BRA
BRH
BS1
BS2
BS3
BSA
BSB
BSC
BSD
BSE
BSF
BSG
BSH
BSI
BSJ
BSK
BSL
BSM
BU1
BU2
BU3
BU4
BU5
BU6
BU7
BU8
BU9
BUC
BUD
BUE
BUF
BUG
BUH
Plan / Benefit Description
SV 10/200A SG CB
SV 20/20%
SV 20/20% CB
SV 20/20%
SV 20/20% CB
SV 20-40/250D
SV 20-40/250D CB
SV 20-40/250D
SV 20-40/250D CB
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
20-40/250D BH 07
15/250A BH 08
HMO 10 SMALL GROUP COBRA
HMO 10 SMALL GROUP COBRA
HMO 10 SMALL GROUP COBRA
HMO 10 SMALL GROUP
HMO 10 SMALL GROUP
HMO 10 SMALL GROUP
SG CD/MH $10/$200
SG CD/MH $15/$300
SG CD/MH $20/$400
SG CD/MH $25/$600
SG CD/MH $20/$40/$250D
SG CD/MH $10/$200
SG CD/MH $15/$300
SG CD/MH $20/$400
SG CD/MH $25/$600
SG SMI/CD/MH $20/$40/$250D
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
305 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
BUI
BUJ
BUK
BUL
BUM
BUN
BUO
BUP
BUQ
BUR
BUS
BUT
BUU
BUV
BUW
BUX
BUY
BUZ
BVE
BVG
BVK
BVL
BVN
BX2
BX3
BX4
BX5
BX6
BX7
BX8
BX9
BXA
BXB
BXC
BXD
BXE
BXF
BXG
BXH
BXJ
BXK
BXL
BXM
BXN
BXP
BXR
BXS
BXT
BXU
BXV
Plan / Benefit Description
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
SMI/CD/BH $10/$20/$100
SMI/CD/BH $15/$30/$250
SMI/CD/BH $15/$30/$400
SMI/CD/BH $20/$40/$250
SMI/CD/BH $20/$40/$400
NA SMI/CD/MH $5/100%
NA SMI/CD/MH $10/100%
NA SMI/CD/MH $10/$100
NA SMI/CD/MH $10/$250
NA SMI/CD/MH $15/100%
NA SMI/CD/MH $15/$100
NA SMI/CD/MH $15/$250
15/100A BOEING VEBA GR07
25/240A BH07
15/100A BOEING VEBA GR07
15 BO-VEBA NON-AARP GR08
15 BO-VEBA NON-AARP GR08
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
306 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
BXW
BXX
BXY
BXZ
BYA
BYB
BYC
BYD
BYE
BYF
BYG
BYH
BYJ
BYK
BYL
BYM
BYN
BYP
BYR
BYS
BZ1
BZ2
BZ3
BZ4
BZ5
BZ6
BZ7
BZ8
BZ9
BZA
BZB
BZC
BZD
BZE
BZF
BZG
BZH
BZJ
BZK
BZL
BZM
BZN
BZP
BZR
BZS
BZT
BZV
BZW
BZX
BZY
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
BASIC PLAN (COBRA)
BASIC PLAN (COBRA)
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
OPT BASIC PLAN (COBRA)
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
307 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
BZZ
C1C
C1H
C1L
C1M
C1X
C1Z
C27
C7A
C7E
C7F
C7G
C7H
C7J
C7K
C7L
C7M
C7P
C7S
C7U
C7W
C7Y
CD1
CD5
CD8
CDA
CDB
CDC
CDD
CDE
CDF
CDG
CDH
CDI
CDJ
CDP
CDQ
CDR
CDS
CDT
CDU
CDV
CDW
CEO
CF1
CF2
CF3
CFA
CFC
CFD
Plan / Benefit Description
RESERVED RX PPO
STANDARD PLAN
STANDARD PLAN COBRA
STANDARD PLAN
STANDARD PLAN
STANDARD PLAN
COBRA
STANDARD PLAN
COBRA
SC 90 ELIGIBILITY ONLY
5/12V 1YR GR-CH07
10/12V 1YR GR-CH07
10/20V 1YR GR-CH07
10/30V 1YR GR-CH07
15/12V 1YR GR-CH07
15/20V 1YR GR-CH07
0/20V 1YR GR-CH07
15/30V 1YR GR-CH07
20/12V 1YR GR-CH07
5/10V 1YR GR-CH07
30/12V 1YR GR-CH07
5/20V 1YR GR-CH07
5/30V 1YR GR-CH07
5/40 1YR GR-CH07
CHEM DEP-STANDARD EFF 1-99
CHEM DEP IP/100% OP COPAY
CHEMICAL DEPENDENCY - 80%
CHEM DEP IP/100% OP COPAY
CHEM DEP IP/$250 OP $15
CD OPOV/40VISIT IP100% CST
CD $15OV/30VISIT IP$50030D
CD FEDS IP100% OP$20WLIMIT
CHEM DEP - I/P 100%
CHEM DEP - I/P 90%
CHEM DEP - I/P 80%
CHEM DEP - I/P $150
CHEM DEP IP $250 OP $20
CHEM DEP-I/P $200
CHEM DEP-I/P $300
CHEM DEP-I/P $400
CHEM DEP-I/P $600
CHEM DEP-I/P 90%
CHEM DEP-I/P 80%
CHEM DEP-I/P $100
CD I/P $250
15/30V CH 07
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
FEDERAL EMPLOYEE PLAN
RESERVED FOR RX PPO
308 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
CFE
CFF
CFL
CFM
CG8
CG9
CGG
CGI
CGL
CGP
CGR
CGS
CGU
CGV
CGX
CH5
CHA
CHB
CHC
CHD
CHE
CHF
CHG
CHH
CHL
CHM
CHQ
CHU
CHW
CHX
CIC
CIL
CIM
CJC
CJL
CJM
CKC
CKD
CKE
CKF
CKM
CKN
CL1
CL2
CLA
CLB
CMH
CMJ
CML
CN4
Plan / Benefit Description
RESERVED FOR RX PPO
RESERVED FOR RX PPO
FEDERAL EMPLOYEE PLAN
FEDERAL EMPLOYEE PLAN
10/20V CH 07
15/20V CH 07
CAREGIVER-SH GOLD
CAREGIVER-SH INDIV
CAREGIVER LITE SH06
CAREGIVER PROGRAM
CAREGIVER-RESPITE SH07
CAREGIVER PROGRAM
CAREGIVER-RESPITE CG-SH08
CAREGIVER CG-GR08
CAREGIVER ENHANCED
CHIRO-STATE OF OK. HIGH
CHIRO-STATE OF OK. LOW
CHIRO $20/15 ST OF OK-LOW
FEDERAL EMPLOYEES PLAN-FEH
CHIRO $10/15 ST OF OK-HIGH
CHIRO $5/10 VISITS
CHIRO $10/10 VISITS
CHIRO $15/10 VISITS
CHIRO $30/15 ST OF OK-LOW
FEDERAL EMPLOYEES PLAN-FEH
FEDERAL EMPLOYEES PLAN-FEH
FEDS 20/20V ACU/CHIRO 05
10/12V 1YR SH-CH07
10/12V 1YR SH-CH08
15/10V CH 07
FEDERAL EMPLOYEES PLAN1-99
FEDERAL EMPLOYEES PLAN1-99
FEDERAL EMPLOYEES PLAN1-99
FEDS $10 CUSTOM EFF 1-00
FEDS $10 CUSTOM EFF 1-00
FEDS $10 CUSTOM EFF 1-00
FEDS 2001
FEDS 2003
FEDS 2004
FEDS 2004
FEDS 2001
FEDS 2003
HMO LARGE GRP $20/80% CBR
HMO LARGE GRP $20/80% CBR
HMO LARGE GROUP $20/80%
HMO LARGE GROUP $20/80%
CHEMICAL/MENTAL -LDDS HIGH
SV 25/250A CHEV-TEX 08
CHEMICAL/MENTAL LDDS LOW
5/30V CH 07
309 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
CN9
CPA
CQ1
CQ8
CQJ
CR3
CR4
CR5
CR6
CRG
CRP
CRX
CRY
CS1
CS2
CS8
CSA
CSB
CSH
CSL
CT1
CT2
CT3
CT4
CT5
CUJ
CV1
CV2
CV3
CV4
CVA
CVB
CVC
CVD
CWJ
CXH
D00
D02
D10
D1C
D1G
D1H
D1K
D1L
D1M
D1U
D1V
D1X
D1Z
D20
Plan / Benefit Description
FEDS 20/20V ACU/CHIRO 07
RESERVED PFFS
10/30V CH 07
20/15V CH - ST OF OKLA 07
SV 25/250A CHEV-TEX 08 CB
GRP RET CHIRO $5/12VISITS
GRP RET CHIRO $10/12VISITS
GRP RET CHIRO $15/12VISITS
GRP RET CHIRO $20/12VISITS
CUSTOM PPO
$5G/$25BR RETIREE
$10G/$25B 1500 ANN.MAX.
RESERVED FOR RX PPO
$10/250 CENTRAL & SW COBRA
$10/250 CENTRAL & SW COBRA
INPAT CHEM DEP (ST OF OK)
$10/250 CENTRAL-SOUTHWEST
$10/250 CENTRAL-SOUTHWEST
STATE OF OKLAHOMA
STATE OF OKLAHOMA
NAT'L CHIRO $10/20 VISITS
NAT'L CHIRO $15/20 VISITS
NAT'L CHIRO $15/30 VISITS
NAT'L CHIRO $5/30 VISITS
NAT'L CHIRO $10/30 VISITS
SV 25/250A CHEV-TEX 08
CHEVRON TEX $20/100%
CHEVRON TEX $20/100% COBRA
CHEVRON TEX $20/100%
CHEVRON TEX $20/100% COBRA
SV 20/100% W/BU CHEVRON
SV 20/100% W/BU CHEVRON CB
SV 20/100% W/BU CHEVRON
SV 20/100% W/BU CHEVRON CB
SV 25/250A CHEV-TEX 08 CB
DONOT USE/FOR CA USE
DURABLE MED EQUIP
DME 10% (LDDS)
DURABLE MEDICAL EQUIPMENT
STANDARD 5 PLAN
KP100
CTANDARD 5 PLAN COBRA
KP100
STANDARD 5 PLAN
STANDARD 5 PLAN
KP100
KP100
STANDARD 5 PLAN COBRA
STANDARD 5 PLAN - COBRA
DURABLE MED EQUIP 20%
310 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
D2C
D2Z
D6V
D8A
D8E
D8L
DBA
DE6
DFC
DFM
DFX
DFZ
DGC
DGZ
DHC
DHZ
DIR
DL1
DL2
DLA
DLB
DMC
DMH
DML
DMM
DMX
DMZ
DN2
DN3
DNE
DNT
DNY
DO2
DP1
DPA
DPB
DPC
DQ6
DS1
DS2
DSA
DSB
DZC
DZZ
E2O
E3O
E4O
E5O
EC6
EL1
Plan / Benefit Description
STANDARD 5100 HILLCREST
STD 5100 COBRA HILLCREST
DENTAL - VISION GR06
DELUXE OPTION DN-SH08
$20 469 DN-SH08
$0 466 DN-SH08
100%/70% DISCOUNT GR-DN07
$0 466 SH-DN06
FORD MOTOR CREDIT PLAN
FORD MOTOR CREDIT CO PLAN
FORD MOTOR CREDIT CO COBRA
FORD MOTOR CREDIT CO.COBRA
NORTHROP GRUMAN PLAN
NORTHROP GRUMAN PLAN COBRA
NORTHROP GRUMAN PLAN
NORTHROP GRUMAN PLAN COBRA
DUMMY-USED FOR VRU CODING
HMO LARGE GRP $25/$600 CBR
HMO LARGE GRP $25/$600 CBR
HMO LARGE GROUP $25/$600
HMO LARGE GROUP $25/$600
MCDONNELL DOUGLAS PLAN
MCDONNELL DOUGLAS PLAN
MCDONNELL DOUGLAS PLAN
MCDONNELL DOUGLAS PLAN
MCDONNELL DOUGLAS PLAN CBR
MCDONNELL DOUGLAS PLAN CRB
PPO 460 GRP BILLED - GR
PPO 462 INDIV BILLED -GR
EVERCARE $5 SH-DN07
PREVENTIVE DENTAL PLAN
DELUXE OPTION SH-DN07
OK SH OPT DENTAL
DEPENDENT LIFE BENE
SAME SEX DOMESTIC PARTNER
OPPOSITE DOMESTIC PARTNER
DOMESTIC PARTNER SAME/OPPO
$20 469 SH-DN06
SMALL GRP HMO $10/$200 CBR
HMO SMALL GRP $10/$200 CBR
HMO SMALL GROUP $10/$200
HMO SMALL GROUP $10/$200
DUMMY CODE
DUMMY CODE
EVERCARE OKCTY DH-D SH08
EVERCARE TULSA DH-D SH08
EVERCARE OKCTY MH-D SH08
EVERCARE TULSA MH-D SH08
EVERCARE OKCTY DH SH07
HMO LARGE GRP $20/100% CBR
311 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
EL2
ELA
ELB
EOA
EOD
EOE
EOF
EOG
EOH
ES1
ES2
ESA
ESB
ETK
ETM
ETP
EXO
EYO
EZO
F01
F02
F03
F04
F05
F06
F07
F08
F09
F10
F11
F12
F13
F14
F15
F16
F17
F18
F19
F1B
F1C
F1F
F1G
F1H
F1K
F1L
F1M
F1P
F1R
F1S
F1T
Plan / Benefit Description
HMO LARGE GRP $20/100% CBR
HMO LARGE GROUP $20/100%
HMO LARGE GROUP $20/100%
EVERCARE OKCTY DH SH08
EVERCARE TULSA DH SH08
EVERCARE OKCTY IH SH08
EVERCARE TULSA IH SH08
EVERCARE OKCTY MH SH08
EVERCARE TULSA MH SH08
HMO SMALL GRP $15/$300 CBR
HMO SMALL GRP $15/$300 CBR
HMO SMALL GROUP $15/$300
HMO SMALL GROUP $15/$300
USED IN TX
USED IN TX
USED IN TX
USED IN TX
EVERCARE CC MH-D SH08
USED IN TX
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
KP100 ($10 OV)
STANDARD 10 PLAN
KP100 ($10 OV) COBRA
KP100 ($10 OV)
STANDARD 10 PLAN COBRA
KP100 ($10 OV)
STANDARD 10 PLAN
STANDARD 10 PLAN
STANDARD 10 PLAN (OPT)
STANDARD 10 OPT PLAN
STANDARD 10 OPT PLAN
STANDARD 10 OPT PLAN COBRA
312 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
F1U
F1V
F1W
F1X
F1Y
F1Z
F20
F21
F22
F23
F24
F25
F26
F27
F28
F29
F30
F31
F32
F33
F34
F35
F36
F37
F38
F39
F40
F41
F42
F43
F44
F45
F46
F47
F48
F49
F50
F51
F52
F53
F54
F55
F56
F57
F58
F59
F60
FA2
FA3
FA4
Plan / Benefit Description
KP100 ($10 OV) COBRA
KP100 ($10 OV) COBRA
STANDARD 10 OPT PLAN COBRA
STANDARD 10 PLAN COBRA
STANDARD 10 OPT PLAN COBRA
STANDARD 10 PLAN COBRA
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
AT&T NATL $10-$15/$100
AT&T NATL $10-$15/$100 CBR
AT&T NATL $10-$15/$100
313 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
FA5
FA6
FA7
FA8
FA9
FB3
FB5
FB6
FB7
FBA
FBH
FBJ
FC8
FC9
FCA
FCB
FCD
FCE
FCF
FCI
FCJ
FCL
FCM
FCN
FD1
FD2
FD3
FD4
FD6
FD7
FD8
FD9
FDA
FDB
FE1
FE2
FFF
FH6
FID
FJ3
FJ4
FJ5
FJ6
FKF
FM1
FM3
FM5
FM7
FM8
FMH
Plan / Benefit Description
AT&T NATL $10-$15/$100 CBR
SV 10/15/100A W/BU AT&T
SV 10/15/100A W/BU AT&T CB
SV 10/15/100A W/BU AT&T
SV 10/15/100A W/BU AT&T CB
$3
23
SV 20-40/250D FEDS 06
$7
$5G/$10B
FEDS 2003 I/P BH/MH 100%
FEDS 2004 I/P MH/CD
RESERVED FOR RX PPO
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
I/P CD 100% FEDS
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
SV 10/100% FORD HRLY 05
SV 10/100% FORD HRLY 05 CB
SV 10/100% FORD HRLY 05
SV 10/100% FORD HRLY 05 CB
SV 20/100% FORD SAL 05
SV 20/100% FORD SAL 05 CB
SV 20/100% FORD SAL 05
SV 20/100% FORD SAL 05 CB
SV 20-40/400D FEDS
SV 20-40/400D FEDS
FEDERAL EMPLOYEES PLAN
FEDERAL EMPLOYEE PLAN 1992
ADMINISTRATIVE RETENTION
SV 20-40/250D FEDS 06
FEDS DENTAL INDEMNITY 2001
SV 10/100% FORD HRLY 06
SV 10/100% FORD HRLY 06 CB
SV 10/100% FORD HRLY 06
SV 10/100% FORD HRLY 06 CB
SV 25/240A FIDELITY 07
$10G/RESCRIP DRUG $10 (FM)
O/P PRESCRIP DRUGS $3 (MF)
O/P PRESCRIP DRUGS $5 (MF)
O/P PRESCRIP DRUGS $7 (MF)
O/P PRESCRIP DRUGS $8 (MF)
I/P MH 100% FEDS
314 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
FMM
FMN
FMZ
FN1
FN2
FN3
FN4
FN5
FN6
FN7
FN8
FNA
FNB
FND
FNE
FNZ
FQB
FQF
FR1
FR2
FR3
FR4
FR5
FRA
FRC
FRD
FRE
FRM
FRS
FRX
FRZ
FS1
FS2
FS3
FS4
FSA
FSB
FSC
FSD
FSL
FTL
FUB
FV2
FV3
FV4
FV5
FWD
FX3
FX5
FX7
Plan / Benefit Description
SV $15-$30/$250A FARMER
SV $15-$30/$250A FARMER
SV $15-$30/$250A FARMER CB
FNF $10 - $15 / $250
FNF $10 - $15 / $250 COBRA
FNF $10 - $15 / $250
FNF $10 - $15 / $250 COBRA
NORTHROP GRUMANN $10/$20
NORTHROP GRUMANN 10/20 CBR
NORTHROP GRUMANN $10/$20
NORTHROP GRUMANN 10/20 CBR
SV 10-15/250A W/BU FID
SV 10-15/250A W/BU FID CB
SV 10-15/250A W/BU FID
SV 10-15/250A W/BU FID CB
SV $15-$30/$250A FARMER CB
SV 20-40/250D FEDS 08
SV 25/240A FIDELITY 07 CB
FEDERAL RETIREES PLAN
FARMERS $15-$30/$250
FARMERS $15-$30/$250 COBRA
FARMERS $15-$30/$250
FARMERS $15-$30/$250 COBRA
RISK CHARGE - AGGREGATE
ROCKWELL INT. HOURLY
FORD SALARIED $20/100%
FORD SALARIED $20/100%
ROCKWELL INT. HOURLY
RISK CHARGE - SPECIFIC
ROCKWELL INT. HOURLY-COBRA
ROCKWELL INT HOURLY-COBRA
HMO SMALL GRP $20/$400 CBR
HMO SMALL GRP $20/$400 CBR
OK SG HMO $20/$40/$250D CB
OK SG HMO $20/$40/$250D CB
HMO SMALL GROUP $20/$400
HMO SMALL GROUP $20/$400
OK SG HMO $20/$40/$250D
OK SG HMO $20/$40/$250D
SILVER SNEAKER SH/GR-WL07
SILVER SNEAKER SH/GR-WL08
SV 20-40/250D FEDS 08
FORD-VISTEON $10/100%
FORD-VISTEON $10/100% CBRA
FORD-VISTEON $10/100%
FORD-VISTEON $10/100% CBRA
SV 25/240A FIDELITY 07
O/P PRESCRIP DRUGS $3 (F)
$5G FORMULARY
O/P PRESCRI DRUGS $7 (F)
315 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
FX8
FYD
FZD
FZE
GDC
GDF
GEC
GEF
GKB
GKD
GKE
GKG
GM1
GM2
GM3
GM4
GM5
GM6
GM7
GM8
GMC
GME
GMF
GMG
GMH
GMJ
GMK
GMR
GP2
GP3
GP4
GP5
GP6
GP7
GP8
GP9
GS1
GS2
GSA
GSB
H01
H02
H03
H04
H05
H06
H07
H08
H09
H10
Plan / Benefit Description
$8G FORMULARY
)
SV 25/240A FIDELITY 07 CB
FORD SALARIED $20/100% CBR
FORD SALARIED $20/100% CBR
SV 10/100% GM 06
SV 10/100% GM 06 CB
SV 10/100% GM 06
SV 10/100% GM 06 CB
SV 20-40/250A 07
SV 20-40/250A 07 CB
SV 20-40/250A 07
SV 20-40/250A 07 CB
GM SAL 2003 $15/100%
GM SAL 2003 $15/100% COBRA
GM HRLY 2003 $10/100%
GM HRLY 2003 $10/100% CBR
GM SAL 2003 $15/100%
GM SAL 2003 $15/100% COBRA
GM HRLY 2003 $10/100%
GM HRLY 2003 $10/100% CBR
SV 20-30/100% 06
SV 20/100% GM SALARIED
SV 20/100% GM SALARIED CB
SV 20/100% GM SALARIED
SV 20/100% GM SALARIED CB
SV 20-30/100% 06 CB
SV 20-30/100% 06
SV 20-30/100% 06 CB
PBG 20-30/100D
PBG 20-30/100D COBRA
PBG 20-30/100D
PBG 20-30/100D COBRA
SV 20-30/100D W/BU PBG
SV 20-30/100D W/BU PBG CB
SV 20-30/100D W/BU PBG
SV 20-30/100D W/BU PBG CB
HMO SMALL GRP $25/$600 CBR
HMO SMALL GRP $25/$600 CBR
HMO SMALL GROUP $25/$600
HMO SMALL GROUP $25/$600
DOMESTIC PARTNERSHIP PPO
VISION CARE BENEFIT PPO
FAMILY PLANING BENEFIT PPO
24/HOUR HEALTH INFO PPO
HEARING AID BENEFIT PPO
MENTAL NON-SMI PPO 90/70
RESERVED FOR PPO PRODUCT
RESERVED FOR PPO PRODUCT
MENTAL NON-SMI PPO 80/60
MENTAL NON-SMI PPO 80/50
316 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
H11
H12
H13
H14
H15
H16
H17
H18
H19
H1A
H1C
H1F
H1H
H1L
H1M
H1P
H1R
H1S
H1T
H1W
H1X
H1Y
H1Z
H20
H21
H22
H23
H24
H25
H26
H27
H28
H29
H30
H31
H32
H33
H34
H35
H36
H37
H38
H39
H40
H41
H42
H43
H44
H45
H46
Plan / Benefit Description
MENTAL NONSMI INDEMNITY 80
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
HEARING AID BENEFIT
BASIC PLAN
CREATED IN ERROR
BASIC PLAN
COBRA
BASIC PLAN
BASIC PLAN
BASIC PLAN (OPT)
BASIC PLAN (OPT)
BASIC PLAN (OPT)
BASIC PLAN (OPT) COBRA
BASIC PLAN (OPT) COBRA
BASIC PLAN
COBRA
BASIC PLAN (OPT)
BASIC PLAN
COBRA
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
317 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
H47
H48
H49
H50
H51
H52
H53
H54
H55
H56
H57
H58
H59
H60
H61
H62
H63
H64
H65
H66
H67
H68
H69
H6P
H70
H71
H72
H73
H74
H75
H76
H77
H78
H79
H80
H81
H82
H83
H84
H85
H86
H87
H88
H89
H8A
H8B
H8D
H8J
H90
H91
Plan / Benefit Description
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
15-25/100A GR06
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
0/500A 3YRS PL HA-SH08
0/1300A 3YRS DX HA-SH08
0/800A 3YRS DX HA-SH08
5/400A 3YRS HA-SH08
RESERVED FOR PPO
RESERVED FOR PPO
318 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
H92
H93
H94
H95
H96
H97
H98
H99
HA0
HA5
HAA
HAC
HAJ
HAN
HB1
HB2
HB3
HDE
HF6
HHE
HL8
HOA
HOE
HOI
HPE
HQ6
HQ7
HQ9
HQD
HQE
HQN
HQO
HQP
HR2
HR3
HRD
HRE
HRP
HRY
HTC
HU6
HU7
HU9
HUD
HUE
HUN
HUO
HUP
I01
I02
Plan / Benefit Description
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
HEARING AID BENEFIT
HEARING AID ($500 MAX)
HEARING AID BENEFIT-CUSTOM
HEAR AID 1EA EAR EA36 13YR
HEARING AID $500 EVERY 3YR
300A/24M GR-HA07
RESERVED FOR PPO PRODUCT
RESERVED FOR PPO PRODUCT
RESERVED FOR PPO PRODUCT
300A 2YRS HA-GR08
25/400A 3 YRS SH-HA06
500A 3YRS HA-GR08
400A 3YRS 0PREM HA-GR08
RESERVED HEARING PFFS
RESERVED HEARING PFFS
RESERVED HEARING PFFS
RESERVED PFFS
MCC OKCTY PP-PL SH07
MCC OKCTY EP-PL SH07
MCC OKCTY PLUS SH07
MCC OKCTY DELUXE SH07
MCC OKCTY EP SH07
MC COMP OKCTY SH07
MCC OKCTY PL-DLXE SH07
MCC OKCTY PP SH07
HRING AID $500 ALLOWANCE
HRING AID $300 ALLOWANCE
0/800A 3YRS DX SH-HA07
5/400A 3YRS SH-HA07
0/500A 3YRS PL SH-HA07
0/1300A 3YRS DX SH-HA07
500A 2YRS HA-GR08
MCC ESS OKCTY PP-PL SH07
MCC ESS OKCTY EP-PL SH07
MCC ESS OKCTY PLUS SH07
MCC ESS OKCTY DELUXE SH07
MCC ESS OKCTY EP SH07
MC COMP ESS OKCTY SH07
MCC ESS OKCTY PL-DLXE SH07
MCC ESS OKCTY PP SH07
INDEMNITY COVERAGE PLAN
INDEMNITY COVERAGE PLAN
319 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
I03
I0K
I0L
I0T
I11
I12
I13
I16
I17
I1A
I1B
I1C
I1J
I1K
I1P
I1Z
I21
I22
I23
I26
I27
I2A
I2B
I2C
I2J
I2K
I2P
I2Z
I31
I32
I33
I36
I37
I3A
I3B
I3C
I3J
I3K
I3P
I3Z
I41
I42
I43
I46
I47
I4A
I4B
I4C
I4J
I4K
Plan / Benefit Description
INDEMNITY PLAN
INDEMNITY OKLAHOMA CITY
23DEMNITY SOUTHWEST
INDEMNITY TULSA
LARGE GRP PPO PLAN 1 CBRA
LARGE GRP PPO PLAN 1 CBRA
LARGE GRP PPO PLAN 1 CBRA
PPO PLAN1 LG/CBR-PHCS NTWK
PPO PLAN1 LG/CBRA-PHCS NET
LARGE GROUP PPO PLAN 1
LARGE GROUP PPO PLAN 1
LARGE GROUP PPO PLAN 1
PPO PLAN 1 LG-PHCS NETWORK
PPO PLAN 1 LG-PHCS NETWORK
NATIONAL PPO TULSA
NATIONAL PPO/COBRA TULSA
LARGE GRP PPO PLAN 2 CBRA
LARGE GRP PPO PLAN 2 CBRA
LARGE GRP PPO PLAN 2 CBRA
PPO PLAN2 LG/CBRA-PHCS NET
PPO PLAN2 LG/CBRA-PHCS NET
LARGE GRP PPO PLAN 2
LARGE GRP PPO PLAN 2
LARGE GRP PPO PLAN 2
PPO PLAN 2 LG-PHCS NETWORK
PPO PLAN 2 LG-PHCS NETWORK
NATIONAL PPO OKLAHOMA CITY
NATIONAL PPO/COBRA OK CITY
LARGE GRP PPO PLAN 3 CBRA
LARGE GRP PPO PLAN 3 CBRA
LARGE GRP PPO PLAN 3 CBRA
PPO PLAN3 LG/CBRA-PHCS NET
PPO PLAN3 LG/CBRA-PHCS NET
LARGE GROUP PPO PLAN 3
LARGE GROUP PPO PLAN 3
LARGE GROUP PPO PLAN 3
PPO PLAN 3 LG-PHCS NETWORK
PPO PLAN 3 LG-PHCS NETWORK
NATIONAL PPO LAWTON
NATIONAL PPO/COBRA LAWTON
LARGE GRP PPO PLAN 4 CBRA
LARGE GRP PPO PLAN 4 CBRA
LARGE GRP PPO PLAN 4 CBRA
PPO PLAN4 LG/CBRA-PHCS NET
PPO PLAN4 LG/CBRA-PHCS NET
LARGE GROUP PPO PLAN 4
LARGE GROUP PPO PLAN 4
LARGE GROUP PPO PLAN 4
PPO PLAN 4 LG-PHCS NETWORK
PPO PLAN 4 LG-PHCS NETWORK
320 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
I51
I52
I53
I56
I57
I5A
I5B
I5C
I5J
I5K
I5P
I5X
I61
I62
I63
I6A
I6B
I6C
I6P
I6X
I71
I72
I73
I7A
I7B
I7C
I81
IA0
IA1
IA2
IA3
IA4
IA5
IA6
IA7
IA8
IA9
IB0
IB1
IB2
IB3
IB4
IB5
IB6
IB7
IB8
IB9
IBZ
IC1
IC2
Plan / Benefit Description
LARGE GRP PPO PLAN 5 CBRA
LARGE GRP PPO PLAN 5 CBRA
LARGE GRP PPO PLAN 5 CBRA
PPO PLAN5 LG/CBRA-PHCS NET
PPO PLAN5 LG/CBRA-PHCS NET
LARGE GROUP PPO PLAN 5
LARGE GROUP PPO PLAN 5
LARGE GROUP PPO PLAN 5
PPO PLAN 5 LG-PHCS NETWORK
PPO PLAN 5 LG-PHCS NETWORK
NATIONAL PPO- PHCS NETWORK
NATIONAL PPO-PHCS NTWK COB
LARGE GRP IND PLAN 6 CBRA
LARGE GRP IND PLAN 6 CBRA
LARGE GRP IND PLAN 6 CBRA
LARGE GRP INDEMNITY PLAN 6
LARGE GRP INDEMNITY PLAN 6
LARGE GRP INDEMNITY PLAN 6
NATIONAL PPO- PHCS NETWORK
NATIONAL PPO-PHCS NTWK COB
LARGE GRP IND PLAN 7 CBRA
LARGE GRP IND PLAN 7 CBRA
LARGE GRP IND PLAN 7 CBRA
LARGE GRP INDEMNITY PLAN 7
LARGE GRP INDEMNITY PLAN 7
LARGE GRP INDEMNITY PLAN 7
IND.CONV.PLAN-880
PPO PLAN10 15 80/60 250
PPO PLAN1 15 90/70 250
PPO PLAN2 20 90/70 250
PPO PLAN3 10 90/70 250
PPO PLAN4 20 90/70 500
PPO PLAN5 15 80/60 500
PPO PLAN6 20 90/70 500
PPO PLAN7 10 80/60 500
PPO PLAN8 20 80/60 500
PPO PLAN9 25 80/60 500
PPO PLAN10 15 80/60 250
PPO PLAN1 15 90/70 250
PPO PLAN2 20 90/70 250
PPO PLAN3 10 90/70 250
PPO PLAN4 20 90/70 500
PPO PLAN5 15 80/60 500
PPO PLAN6 20 90/70 500
PPO PLAN7 10 80/60 500
PPO PLAN8 20 80/60 500
PPO PLAN9 25 80/60 500
RESERVED
INDEMNITY PPO - COBRA
INDEMNITY PPO - COBRA
321 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
IC3
IC4
IC5
IC6
IC7
ICA
ICB
ICC
ICD
IE1
IG1
IG2
IG3
IJ1
IK1
IK2
IK3
IK4
IN1
IN2
IN3
IN4
IP1
IP2
IP3
IQ1
IQ2
IQ3
IS1
IS2
IS3
IS4
IX1
IX2
IX3
IX4
IZ1
IZ2
IZ3
IZK
IZL
IZT
J1C
J1D
J1F
J1G
J1H
J1I
J1J
J1K
Plan / Benefit Description
INDEMNITY PPO - COBRA
PPO CUSTOM COBRA
PPO CUSTOM COBRA
PPO CUSTOM COBRA-PHCS NTWK
PPO CUSTOM COBRA-PHCS-NTWK
PPO CUSTOM
PPO CUSTOM
PPO CUSTOM - PHCS NETWORK
PPO CUSTOM - PHCS NETWORK
PPO PLAN11 20 80/60 250
INDEMNITY PLAN - GI
INDMENITY PLAN - GI
INDEMNITY PLAN - GI
PPO PLAN11 20 80/60 250
INDEMNITY CUSTOM
INDEMNITY CUSTOM COBRA
INDEMNITY CUSTOM
INDEMNITY CUSTOM COBRA
INDEMNITY PLAN1 80% 250
INDEMNITY PLAN2 80% 500
INDEMNITY PLAN1 80% 250
INDEMNITY PLAN2 80% 500
INDEMNITY PPO
INDEMNITY PPO
INDEMNITY PPO
INDEMNITY PLAN - GI
INDEMNITY PLAN - GI
INDEMNITY PLAN
REGIONAL LG $20/80%
REGIONAL LG $20/80% COBRA
REGIONAL LG $20/80%
REGIONAL LG $20/80% COBRA
INDEMNITY PLAN1 80% 250 CB
INDEMNITY PLAN2 80% 500 CB
INDEMNITY PLAN1 80% 250 CB
INDEMNITY PLAN2 80% 500 CB
INDEMNITY PLAN
COBRA
INDEMNITY PLAN
COBRA
INDEMNITY PLAN
INDEMNITY-OK CITY COBRA
INDEMNITY-SOUTHWEST COBRA
INDEMNITY COBRA
880 PLAN
PLAN ONE
PLAN ONE
23200
880 PLAN
COBRA
880 PLAN - IND. CONVR.
880 PLAN - INDVDL CNVRSN
KP200
322 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
J1L
J1M
J1N
J1P
J1Q
J1R
J1S
J1T
J1U
J1V
J1W
J1X
J1Y
J1Z
JMD
JMF
JMQ
JMZ
JNZ
JPM
JPN
JR1
JR2
K6E
K6M
KA2
KA3
KA4
KA5
KA6
KA7
KA8
KA9
KB2
KB3
KB4
KB5
KB6
KB7
KB8
KB9
KC6
KCE
KCN
KD2
KD3
KD4
KD5
KD6
KD7
Plan / Benefit Description
880 PLAN
880 PLAN
880 PLAN - IND. CONVRN.
880 PLAN (OPT)
PLAN ONE
880 PLAN (OPT)
880 PLAN (OPT)
880 PLAN (OPT) COBRA
KP200
KP200
880 PLAN (OPT) COBRA
880 PLAN
COBRA
880 PLAN (OPT) COBRA
880 PLAN
COBRA
PLAN ONE
PLAN ONE
PLAN ONE
SV 20-30/250A JPMORGAN CB
SV 20-30/250A JPMORGAN CB
SV 20-30/250A JPMORGAN
SV 20-30/250A JPMORGAN
JCPENNY GRP RET $5/100%
JC PENNY GRP RET $5/100%
5/10 OKCITY CE SH06 D466
5/10 OKCITY M SH06 D466
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
ESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
5/25 OKCITY C SH06 D466
5/25 OKCITY C SH06 EPO
5/25 OKCITY C SH06
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
323 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
KD8
KD9
KE2
KE3
KE4
KE5
KE6
KE7
KE8
KE9
KEE
KEN
KF2
KF3
KF4
KF5
KF6
KF7
KF8
KF9
KG2
KG3
KG4
KG5
KG6
KG7
KG8
KG9
KH1
KH2
KH3
KH4
KH5
KH6
KH7
KH8
KH9
KJ2
KJ3
KJ4
KJ5
KJ6
KJ7
KJ8
KJ9
KJI
KJO
KJQ
KJU
KJV
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
5/10 OKCITY CE SH06 EPO
5/10 OKCITY CE SH06
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
HEALTH EVALUATION RIDER
HEALTH EVALUATION RIDER
HEALTH EVALUATION RIDER
HEALTH EVALUATION RIDER
HEALTH EVALUATION RIDER
HEALTH EVALUATION RIDER
HEALTH EVALUATION RIDER
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
ARP MCC OKCTY EP-PL SH08
ARP MCC OKCTY PL-DLX SH08
ARP MCC OKCTY PP-PL SH08
ARP MCC OKCTY PP SH08
ARP MCC OKCTY PLUS SH08
324 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
KJW
KJX
KJY
KL2
KL3
KL4
KL5
KL6
KL7
KL8
KL9
KM2
KM3
KM4
KM5
KM6
KM7
KM8
KM9
KME
KMN
KR2
KR3
KR4
KR5
KR6
KR7
KR8
KR9
KS2
KS3
KS4
KS5
KS6
KS7
KS8
KS9
KT2
KT3
KT4
KT5
KT6
KT7
KT8
KT9
KU2
KU3
KU4
KU5
KU6
Plan / Benefit Description
ARP MCC OKCTY SH08
ARP MCC OKCTY DLX SH08
ARP MCC OKCTY EP SH08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
5/10 OKCITY M SH06 EPO
5/10 OKCITY M SH06
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
325 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
KU7
KU8
KU9
KV2
KV3
KV4
KV5
KV6
KV7
KV8
KV9
KW2
KW3
KW4
KW5
KW6
KW7
KW8
KW9
KX2
KX3
KX4
KX5
KX6
KX7
KX8
KX9
KY2
KY3
KY4
KY5
KY6
KY7
KY8
KY9
L10
L11
L12
L13
L14
L15
L16
L17
L18
L19
L20
L21
L22
L23
L24
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
LIFE W/O SEAT LRG TULSA
LIFE W/O SEAT LRG TULSA
LIFE W/O SEAT LRG TULSA
LIFE W/O SEAT LRG TULSA
LIFE W/SEAT LRG TULSA
LIFE W/SEAT LRG TULSA
LIFE W/SEAT LRG TULSA
LIFE W/SEAT LRG TULSA
LIFE W/O SEAT SMALL TULSA
LIFE W/SEAT SMALL TULSA
LIFE W/O SEAT LRG OK CITY
LIFE W/O SEAT LRG OK CITY
LIFE W/O SEAT LRG OK CITY
LIFE W/O SEAT LRG OK CITY
LIFE W/SEAT LRG OK CITY
326 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
L25
L26
L27
L28
L29
L30
L31
L32
L33
L34
L35
L36
L37
L38
L39
L49
L50
L51
L52
L53
L54
L55
L56
L57
L58
L59
L60
L61
L62
LD1
LD2
LDA
LDB
LF1
LF2
LF3
LH2
LH3
LH4
LH5
LL3
LM1
LO1
LO2
LO3
LO4
LO5
LTD
LTM
M03
Plan / Benefit Description
LIFE W/SEAT LRG OK CITY
LIFE W/SEAT LRG OK CITY
LIFE W/SEAT LRG OK CITY
LIFE W/O SEAT SMALL OK CIT
LIFE W/SEAT SMALL OK CITY
LIFE W/O SEAT LRG LAWTON
LIFE W/O SEAT LRG LAWTON
LIFE W/SEAT LRG LAWTON
LIFE W/SEAT LRG LAWTON
LIFE W/SEAT LRG LAWTON
LIFE W/SEAT LRG LAWTON
LIFE W/SEAT LRG LAWTON
LIFE W/SEAT LRG LAWTON
LIFE W/O SEAT SMALL LAWTON
LIFE W/SEAT SMALL LAWTON
LIFE SMALL GROUP - TULSA
LIFE SMALL GROUP - TULSA
LIFE SM GRP INTERNET TULSA
LIFE SM GRP INTERNET TULSA
LIFE MID/LG GROUP - TULSA
LIFE MID/LG GROUP - TULSA
LIFE MID/LG GROUP - TULSA
LIFE SMALL GROUP - OK CITY
LIFE SMALL GROUP - OK CITY
LIFE SMALL INTERNET OK CIT
LIFE SMALL INTERNET OK CIT
LIFE MID/LG GROUP- OK CITY
LIFE MID/LG GROUP- OK CITY
LIFE MID/LG GROUP- OK CITY
SV 7-ELEVEN 20-30/500A CB
SV 7-ELEVEN 20-30/500A CB
SV 7-ELEVEN 20-30/500A
SV 7-ELEVEN 20-30/500A
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LOCKHEED $20/100%
LOCKHEED $20/100% COBRA
LOCKHEED $20/100%
LOCKHEED $20/100% COBRA
LIFELINK
ALREADY USED
OK PLAN I LIMITED FEE
OK PLAN II LIMITED FEE
OK PLAN III LIMITED FEE
OK PLAN IV LIMITED FEE
OK PLAN V LIMITED FEE
RESERVED FOR PPO LIFE
RESERVED FOR LIFETIME MAX
MEDICAID
327 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
M15
M1C
M1H
M1L
M1M
M1P
M1R
M1S
M1T
M1W
M1X
M1Y
M1Z
MD1
MH1
MH2
MH3
MH5
MH8
MK1
MK2
MK5
MK6
MKZ
MMC
MMH
MML
MMM
MMX
MMZ
MR1
MR2
MR3
MR4
MSC
MSH
MSL
MSM
MSX
MSZ
MTK
MTM
MZ1
MZK
N02
N04
N05
N06
N07
N08
Plan / Benefit Description
$15
2070 PLAN
2070 PLAN
COBRA
2070 PLAN
2070 PLAN
2070 PLAN (OPT)
2070 PLAN (OPT)
2070 PLAN (OPT)
2070 PLAN (OPT) COBRA
2070 PLAN (OPT) COBRA
2070 PLAN COBRA
2070 PLAN (OPT) COBRA
2070 PLAN
COBRA
MC DONNELL DOUGLAS PLAN
MENTAL HEALTH O/P $5 OV
MENTAL HEALTH O/P $10 OV
MENTAL HEALTH O/P $15 OV
MENTAL HEALTH - $500/DAY
MENTAL HEALTH - 80%
MCKESSON RET $0/100%
MCKESSON RET $0/100%
SV 20-30/90% MCKESSON
SV 20-30/90% MCKESSON
SV 20-30/90% MCKESSON CB
2070 UNINSURED WORKERS
2070 UNINSURED WRKRS COBRA
2070 UNINSURED WORKERS
2070 UNINSURED WORKERS
2070 UNINSURED WRKRS COBRA
2070 UNINSURED WRKS COBRA
MARRIOTT $15-$25/$100
MARRIOTT $15-$25/$100 CBRA
MARRIOTT $15-$25/$100
MARRIOTT $15-$25/$100 CBRA
STATE CERTIFIED PLAN
STATE CERTIFIED PLAN
STATE CERTIFIED PLAN
STATE CERTIFIED PLAN
STATE CERTIFIED PLAN
STATE CERTIFIED PLAN
10/5V 1YR MSG THRPY SH07
10/5V 1YR MSG THRPY SH08
MC DONNELL DOUGLAS (COBRA)
SV 20-30/90% MCKESSON CB
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
328 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
N09
N10
N11
N12
N13
N14
N15
N16
N17
N18
N19
N1C
N1G
N1H
N1K
N1L
N1M
N1P
N1R
N1S
N1T
N1U
N1V
N1W
N1X
N1Y
N1Z
N20
N21
N22
N23
N24
N25
N26
N27
N28
N29
N30
N8F
NA1
NA2
NA3
NA4
NA5
NA6
NA7
NA8
NAA
NAB
NAC
Plan / Benefit Description
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
SHARE PLAN
KP300
SHARE PLAN COBRA
KP300
SHARE PLAN
SHARE PLAN
SHARE PLAN (OPT)
SHARE PLAN (OPT)
SHARE PLAN (OPT)
SHARE PLAN (OPT) COBRA
KP300
KP300
SHARE PLAN (OPT) COBRA
SHARE PLAN
COBRA
SHARE PLAN (OPT) COBRA
SHARE PLAN
COBRA
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
SV $20-$40/$400D CB
PHS NATL $5/100% COBRA
PHS NATL $10/100% COBRA
PHS NATL $10/$100/100% CBR
PHS NATL $10/$250/100%CBRA
PHS NATL $15/$250/100%CBRA
PHS NATL $15/100% COBRA
NATIONAL $15/$100 COBRA
NATIONAL $20/$250 COBRA
PHS NATL $5/100%
PHS NATL $10/100%
PHS NATL $10/$100/100%
329 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
NAD
NAE
NAF
NAG
NAH
NAK
NAL
NAM
NAN
NAO
NAP
NAQ
NAR
NAX
NB1
NB2
NB3
NB4
NC1
NC2
NC3
NCA
NCB
NCC
NF0
NF4
NF5
NF6
NF7
NF8
NF9
NFD
NFE
NFF
NFG
NFH
NFI
NFJ
NFK
NFL
NFM
NFY
NGA
NGB
NGC
NGD
NGZ
NHZ
NJ1
NJ2
Plan / Benefit Description
PHS NATL $10/$250/100%
PHS NATL $15/$250/100%
PHS NATL $15/100%
NATL POS $10/100%/70%
NATL POS $10/90%/70%
NATL POS $15/80%/60%
NATL POS $15/$150/70%
NATIONAL $15/$100
NATL POS $10/100%/70%
NATL POS $10/90%/70%
NATIONAL $20/$250
NATL POS $15/80%/60%
NATL POS $15/$150/70%
DUMMY OK TO USE
BOEING IAM $10/100%
BOEING IAM $10/100% COBRA
BOEING IAM $10/100%
BOEING IAM $10/100% COBRA
$10/100% MERCER PLAN 1 CBR
$15/100% MERCER PLAN 2CBRA
$15/$500 MERCER PLAN 3CBRA
$10/100% MERCER PLAN 1
$15/100% MERCER PLAN 2
$15/$500 MERCER PLAN 3
SV 15-30/250A NAT'L CB
SV 10-20/100A CB
SV 15-30/250A NAT'L CB
SV $15-$30/$400A CB
SV $20-$40/$250D CB
SV $20-$40/$400D CB
SV 10-20/100A CB
SV 10-20/100A
SV 15-30/250A NAT'L
SV $15-$30/$400A
SV $20-$40/$250D
SV $20-$40/$400D
SV 10-20/100A
SV 15-30/250A NAT'L
SV $15-$30/$400A
SV $20-$40/$250D
SV $20-$40/$400D
SV $15-$30/$400A CB
NAT'L PLN 2C $20 GRP RET
NAT'L PLN 2C $20 GRP RET
NAT'L PLN 2D $20 GRP RET
NAT'L PLN 2D $20 GRP RET
NATL POS $10/100%/70% CBRA
NATL POS $10/90%/70% COBRA
SV $5/100% NATL CB
SV $10/100% NATL CB
330 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
NJ3
NJ4
NJ5
NJ6
NJ7
NJA
NJB
NJC
NJD
NJE
NJF
NJG
NK1
NK2
NK3
NK4
NK5
NK6
NK7
NKZ
NL8
NLF
NLG
NLZ
NMC
NMH
NML
NMM
NMX
NMZ
NN1
NN2
NN3
NN4
NN5
NN6
NN7
NNA
NNB
NNC
NND
NNE
NNF
NNG
NNZ
NO1
NO2
NO3
NO4
NOZ
Plan / Benefit Description
SV $15/100% CB
SV $10/$100A NATL CB
SV $10/$250A NATL CB
SV $15/$250A CB
SV $15/$100A CB
SV $5/100% NATL
SV $10/100% NATL
SV $15/100%
SV $10/$100A NATL
SV $10/$250A NATL
SV $15/$250A
SV $15/$100A
NAT'L PLN 1 $5 GRP RET
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 3 $15 GRP RET
NAT'L PLN 2A $10 GRP RET
NAT'L PLN 2B $10 GRP RET
NAT'L PLN 3A $15 GRP RET
NAT'L PLN 3B $15 GRP RET
NATL POS $15/80%/60% COBRA
24HR NURSLINE WL-SH/GR08
SV $20-$40/$250D CB
24HOUR NURSE LINE SH07
NATL POS $15/$150/70% CBRA
SHARE PLAN
SHARE PLAN COBRA
SHARE PLAN
SHARE PLAN
SHARE PLAN
COBRA
SHARE PLAN
COBRA
SV $5/100% NATL CB
SV $10/100% NATL CB
SV $15/100% CB
SV $10/$100A NATL CB
SV $10/$250A NATL CB
SV $15/$250A CB
SV $15/$100A CB
SV $5/100% NATL
SV $10/100% NATL
SV $15/100%
SV $10/$100A NATL
SV $10/$250A NATL
SV $15/$250A
SV $15/$100A
NATL POS $10/100%/70% CBRA
ORU $15/$250/100%
ORU $15/$250/100% COBRA
ORU $15/$250/100%
ORU $15/$250/100% COBRA
NATL POS $10/90%/70% COBRA
331 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
NQZ
NR0
NR1
NR2
NR3
NR4
NR5
NR6
NR7
NR8
NR9
NRA
NRB
NRC
NRD
NRE
NRF
NRG
NRH
NRI
NRJ
NRZ
NS1
NS2
NSC
NSF
NSH
NSL
NSM
NSX
NSZ
NT1
NT2
NT3
NT4
NT5
NT6
NT7
NTB
NTL
NTU
NV1
NV2
NV3
NVA
NVB
NVC
NW1
NW2
NW3
Plan / Benefit Description
NATL POS $15/80%/60% COBRA
NAT'L $20/$40/$400 DAY CBR
NAT'L $10/$20/$100 COBRA
NAT'L $15/$30/$250 COBRA
NAT'L $15/$30/$400 COBRA
NAT'L $20/$40/$250 DAY CBR
NAT'L $20/$40/$400 DAY CBR
NAT'L $10/$20/$100 COBRA
NAT'L $15/$30/$250 COBRA
NAT'L $15/$30/$400 COBRA
NAT'L $20/$40/$250 DAY CBR
NAT'L $10/$20/$100
NAT'L $15/$30/$250
NAT'L $15/$30/$400
NAT'L $20/$40/$250 PER DAY
NAT'L $20/$40/$400 PER DAY
NAT'L $10/$20/$100
NAT'L $15/$30/$250
NAT'L $15/$30/$400
NAT'L $20/$40/$250 PER DAY
NAT'L $20/$40/$400 PER DAY
NATL POS $15/$150/70% CBRA
NEW SHARE PLAN
NEW SHARE PLAN
STATE OF OKLA. LOW OPTION
OPT SHARE PLAN
STATE OF OKLAHOMA
STATE OF OKLAHOMA
STATE OF OKLAH. LOW
STATE OF OKLAH. LOW COBRA
STATE OF OKLAH. LOW COBRA
NAT'L PLN 1 $5 GRP RET
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 3 $15 GRP RET
NAT'L PLN 2A $10 GRP RET
NAT'L PLN 2B $10 GRP RET
NAT'L PLN 3A $15 GRP RET
NAT'L PLN 3B $15 GRP RET
0/24-1W NON-ER TRANS SH07
0/24-1W NON-ER TRANS SH08
0/20-1W NON-ER TRANS SH08
$10/100% MERCER PLAN 1CBRA
$15/100% MERCER PLAN2 COBR
$15/$500 MERCER PLAN 3 CBR
$10/100% MERCER PLAN 1
$15/100% MERCER PLAN 2
$15/$500 MERCER PLAN 3
$10/100% MERCER PLAN 1 CBR
$15/100% MERCER PLAN 2CBRA
$15/$500 MERCER PLAN 3CBRA
332 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
NWA
NWB
NWC
NX1
NX2
NX3
NX4
NX5
NX6
NXA
NXB
NXC
NXD
NXE
NXF
NY1
NY2
NY3
NY4
NY5
NY6
NY7
NY8
NYA
NYB
NYC
NYD
NYE
NYF
NYM
NYP
O12
O14
O1C
O1K
O1Q
O1R
O1T
O1U
O1V
O1W
O1X
O22
O27
O2A
O2C
O2D
O2G
O2H
O2K
Plan / Benefit Description
$10/100% MERCER PLAN 1
$15/100% MERCER PLAN 2
$15/$500 MERCER PLAN 3
PHS NATL $5/100% COBRA
PHS NATL $10/100%
PHS NATL $10/$100/100%CBRA
PHS NATL $10/$250/100%CBRA
PHS NATL $15/$250/100%CBRA
PHS NATL $15/100% COBRA
PHS NATL $5/100%
PHS NATL $10/100%
CHS NATL $10/$100/100%
PHS NATL $10/$250/100%
PHS NATL $15/$250/100%
PHS NATL $15/100%
PHS NATL $5/100% COBRA
PHS NATL $10/100% COBRA
PHS NATL $10/$100/100%CBRA
PHS NATL $10/$250/100%CBRA
PHS NATL $15/$250/100%CBRA
PHS NATL $15/100% COBRA
NATIONAL $15/$100 COBRA
NATIONAL $20/$250 COBRA
PHS NATL $5/100%
PHS NATL $10/100%
PHS NATL $10/$100/100%
PHS NATL $10/$250/100%
PHS NATL $15/$250/100%
PHS NATL $15/100%
NATIONAL $15/$100
NATIONAL $20/$250
NAT'L PLN 1 $5 GR 06
NAT'L PLN 1 $5 GR 06
SH-MCDONNELL DOUGLAS - C
NAT'L PLN 1 $5 GRP RET
10-20/750A T2A GR07
15-25/200D T3A GR07
NAT'L PLN 1 $5 GRP RET
15-25/200D T3A GR07
10-20/750A T2A GR07
10-15/50A T1A GR07
10-15/50A T1A GR07
NAT'L PLN 2 $10 GRP RET
2070 PLAN
SV 10/100%
SH-MCDONNELL DOUGLAS - C
SV 20/100% 05
SV 20/400A 05
BOEING NA-HRLY $10 GRP RET
NAT'L PLN 2 $10 GRP RET
333 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
O2N
O2Q
O2R
O2T
O2U
O2V
O2W
O2X
O3A
O3D
O3G
O3H
O3Q
O3R
O3U
O3V
O3W
O3X
O41
O42
O44
O4H
O4K
O4Q
O4R
O4U
O4V
O4W
O4X
O52
O5H
O5M
O5P
O5Q
O5R
O5U
O5V
O5W
O5X
O61
O62
O64
O6Q
O6R
O6U
O6V
O6W
O6X
O71
O72
Plan / Benefit Description
NAT'L PLN 2 $10 GRP RET
10-20/750A T2A GR07
15-25/200D T3A GR07
NAT'L PLN 2 $10 GRP RET
15-25/200D T3A GR07
10-20/750A T2A GR07
10-15/50A T1A GR07
10-15/50A T1A GR07
SV 10/100% CB
SV 20/100% 05 CB
SV 20/400A 05 CB
BOEING NA-HRLY $10 GRP RET
10-20/750A T2A GR07
15-25/200D T3A GR07
15-25/200D T3A GR07
10-20/750A T2A GR07
10-15/50A T1A GR07
10-15/50A T1A GR07
NAT'L PLN 2A $10 GR 06
NAT'L PLN 2A $10 GR 06
NAT'L PLN 2A $10 GR 06
BOEING HOURLY $15 GRP RET
NAT'L PLN 2A $10 GRP RET
15-25/130D T2B GR07
15-30/220D T3B GR07
15-30/220D T3B GR07
15-25/130D T2B GR07
5-20/100A T1B GR07
5-20/100A T1B GR07
5100 PLAN
BOEING HOURLY $15 GRP RET
15 BO SCPEA NO-AARP GR08
15 BO SCPEA NO-AARP GR08
15-25/130D T2B GR07
15-30/220D T3B GR07
15-30/220D T3B GR07
15-25/130D T2B GR07
5-20/100A T1B GR07
5-20/100A T1B GR07
NAT'L PLN 3A $15 GR 06
NAT'L PLN 3A $15 GR 06
NAT'L PLN 3A $15 GR 06
15-25/130D T2B GR07
15-30/220D T3B GR07
15-30/220D T3B GR07
15-25/130D T2B GR07
5-20/100A T1B GR07
5-20/100A T1B GR07
NAT'L PLN 3B $15 GR 06
NAT'L PLN 3B $15 GR 06
334 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
O74
O7H
O7Q
O7R
O7T
O7U
O7V
O7W
O7X
O82
O88
O8B
O8F
O8Q
O8R
O8U
O8V
O8W
O8X
O91
O92
O94
O9Q
O9R
O9U
O9V
O9W
O9X
OA2
OA3
OA5
OA6
OA7
OA8
OAN
OB2
OBA
OBR
OBZ
OC1
OC2
OCA
OCB
OCC
OCN
OCR
OCZ
OD2
OD3
ODN
Plan / Benefit Description
NAT'L PLN 3B $15 GR 06
$15/$200 BOEING GR
10-25/150D T2C GR07
20-35/250D T3C GR07
NAT'L PLN 3B $15 GRP RET
20-35/250D T3C GR07
10-25/150D T2C GR07
10-20/200A T1C GR07
10-20/200A T1C GR07
880 PLAN
880 PLAN
$15/$200 BOEING GR
880 PLAN OPT
10-25/150D T2C GR07
20-35/250D T3C GR07
20-35/250D T3C GR07
10-25/150D T2C GR07
10-20/200A T1C GR07
10-20/200A T1C GR07
NAT'L PLN 2B $10 GR 06
NAT'L PLN 2B $10 GR 06
NAT'L PLN 2B $10 GR 06
10-25/150D T2C GR07
20-35/250D T3C GR07
20-35/250D T3C GR07
10-25/150D T2C GR07
10-20/200A T1C GR07
10-20/200A T1C GR07
SV 10/100%
SV 10/100% CB
STATE OF OK ALT OPTION
STATE OF OK ALT OPTION CBR
STATE OF OK ALT OPTION
STATE OF OK ALT OPTION CBR
NATIONAL ACCT EXTENDED OOA
BASIC PLAN
BASIC PLAN
5/100% AARP GR08
15/250A NON-AARP GR08
OKLAHOMA CITY PLAN 1
OKLAHOMA CITY PLAN 2
OK SH STANDARD PLAN
OK SH STANDARD PLAN 05
OK SH STANDARD PLAN W/D
SV 20-40/250D OC PET 07
5/100% AARP GR08
15/250A NON-AARP GR08
SV 20/100% 05
SV 20/100% 05 CB
SV 20-40/250D OC PET 07
335 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
ODT
OE1
OE2
OE4
OEN
OEQ
OET
OF1
OF2
OF3
OF4
OF5
OF6
OF7
OF8
OF9
OFA
OFB
OFC
OFD
OFE
OFQ
OG2
OG3
OGA
OGB
OGJ
OGL
OGR
OH1
OH2
OH3
OH4
OH5
OH6
OH7
OH8
OHR
OI1
OI2
OI4
OI8
OJ1
OJ2
OJ4
OJN
OK1
OK2
OK3
OK4
Plan / Benefit Description
10/100% AARP GR08
NAT'L PLN 2D $20 GR 06
NAT'L PLN 2D $20 GR 06
NAT'L PLN 2D $20 GR 06
SV 20-40/250D OC PET 07 CB
20/100% NON-AARP GR08
10/100% AARP GR08
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
20/100% NON-AARP GR08
SV 20/400A 05
SV 20/400A 05 CB
NAT'L PLN 2C $20 GRP RET
NAT'L PLN 2C $20 GRP RET
20/100% NON-AARP GR08
20/100% NON-AARP GR08
5/100% NON-AARP GR08
STATE OF OK HI OPTION
STATE OF OK HI OPTION CBRA
STATE OF OK HI OPTION
STATE OF OK HI OPTION CBRA
STATE OF OK HI OPTION
STATE OF OK HI OPTION CBR
STATE OF OK HI OPTION
STATE OF OK HI OPTION CBR
5/100% NON-AARP GR08
NAT'L PLN 2A $10 GR 06
NAT'L PLN 2A $10 GR 06
NAT'L PLN 2A $10 GR 06
IND.CONV.PLAN-880
NAT'L PLN 3B $15 GR 06
NAT'L PLN 3B $15 GR 06
NAT'L PLN 3B $15 GR 06
SV 20-40/250D OC PET 07 CB
OKLAHOMA CTY STANDARD PLAN
OKLAHOMA CTY PRT B ONLY
OKLHMA CTY AREA-SH INDIV.
OKLHMA CTY-AREA SH PRT B
336 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
OK6
OK7
OKG
OKK
OKL
OKN
OKP
OKT
OL1
OL2
OL3
OL4
OL5
OL6
OL7
OL8
OLT
OM1
OM2
OMD
ON1
ON2
ON3
ON4
ON5
ON6
ON7
ON8
ONF
ONK
ONS
OO2
OO4
OO8
OON
OP0
OP2
OP8
OPL
OPR
OPS
OQ2
OQ4
OR1
OR2
OR4
OR5
ORX
OS2
OS3
Plan / Benefit Description
NAT'L PLN 3A $15 GRP RET
NAT'L PLN 3B $15 GRP RET
15 BO HRLY-F NO-AARP GR08
NAT'L PLN 2 $10 GRP RET
10 BO HRLY NO-AARP GR08
NAT'L PLN 1 $5 GRP RET
15 BO HRLY-F NO-AARP GR08
10/100% NON-AARP GR08
STATE OF OK LOW OPTION
STATE OF OK LOW OPTION CBR
STATE OF OK LOW OPTION
STATE OF OK LOW OPTION CBR
STATE OF OK LOW OPTION
STATE OF OK LOW OPTION CBR
STATE OF OK LOW OPTION
STATE OF OK LOW OPTION CBR
10/100% NON-AARP GR08
MCDONNELL DOUG PLAN OKCITY
$10G/$20B/$30NF
NEW SHARE PLAN
$10G/$25B/$50NF
$15G/$25B/$40NF
$15G/$25B
$15G/$35B
$10G/$25B/$40NF
$10G/$35B
SHARE PLAN (OPT)
NAT'L PLN 2 $10 GRP RET
NEW SHARE PLAN
NAT'L PLN 1 $5 GR 06
NAT'L PLN 1 $5 GR 06
NOT USED
POS - OUT OF AREA
I/P PSYCH (45 DAY-100%)
PREFERED PLAN
I/P PSYCH (45 DAY-80%)
10 BO HRLY NO-AARP GR08
PREFERRED PLAN
I/P PSYCH (STATE OF OKLA)
NAT'L PLN 2C $20 GR 06
NAT'L PLN 2C $20 GR 06
NAT'L PLN 2D $20 GR 06
NAT'L PLN 2D $20 GR 06
NAT'L PLN 2D $20 GR 06
SH GRP RET $5/100% 2001
OTHR RX NOT THRU RX SOL
STANDARD PLAN
STATE OF OKLA. 1992
337 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
OS5
OST
OSZ
OT1
OT2
OT4
OT6
OTA
OTB
OTC
OTG
OTJ
OTL
OTT
OU1
OU2
OU3
OU4
OU5
OU6
OUG
OV1
OV2
OV4
OW1
OW2
OW4
OX2
OX4
OXW
OYW
OYZ
OZ0
OZ1
OZ2
OZ3
OZ5
OZ7
OZ8
OZA
OZB
OZD
OZF
OZN
OZP
OZR
OZS
OZT
OZZ
P00
Plan / Benefit Description
5100 PLAN
STANDARD PLAN
STANDARD PLAN
NAT'L PLN 1 $5 GRP RET
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 2A $10 GRP RET
NAT'L PLN 3A $15 GRP RET
OK SH STANDARD PLAN
OK SH STANDARD PLAN 05
OK SH STANDARD PLAN W/D
15-25/500A AARP GR08
15/250A AARP GR08
15/250A AARP GR08
NAT'L PLN 2 $10 GRP RET
OKLAHOMA SM GRP PLAN I UC
OKLAHOMA SM GRP PLAN II UC
OKLAHOMA SM GRP PLN III UC
OKLAHOMA SM GRP PLAN IV UC
OKLAHOMA SM GRP PLAN V UC
OKLAHOMA SM GRP INDEM UC
15-25/500A AARP GR08
NAT'L PLN 2B $10 GR 06
NAT'L PLN 2B $10 GR 06
NAT'L PLN 2B $10 GR 06
NAT'L PLN 3A $15 GR 06
NAT'L PLN 3A $15 GR 06
NAT'L PLN 3A $15 GR 06
NAT'L PLN 2C $20 GR 06
NAT'L PLN 2C $20 GR 06
10-20/250A NON-AARP GR08
10-20/250A NON-AARP GR08
10/100% NON-AARP GR08
880 PLAN (COBRA)
OKLAHOMA CITY PLAN 1 COBRA
OKLAHOMA CITY PLAN 2 COBRA
STATE OF OKLA. 1992
5100 PLAN COBRA
2070 PLAN
880 PLAN (COBRA)
BASIC PLAN (COBRA)
BASIC PLAN (COBRA)
MCDON. DOUG OKCITY COBRA
SHARE PLAN (COBRA-OPT)
NEW SHARE PLAN (COBRA)
PREFERRED PLAN (COBRA)
PREFERRED PLAN
NEW SHARE PLAN (COBRA)
STANDARD PLAN (COBRA)
10/100% NON-AARP GR08
INPATIENT PSYCHIATRIC 100%
338 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
P0C
P1C
P2A
P2C
P2P
P3P
P45
P4P
P5C
P5P
P6C
P6H
P6P
P7C
P7P
P80
P8C
P8P
P9C
P9P
PA2
PA3
PA4
PA5
PA6
PA7
PA8
PA9
PAA
PAB
PAC
PAD
PAE
PAF
PAG
PAH
PAK
PB1
PB2
PB3
PB4
PBA
PBB
PBF
PBG
PCD
PCE
PCH
PCI
PCW
Plan / Benefit Description
INPATIENT PSYCH 100%
INPATIENT PSYCH $100
MENTAL HEALTH (AAON)
INPATIENT PSYCH 80%
RESERVED PPO
RESERVED PPO
I/P PSYCHIATRIC (45 DAY)
RESERVED PPO
INPATIENT PSYCH 50%
RESERVED PPO
INPATIENT PSYCH/MH
15-25/100A GR06
RESERVED PPO
IP MH/PSYCH 100% 30D MERCE
RESERVED PPO
INPATIENT PSTCHIATRIC 80%
IP MH/PSYCH $500 COPAY 30D
RESERVED PPO
IP MH 30 DAYS 100% FEDS
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
PPO-PFFS
RESERVED PFFS
PPO ADMINISTRATIVE CHARGE
RESERVED PFFS
PPO - PFFFS
RESERVED PFFS
RESERVED PFFS
RESERVED PFFS
RESERVED PFFS
PPO CUSTOM
PPO CUSTOM COBRA
PPO CUSTOM
PPO CUSTOM COBRA
PPO - PFFS
RESERVED PFFS
RESERVED PFFS
RESERVED PFFS
PBHI CHEMICAL DEP.-CUSTOM
PPO - PFFS
SV $15-$30/$100A PHS
SV $15-$30/$100A PHS
$45/Q PHB CREDIT SH08
339 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
PD1
PD2
PD3
PD4
PD5
PD6
PD7
PDH
PDS
PDW
PEH
PEK
PEY
PF2
PF3
PF4
PF5
PF6
PF7
PF8
PF9
PFA
PFB
PFC
PFD
PG1
PG2
PG3
PG4
PGD
PH2
PH3
PH4
PH5
PH6
PH7
PH8
PH9
PHE
PHF
PHG
PHH
PHV
PIE
PIF
PIG
PIH
PII
PIK
PIL
Plan / Benefit Description
$10G/$25B $1000 CMBNED MAX
PDV CUSTOM DENTAL ONLY
PDV VISION ONLY
PDV CUSTOM VISION ONLY
PDV DENTAL & VISION
PDV CUSTOM DENTAL & VISION
PDV DENTAL ONLY
O/4V 1YR POD SH07
O/3V 1YR POD SH08
O/6V 1YR POD SH08
RESERVED PFFS
RESERVED PFFS
$20/Q PHB CREDIT SH08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 20-40/200A PHS 06
SV 20-40/200A PHS 06 CB
SV 20-40/200A PHS 06
SV 20-40/200A PHS 06 CB
PBG $20/$200
PBG $20/$200 COBRA
PBG $20/$200
PBG $20/$200 COBRA
RESERVED PFFS
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 20-30/100D 06
SV 20-30/100D 06 CB
SV 20-30/100D 06
SV 20-30/100D 06 CB
$45/Q PHB CREDIT SH07
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
340 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
PIN
PIO
PKC
PKH
PKL
PKM
PKX
PKZ
PLC
PLD
PLE
PLF
PLG
PLH
PLJ
PLK
PLL
PLM
PLP
PLX
PLZ
PMC
PMH
PPA
PPD
PPE
PPF
PPG
PPH
PPK
PPL
PPM
PPQ
PPR
PPS
PPT
PPU
PPV
PPW
PPX
PPY
PR1
PR2
PRM
PS0
PS1
PS2
PS3
PS4
PS5
Plan / Benefit Description
RESERVED RX PFFS
RESERVED RX PFFS
STATE OF OKLAHOMA-HIGH
STATE OF OKLAHOMA HIGH
STATE OF OKLAHOMA HIGH
STATE OF OKLAHOMA HIGH
STATE OF OKLAHOMA HIGH
STATE OF OKLAHOMA HIGH
STATE OF OKLAHOMA HIGH
STATE OF OK HIGH OPTION
STATE OF OK HIGH OPTION CB
STATE OF OK HIGH OPTION
STATE OF OK HIGH OPTION CB
STATE OF OKLAHOMA HIGH
STATE OF OK HIGH OPTION
STATE OF OK HIGH OPTION CB
STATE OF OKLAHOMA HIGH
STATE OF OKLAHOMA HIGH
PAYMENT LAG PREMIUM ALLOC
STATE OF OKLAHOMA HIGH
STATE OF OKLAHOMA HIGH
PBHI MENT/CHEM DEP-CUSTOM
PBHI MENTAL HEALTH CUSTOM
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
PREFERRED PLAN
PREFERRED PLAN
PRIME 06
MENTAL HEALTH $250
INP MNTL HLTH-HIGH (STATE)
INP MENT HLTH LOW (STATE)
INPATIENT PSYCH $200
INPATIENT PSYCH $300
INPATIENT PSYCH $400
341 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
PS6
PS7
PS8
PS9
PSA
PSB
PSC
PSD
PSH
PSL
PSM
PSX
PSZ
PUA
PUC
PXA
PYA
PYI
PZ1
PZ2
PZH
PZI
Q1C
Q1H
Q1I
Q1L
Q1M
Q1X
Q1Z
Q2I
Q3I
QBI
R01
R02
R03
R04
R10
R15
R2B
R3B
R4B
R4C
R4Z
R5B
R5C
R5Z
R6B
R6C
R6Z
RA3
Plan / Benefit Description
INPATIENT PSYCH $600
INPATIENT PSYCH 90%
INPAT MEN HLTH (ST OF OK)
INPATIENT PSYCH $150
INPATIENT PSYCH 100%
INPATIENT PSYCH 90%
STATE OF OKLAHOMA -HIGH
INPATIENT PSYCH 80%
STATE OF OKLAHOMA HIGH COB
STATE OF OKLAHOMA HIGH
STATE OF OKLAHOMA - HIGH
STATE OF OKLAHOMA HIGH COB
STATE OF OKLAHOMA HIGH COB
SV 15-20/100A 06
SV 15-20/100A 06 CB
SV 15-20/100A 06
SV 15-20/100A 06 CB
RESERVED PFFS
PREFERRED PLAN (COBRA)
PREFERRED PLAN (COBRA)
SV $15-$30/$100A PHS CB
SV $15-$30/$100A PHS CB
2050 PLAN
2050 PLAN COBRA
2050 PLAN-INDIVIDUAL
2050 PLAN
2050 PLAN
2050 PLAN COBRA
2050 PLAN COBRA
2050 PLAN - INDIVIDUAL
2050 PLAN - INDIVIDUAL
QUALITY BUSINESS INCENTIVE
REGION LG $20-$40/$250D
REGION LG $20-$40/$250D CB
REGION LG $20-$40/$250D
REGION LG $20-$40/$250D CB
$10
$15
$7G/$14B
$10G/$20B
$10G/$25B
$10/$250 NAT'L ACCT PLAN
$10/$250 NAT'L ACCT /COBRA
$10G/$20B/$40NF
$10/$250 NAT'L ACCT PLAN
$10/$250 NAT'L ACCT/COBRA
$15G/$25B/$40NF
$10/$250 NAT'L ACCT PLAN
$10/$250 NAT'L ACCT/COBRA
$7G/$14B
342 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
RA4
RA5
RA6
RA7
RA8
RB0
RB3
RB4
RB5
RB6
RB7
RB8
RB9
RBA
RBB
RBC
RBD
RBE
RD0
RD8
RDA
RDB
RDC
RGC
RGH
RGL
RGM
RGX
RGZ
RLC
RLH
RLL
RLM
RLX
RLZ
RM1
RM3
RM5
RM7
RM8
RMA
RMB
RMC
RMD
RME
RMF
RMG
RMH
RMI
RO5
Plan / Benefit Description
$10G/$20B
$10G/$25B
$10G/$20B/$40NF
$7
$15G/$25B/$40NF
$0
$3
$7G/$14B
$5
$10G/$20B
$10G/$25B
$10G/$20B/$40NF
$15G/$25B/$40NF
$0
$3
$5
$10
$20
$0
$8
$5/$10/$15
$5/$10/$15
$5/$10/$15
STANDARD PLAN - GI
STANDARD PLAN - GI
STANDARD PLAN - GI
STANDARD PLAN - GI
STANDARD PLAN - GI (COBRA)
STANDARD PLAN - GI (COBRA)
LOW PLAN/LDDS
LOW PLAN/LDDS (COBRA)
LOW PLAN/LDDS
LOW PLAN/LDDS
LOW PLAN/LDDS
LOW PLAN/LDDS
$10
$3
$5
$7
$8
$10
$10
$5
$7
$8
$10
$10
$10
$15
$5
343 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
RPE
RPX
RR1
RRR
RS0
RS4
RTA
RTB
RTN
RX0
RX1
RX2
RX3
RX4
RX5
RX6
RX7
RX8
RXA
RXB
RXC
RXD
RXE
RXF
RXG
RXH
RXI
RXJ
RXK
RXL
RXM
RXN
RXP
S21
S2Z
S50
S52
S5Z
SB2
SB3
SB4
SB5
SB6
SB7
SB8
SB9
SBQ
SBR
SBT
SBU
Plan / Benefit Description
RESPITE/PERS CARE SH07
RESPITE/PERS CARE WL-SH08
LIMITEDRX
LIMITEDRX
$15G
$10G
UNIV OF TULSA
UNIV OF TULSA COBRA
$10G/$25B 1500 ANN.MAX.
$0
$1
$2
$3
$4
$5
$6
$7
$8
$10
$10
$7
DISCOUNT
$3
$5
$5
$7
$8
$10
$10
$10
$10
$15
$8
SHARE PLAN 250
5100 PLAN (COBRA)
5100 PLAN
5100 PLAN
5100 PLAN (COBRA)
BOEING IAM $15/100%
BOEING IAM $15/100% COBRA
BOEING IAM $15/100%
BOEING IAM $15/100% COBRA
BANK ONE 20-30/$250A
BANK ONE 20-30/$250A COBRA
BANK ONE 20-30/$250A
BANK ONE 20-30/$250A COBRA
SV 15/250A BOEING 06
SV 15/250A BOEING 06
SV 15/250A BOEING 06
SV 15/250A BOEING 06
344 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
SC1
SC2
SC3
SCH
SD1
SD2
SD3
SER
SF2
SF3
SF4
SF5
SFC
SFD
SFF
SFG
SFH
SFI
SGC
SGH
SGL
SGM
SGX
SGZ
SH0
SH2
SH3
SH4
SH5
SH6
SH7
SH8
SHC
SHD
SHG
SHH
SHZ
SKR
SLR
SMI
SO1
SO2
SO3
SOK
SOO
SOP
SOT
SP1
SR1
SR2
Plan / Benefit Description
SH-MCDONNELL DOUGLAS - C
SH-MCDONNELL DOUGLAS - C
SH-MCDONNELL DOUGLAS - C
*OK TO USE* ENTRD IN ERROR
SH-MCDONNELL DOUGLAS - D
PH-MCDONNELL DOUGLAS - D
SH-MCDONNELL DOUGLAS - D
SUPP ELIGIBILITY
STATE FARM 20-30/250A
STATE FARM 20-30/250A CBRA
STATE FARM 20-30/250A
STATE FARM 20-30/250A CBRA
SPLIT FAMILY COVERAGE
$10/$30/$60 SF
SV 20-30/250A STATEFARM
SV 20-30/250A STATEFARM CB
SV 20-30/250A STATEFARM
SV 20-30/250A STATEFARM CB
BASIC PLAN GI
BASIC PLAN GI (COBRA)
BASIC PLAN GI
BASIC PLAN GI
BASIC PLAN GI (COBRA)
BASIC PLAN GI
SECURE HORIZONS STANDARD
SECURE HORIZONS-PART B
TULSA SH STANDARD PLAN
OK CITY SH STANDARD
OK SH STANDARD PLAN
OK SH STANDARD PLAN
OK SH STANDARD PLAN
OK SH STANDARD PLAN
SH STANDARD - OKC
SECURE HORIZONS-PART B
OK SH PART B
OK SH PART B
SECURE HORIZONS-PT B ONLY
SV 25-40/500A STFRM 08
SV 25-40/500A STFRM 08 CB
SMI CORE I/P & O/P EFF1-00
STATE OF OKLAHOMA PLAN
STATE OF OKLAHOMA PLAN 2
STATE OF OKLA. 1992
15-30/150D STATE OK GR07
15-30 ST OK NO-AARP GR08
15-30 ST OK NO-AARP GR08
15-30/150D STATE OK GR07
SUPPLEMENTAL LIFE BENE
UAW RETIREE SECURE HORIZON
UAW RETIREE SECURE HORIZON
345 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
SSP
SSR
ST1
ST2
STA
STB
STD
STF
STK
STM
STP
STQ
STZ
SXR
SYR
SZ1
SZ2
SZ3
SZO
T3P
T4P
TA1
TA2
TAX
TB3
TBI
TBO
TBQ
TBU
TBV
TBW
TBX
TBY
TC6
TCE
TCN
TG6
TG7
TG9
TGD
TGE
TGN
TGO
TGP
TJ6
TJ7
TJ9
TJD
TJE
TJN
Plan / Benefit Description
SH SILVER SNEAKERS
SLV SNEAK/FITNESS BEN GR06
STANDARD PLAN
STANDARD PLAN
SV 20-35/200A OK 06
SV 20-35/200A OK 06 CB
RESERVED FOR PPO LIFE
SV 20-35/200A OK 06
SV 20-35/200A OK 06 CB
SV 20-50/500D 06
SV 20-50/500D 06 CB
SV 20-50/500D 06
SV 20-50/500D 06 CB
SV 25-40/500A STFRM 08
SV 25-40/500A STFRM 08 CB
STANDARD PLAN (COBRA)
STANDARD PLAN (COBRA)
STATE OF OKLA. 1992
STATE OF OKLA. COBRA)
15-20/100A GR06
5-10/100% GR06
TULSA AREA-SH INDIVIDUAL
TULSA-SH INDIV.PRT B ONLY
TAX PCOK PREMIUM TAX
$3G/$7B
ARP MCC TULSA EP-PL SH08
ARP MCC TULSA PL-DLX SH08
ARP MCC TULSA PP-PL SH08
ARP MCC TULSA PP SH08
ARP MCC TULSA PLUS SH08
ARP MCC TULSA SH08
ARP MCC TULSA DLX SH08
ARP MCC TULSA EP SH08
15/30 TULSA C SH06 D466
15/30 TULSA C SH06 EPO
15/30 TULSA C SH06
MCC TULSA PP-PL SH07
MCC TULSA EP-PL SH07
MCC TULSA PLUS SH07
MCC TULSA DELUXE SH07
MCC TULSA EP SH07
MC COMP TULSA SH07
MCC TULSA PL-DLXE SH07
MCC TULSA PP SH07
MCC ESS TULSA PP-PL SH07
MCC ESS TULSA EP-PL SH07
MCC ESS TULSA PLUS SH07
MCC ESS TULSA DELUXE SH07
MCC ESS TULSA EP SH07
MC COMP ESS TULSA SH07
346 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
TJO
TJP
TLC
TLH
TLL
TLM
TLX
TLZ
TM3
TM5
TMA
TMB
TMC
TMD
TMP
TP3
TP4
TPH
TPL
TR5
TS1
TS2
TX3
TX5
TXA
TXB
TXC
TXD
TXE
TXF
TXG
TXH
TXI
TXJ
TXK
TXL
TXM
TXN
TXO
TXP
TXQ
TXR
TXS
TZ1
U01
U02
U03
U04
U05
U06
Plan / Benefit Description
MCC ESS TULSA PL-DLXE SH07
MCC ESS TULSA PP SH07
HIGH PLAN/LDDS
HIGH PLAN/LDDS (COBRA)
HIGH PLAN/LDDS
HIGH PLAN/LDDS
HIGH PLAN/LDDS (COBRA)
HIGH PLAN/LDDS (COBRA)
$3/$8/$13
$5/$10/$15
$3/$8/$13
$5/$10/$15
$5/$10/$15
20%/40%
20%/40%
TOWERS PERRIN $15 PLAN
TOWERS PERRIN $15 PLAN
5-10/100% GR06
15-20/100A GR06
SH GRP RET $5/100% 2001
TULSA STANDARD PLAN
TULSA STNDRD PART B ONLY
$3/$8/$13
$5/$10/$15
$5/$10/$15
$5/$10/$15
$5/$10
$5/$10/$15
$5G/$10B
$10G/$20B
$3/$8/$13
$5/$10/$15
$5/$10/$15
$5/$10/$15
20%/40%
$3G/$7B
$5G/$10BR
$10G/$20B $600 BRND MAX.
$10G/$20B
20%/40%
$5/$10/$15
$15G/$30B
$5/$10
SHARE PLAN 250 (COBRA)
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
347 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
U07
U08
U09
U10
U11
U12
U13
U14
U15
U16
U17
U18
U19
U20
U21
U22
U23
U24
U25
U26
U27
U28
U29
U30
U31
U32
U33
U34
U35
U36
U37
U38
U39
U40
U41
U42
U43
U44
U45
U46
U47
U48
U49
U50
U51
U52
U53
U54
U55
U56
Plan / Benefit Description
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY
VSUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
348 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
U57
U58
U59
U60
UFA
UGA
UHA
UHC
UJA
UTC
UZ1
UZ2
UZF
V15
V1P
V1Y
V27
V2F
V8P
V8Q
V8R
V8S
V8T
V8U
V8V
V8W
V8X
VB6
VBD
VBH
VCC
VCK
VCV
VCZ
VDA
VFP
VFQ
VG6
VGP
VGQ
VH0
VH1
VH2
VH3
VH4
VH5
VH6
VHC
VHD
VJM
Plan / Benefit Description
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
SV 20-40/250D 07
SV 20-40/250D 07 CB
SV 20-40/250D 07
DUAL-OPTION - UHC 06
SV 20-40/250D 07 CB
TAKING CHARGE OF YOU
NEW SHARE PLAN (COBRA)
NEW SHARE PLAN (COBRA)
OPT SHARE PLAN (COBRA)
VISION CARE $15 (VSP)
ADVANTAGE PLAN OPTION
ADVANTAGE PLAN OPTION CBR
SC 20 ELIGIBILITY ONLY
25/70A TOWERS GR-VN06 VSP
0 REFRAC 1/V YR VN-GR08
5 REFRAC 1/V YR VN-GR08
10 REFRAC 1/V YR VN-GR08
15 REFRAC 1/V YR VN-GR08
20 REFRAC 1/V YR VN-GR08
25 REFRAC 1/V YR VN-GR08
30 REFRAC 1/V YR VN-GR08
35 REFRAC 1/V YR VN-GR08
40 REFRAC 1/V YR VN-GR08
25/150A 2 YRS SH-VN06
0/0 BOEING IAM GR VN06 COL
$15/$75 BOEING HRLY GP RET
COALITION LOW PLAN
POS-COALITION LOW PLAN
POS-COALITION LOW (COBRA)
COALITION LOW PLAN - COBRA
15/70A GR-VN07
0/75A 2YRS VN-GR08
0/125A 2YRS VN-GR08
25/75A VN-GR06
5/75A 2YRS VN-GR08
5/125A 2YRS VN-GR08
PC VISION CARE - HIGH
VISION $0 COPAY VHO RIDER
VISION $5 COPAY VHO RIDER
VISION $10 COPAY VHO RIDER
VISION $15 COPAY VHO RIDER
VISION $20 COPAY VHO RIDER
VISION $25 COPAY VHO RIDER
VISION $10 EXAM - VSP
VISION $15 EXAM - VSP
0/0 BOEING IAM VN-GR08
349 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
VJP
VJQ
VKP
VM0
VMP
VMQ
VN1
VN2
VN3
VN5
VNQ
VP6
VPE
VPP
VQC
VQD
VQJ
VQP
VQR
VS0
VS1
VS2
VS3
VS4
VS5
VS6
VSK
VSQ
VSX
VV1
VV2
VV3
VV4
VV5
VV6
VV7
VVP
VVQ
VWP
WAP
WBC
WBM
WBX
WBZ
WEL
WKC
WKH
WKL
WKM
WKX
Plan / Benefit Description
20/100M JPM-COLE
10/75A 2YRS VN-GR08
10/125A 2YRS VN-GR08
VISION (MCDONNELL DOUGLAS)
15/12V VN06 VSP
15/125A 2YRS VN-GR08
GRP RET $5OV/$125 ALLOWNCE
GRP RET $10OV/$75 ALLOWNCE
15/75A GR-VN05 COLE
GRP RET $20V/$75 ALLOWANCE
20/75A 2YRS VN-GR08
ADVANCE WELLNESS SH-WL06
RESERVED PFFS
20/125A 2YRS VN-GR08
15/130A 1YR DLX VN-SH08
30/70A 2YRS VN-SH08
5/100A 2YRS VN-SH08
25/70A 2YRS VN-GR08
0/70A 2YRS VN-SH08
PC VISION CARE - STANDARD
VISION $0 COPAY VSO RIDER
VISION $5 COPAY VSO RIDER
VISION $10 COPAY VSO RIDER
VISION $15 COPAY VSO RIDER
VISION $20 COPAY VSO RIDER
VISION $25 COPAY VSO RIDER
5/100A 2YRS SH-VN07
30/70A 2YRS SH-VN07
15/130A 1YR DLX SH-VN07
VISION STANDARD $0 COPAY
VISION STANDARD $5 COPAY
VISION STANDARD $10 COPAY
VISION STANDARD $15 COPAY
VISION STANDARD $20 COPAY
VISION STANDARD $25 COPAY
VISION STANDARD $30 COPAY
15/75A 2YRS VN-GR08
25/75A 2YRS VN-GR08
25/125A 2YRS VN-GR08
RESERVED WT ALT PROGRAMS
MOBIL PLAN
MOBILE PLAN
MOBIL PLAN COBRA
MOBIL PLAN COBRA
SUPPLEMENTAL WELLNESS
STATE OF OKLAHOMA LOW
STATE OF OKLAHOMA LOW
STATE OF OKLAHOMA LOW
STATE OF OKLAHOMA LOW
STATE OF OKLAHOMA LOW
350 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
WKZ
WLC
WLD
WLE
WLF
WLG
WLH
WLJ
WLK
WLL
WLM
WLX
WLZ
WMC
WMM
WMX
WMZ
WPR
WPS
WPT
WQR
WQS
WQT
WRR
WRS
WRT
WS1
WS2
WS3
WS4
WS5
WS6
WSC
WSH
WSL
WSM
WSP
WSQ
WSX
WSZ
WUR
WUS
WUT
WVR
WVS
WVT
WXR
WXS
WXT
X10
Plan / Benefit Description
STATE OF OKLAHOMA LOW
STATE OF OKLAHOMA LOW
STATE OF OK LOW OPTION
STATE OF OK LOW OPTION CBR
STATE OF OK LOW OPTION
STATE OF OK LOW OPTION CBR
STATE OF OKLAHOMA LOW
STATE OF OK LOW OPTION
STATE OF OK LOW OPTION CBR
STATE OF OKLAHOMA LOW
STATE OF OKLAHOMA LOW
STATE OF OKLAHOMA LOW
STATE OF OKLAHOMA LOW
MOBIL PLAN
MOBIL PLAN
MOBIL PLAN (COBRA)
MOBIL PLAN (COBRA)
10-15/50A T1A GR07
5-20/100A T1B GR07
10-20/200A T1C GR07
10-20/750A T2A GR07
15-25/130D T2B GR07
10-25/150D T2C GR07
15-25/200D T3A GR07
15-30/220D T3B GR07
20-35/250D T3C GR07
WILLIAM SONOMA $20/100A
WILLIAM SONOMA $20/100A CB
WILLIAM SONOMA $20/100A
WILLIAM SONOMA $20/100A CB
SV 20/100A WS 05
SV 20/100A WS 05 CB
LOW PLAN-ST OF OKLAHOMA
LOW PLAN-ST OF OK (COBRA)
LOW PLAN-ST OF OKLAHOMA
LOW PLAN-ST OF OKLAHOMA
SV 20/100A WS 05
SV 20/100A WS 05 CB
LOW PLAN-ST OF OK (COBRA)
LOW PLAN-ST OF OK (COBRA)
15-25/200D T3A GR07
15-30/220D T3B GR07
20-35/250D T3C GR07
10-20/750A T2A GR07
15-25/130D T2B GR07
10-25/150D T2C GR07
10-15/50A T1A GR07
5-20/100A T1B GR07
10-20/200A T1C GR07
$10
351 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
X15
XA7
XAF
XKE
XMK
XML
XMM
XMN
XMO
XMP
XMQ
XMR
XMS
XMT
XMU
XMV
XXX
Y1K
Y1V
Y2K
Y2V
YCC
YCK
YCV
YCZ
YXA
YXJ
YYA
YYB
YZC
Z2P
Z2T
Z2U
Z2X
Z5R
Z5T
Z5U
Z5V
Z8F
Z8P
Z8X
ZA2
ZA3
ZA4
ZA5
ZA6
ZA7
ZA8
ZA9
ZB2
Plan / Benefit Description
$15
$7
$5G/$15B
SVA 1530/250A SG07
$10
$5GF/$10BF
$5GF/$15BF
$10GF/$15BF
$10GF/$25BF
$5/$10/$25
$10GF/$15BF
$10GF/$25BF
$5G/$10B
$5GF/$10BF
$5/$10/$25
$5GF/$10BF
PREMIUM ALLOCATION
KP400 - AAON CUSTOM PLAN
KP400 - AAON COBRA CUSTOM
KP500 KEY PLAN
KP500 KEY PLAN COBRA
COALITION HIGH PLAN
POS-COALITION HIGH PLAN
POS-COALITION HIGH (COBRA)
COALITION HIGH PLAN-COBRA
SV 35/240A W/BH9 06
SV 35/240A W/BH9 06 CB
SV 35/240A W/BH9 06
SV 35/240A W/BH9 06 CB
DUMMY CODE
10-15/50A T1A NON-AARP GR8
15-25/200D T3A NO-AARP GR8
15-25/200D T3A NO-AARP GR8
10-15/50A T1A NON-AARP GR8
15-25/130D T2B NO-AARP GR8
15-30/220D T3B NO-AARP GR8
15-30/220D T3B NO-AARP GR8
15-25/130D T2B NO-AARP GR8
880 PLAN OPT COBRA
10-20/200A T1C NO-AARP GR8
10-20/200A T1C NO-AARP GR8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
352 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
ZB3
ZB4
ZB5
ZB6
ZB7
ZB8
ZB9
ZC2
ZC3
ZC4
ZC5
ZC6
ZC7
ZC8
ZC9
ZD2
ZD3
ZD4
ZD5
ZD6
ZD7
ZD8
ZD9
ZE2
ZE3
ZE4
ZE5
ZE6
ZE7
ZE8
ZE9
ZF2
ZF3
ZF4
ZF5
ZF6
ZF7
ZF8
ZF9
ZG2
ZG3
ZG4
ZG5
ZG6
ZG7
ZG8
ZG9
ZH2
ZH3
ZH4
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
353 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
OK
Plan / Benefit
ZH5
ZH6
ZH7
ZH8
ZH9
ZJ2
ZJ3
ZJ4
ZJ5
ZJ6
ZJ7
ZJ8
ZJ9
ZK2
ZK3
ZK4
ZK5
ZK6
ZK7
ZK8
ZK9
ZM2
ZM3
ZM4
ZM5
ZM6
ZM7
ZM8
ZM9
ZN2
ZN3
ZN4
ZN5
ZN6
ZN7
ZN8
ZN9
ZP2
ZP3
ZP4
ZP5
ZP6
ZP7
ZP8
ZP9
ZR2
ZR3
ZR4
ZR5
ZR6
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
354 of 640
Plan Benefit - OK
State
OK
OK
OK
OK
Plan / Benefit
ZR7
ZR8
ZR9
ZZZ
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
HISTORICAL PLAN
355 of 640
Plan Benefit - OR
Cap/Eligibility CP7810
Assigned Plan Benefit Codes & Descriptions
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
1BS
1C1
1C2
1OS
1Z2
2AL
2AN
2AT
2AY
2BL
2C1
2C4
2CA
2CJ
2CK
2FH
2FL
2GH
2HH
2JH
2KH
2MH
2MN
2NH
2ON
2PH
2QD
2QH
2S1
2S2
2S3
2S4
2S5
2S6
2S7
2S8
2S9
2SA
2SB
2SC
2SD
2SE
Plan / Benefit Description
15 SH-RX05
$7/$7
$5G/$5B UMTA
$9G SH
SHARE PLAN (PACIFICARE EE)
5/10 RX 06
4/20/40 LO GR-RX07
5/15 RX 06
4/25/50 HI GR-RX07
10/25/50 RX-GR08
$7.50G/$15B
$5G/$15B AT&T
$5G/$15B
$5G/$15B
$10G/$20B
4/15/30 RX-GR08
5/20/45 RX-GR08
4/20/40 RX-GR08
4/15/30 RX-GR08
4/20/40 RX-GR08
4/25/50 RX-GR08
4/25/45 RX-GR08
ALREADY USED
4/28/55 RX-GR08
POS OUT OF NETWORK
4/28/58 RX-GR08
OK TO USE CODE FOR CO 33
4/25/50 RX-GR08
$5G/$10B
$5G/$15B
$5G/$20B
$5G/$25B
$10G/$20B
$10G/$25B
$10G/$35B
$5G/$5B
$25B/$25G
$15G/$40B
WA RX DONT USE IN OR
$10/$20
$10/$25
WA RX DONT USE IN OR
356 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
2SF
2SH
2SJ
2U1
2U2
2U3
2U4
2U5
2U6
2U7
2U8
2U9
2UA
2UB
2UC
2UD
2UE
2UF
2UH
2UK
2UL
2UM
2UN
2UO
2UP
2UQ
2VH
2WH
2XH
2YH
2ZA
2ZB
2ZC
2ZD
2ZE
2ZF
39C
3B4
3C1
3C2
3C3
3C4
3C6
3C7
3C8
3C9
3CB
3CF
3CX
3CY
Plan / Benefit Description
$10/$35
$15/$40
RESERVED RX LOW
$5G/$10B
$5G/$15B
$5G/$20B
$5G/$25B
$10G/$20B
$10/$25
$10G/$35B
$5G/$15B
$10G/$35B
$15G/$25B
$5G/$15B
$15G/$35B
$10G/$20B
$10G/$20B
$10G/$25B
10/25/50 RX-GR08
$5/$10 W/INF
$5/$15 W/INF
$10/$20 W/INF
10/25 W/INF
$10/$35 W/INF
$15/$25 W/INF
$15/$35 W/INF
10/25/50 RX-GR08
5/20/45 RX-GR08
5/20/45 RX-GR08
4/10/20 RX-GR08
0/0 GR-RX07
2/40 GR-RX07
5/25 GR-RX07
5/65 GR-RX07
5/10 GR-RX07
10/20 GR-RX07
WA RX DONT USE IN OR
5G/15B/30NF GRP RT
$10/$15/$30
DO NOT USE DUP TO C COUNTY
$5G/$15B/$30NF
WA RX DONT USE IN OR
$10G/$25B/$50NF
$10G/$20B/$35NF
WA RX DONT USE IN OR
$10G/$20B/$40NF
$5G/$15B/$30NF
$20G/$40B/$50NF
10G/20B/40NF PEPSI
10G/20B/35NF I VBA
357 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
3D1
3D2
3D3
3D4
3D5
3D6
3D7
3D8
3DC
3DR
3EA
3FC
3FD
3GA
3GB
3HA
3HC
3HP
3PA
3PC
3PH
3QB
3QD
3QU
3S1
3S2
3S3
3S4
3S5
3S6
3S7
3S8
3S9
3SA
3SB
3SC
3SD
3SE
3SF
3SH
3SJ
3SK
3SP
3SU
3SV
3TA
3TB
3U1
3U2
3U3
Plan / Benefit Description
$15G/$25B/$40NF $100 DED
$15G/$25B/$40NF $200 DED
$15/30/50/100D E
$15/35/60/200D E
15/25/40 100D
15/25/40 200D
15/30/50 100D E
15/35/60 200D E
10G/20B/35NF SCHWB
10/25/40 RX06
RESERVED FIDELITY RX 06
10/30/50 RX05
15/30/60 RX06 SF
$15G/$25B/$40NF
15G/25B/40NF W/INJ
10/30/45 RX 06
$10G/$25B/$40NF HP
5/30/45 GR-RX07
10/20/40 RX 06
10G/30B/40NF E W/I
10/30/50 RX06
UN USED WRONG STATE
20/40/60 RX06
20/40/60/1000D RX6
$3/$8/$23
$8/$13/$28
$15/$25/$40
$7/$12/$27
$3G/$8B/$23NF
$5G/$10B/$25NF
$8G/$13B/$28NF
$10G/$15B/$30NF
$15G/$25B/$40NF
RX RESERVED
$10G/$20B/$30NF
$10G/$20B/$45NF E
$10G/$30B/$50NF E
$15G/$25B/$50NF E
5/10/25 RX 06
10/20/45 E
$10/$30/$50 E
$15/$25/$50 E
10/15/30
RESERVED RX PREVAILING
15/25/40
10/20/45 RX 05
15/30/50 RX 08
OR RX CODE DONT USE IN WA
OR RX CODE DONT USE IN WA
$10/$15/$30
358 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
3U4
3U5
3U6
3U7
3U8
3U9
3UA
3UB
3UC
3UD
3UE
3UF
3UG
3UH
3UI
3UO
3UP
3UQ
3UR
3US
3UT
3UU
3UW
3UX
3VA
3W3
3W4
3W5
3W6
3ZE
3ZF
3ZG
3ZH
3ZJ
3ZK
3ZL
3ZM
40A
40B
40C
40D
40E
40F
40G
40H
40I
40J
40K
40L
40M
Plan / Benefit Description
OR RX AVAL DONT USE IN WA
$5/$10/$25
$3G/$8B/$23NF
$5G/$10B/$25NF
$8G/$13B/$28NF
$10G/$15B/$30NF
$15G/$25B/$40NF
$10G/$20B/$30NF
$10G/$25B/$40NF
$10G/$25B/$50NF
$10/20/45 W/INF E
$10/30/50 W/INF E
$15/25/50 W/INF E
OR RX AVAL DONT USE IN WA
OR RX AVAL DONT USE IN WA
5/10/25 W/INF
10/15/30 W/INF
15/25/40 W/INF
10/20/30 W/INF
10/25/40 W/INF
10/25/50 W/INF
10/20/45 W/INF E
10/30/50 W/INF E
15/25/50 W/INF E
15/25/50 RX 08
$15/30/50/100D I E
$15/35/60/200D I E
15/30/50 100D I E
15/35/60 200D I E
5/10/20 GR-RX07
10/20/35 GR-RX07
10/20/35 GR-RX07
10/25/55 GR-RX07
10/40/75 GR-RX07
7/20/50% GR-RX07
2/30/60 GR-RX07
10/25/50 GR-RX07
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
359 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
40N
40O
40P
40Q
40R
40S
40T
40U
40V
40W
40X
40Y
40Z
41B
41C
41D
41E
41F
41G
41H
41I
41J
41K
41L
41M
41N
41O
41P
41Q
41R
41S
41T
41U
41V
41W
41X
41Y
41Z
440
49I
4A0
4A1
4AI
4AO
4B0
4B1
4BI
4BO
4C0
4C1
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
360 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
4CI
4CO
4D0
4D1
4E0
4E1
4EI
4EO
4F0
4F1
4FI
4FO
4G0
4G1
4GI
4H0
4H1
4HI
4HO
4I0
4I1
4IA
4IB
4IC
4ID
4IE
4IF
4IG
4IH
4II
4IJ
4IK
4IL
4IN
4IO
4IP
4IQ
4IR
4IS
4IT
4IU
4IV
4IW
4IX
4IY
4IZ
4J0
4J1
4JI
4JO
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
361 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
4K0
4K1
4KI
4KO
4L0
4L1
4LI
4M0
4M1
4MI
4MO
4N0
4N1
4NI
4NO
4O0
4O1
4OA
4OB
4OC
4OD
4OF
4OH
4OI
4OJ
4OK
4OL
4OM
4OO
4OP
4OQ
4OS
4OT
4OU
4OV
4OW
4OX
4OY
4OZ
4P0
4P1
4PI
4PO
4Q0
4Q1
4QI
4QO
4R0
4R1
4RO
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
362 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
4S0
4S1
4T0
4T1
4TI
4U0
4U1
4UI
4UO
4V0
4V1
4VI
4VO
4W0
4W1
4WI
4WO
4X0
4X1
4XI
4XO
4Y0
4Y1
4YI
4YO
4Z0
4Z1
4ZI
4ZO
50A
50B
50C
50D
50E
50F
50G
50H
50I
50J
50K
50L
50M
50N
50O
50P
50Q
50R
50S
50T
50U
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
363 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
50V
50W
50X
50Y
50Z
51A
51B
51C
51D
51E
51F
51G
51H
51I
51J
51K
51L
51M
51N
51O
51P
51Q
51R
51S
51T
51U
51V
51W
51X
51Y
51Z
52I
535
536
537
538
539
53I
540
541
542
543
544
545
546
547
548
549
54I
550
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
364 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
551
552
553
554
555
556
557
558
559
55I
560
561
562
563
564
565
566
567
568
569
56I
570
571
572
573
574
575
576
577
578
579
57I
580
581
582
583
584
585
586
587
588
589
58I
590
591
592
593
594
59I
5A0
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVE DPPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
365 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
5A1
5AI
5AO
5B0
5BI
5BO
5C0
5C1
5CI
5CO
5D0
5D1
5E0
5E1
5EI
5F0
5F1
5FI
5FO
5G0
5G1
5GI
5H0
5H1
5HI
5HO
5I0
5I1
5IA
5IB
5IC
5ID
5IE
5IF
5IG
5IH
5II
5IJ
5IK
5IL
5IN
5IO
5IP
5IQ
5IR
5IS
5IU
5IV
5IW
5IX
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
366 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
5IY
5IZ
5J0
5J1
5JI
5JO
5K0
5K1
5KI
5KO
5L0
5L1
5LI
5M0
5M1
5MI
5N0
5N1
5NI
5NO
5O0
5O1
5O2
5O3
5O4
5O5
5O6
5O7
5O8
5O9
5OA
5OB
5OD
5OF
5OH
5OI
5OJ
5OK
5OL
5OM
5ON
5OO
5OQ
5OS
5OT
5OU
5OV
5OW
5OX
5OY
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
367 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
5OZ
5P0
5P1
5PI
5PO
5Q0
5Q1
5QI
5QO
5R0
5RO
5S0
5T0
5T1
5TI
5U0
5U1
5UI
5UO
5V0
5V1
5VI
5VO
5W0
5W1
5WI
5WO
5X0
5X1
5XI
5XO
5Y0
5Y1
5YI
5YO
5Z0
5Z1
5Z2
5ZI
5ZO
600
601
602
603
604
605
606
607
608
609
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
STANDARD 5 PLAN (COBRA)
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
368 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
610
611
612
613
614
615
616
617
618
619
620
621
622
623
624
625
626
627
628
629
630
635
636
637
638
639
640
641
642
643
644
645
646
647
648
649
650
651
652
653
654
655
656
657
658
659
660
661
662
663
Plan / Benefit Description
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED PPO RIDER PPO
MANDATED OFFER RIDER PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
369 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
664
665
666
667
668
669
670
671
672
673
674
675
676
677
678
679
680
681
682
683
684
685
686
687
688
689
690
691
692
693
694
6AH
6AL
6BH
6BL
6CD
6DH
6DL
6EH
6EL
6FH
6FL
6GP
6HH
6HL
6HR
6JH
6JL
6JP
6KH
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
0/0 HI GR-RX07
0/0 LO GR-RX07
2/30/06 HI GR-RX07
2/30/60 LO GR-RX07
7/14 GR-RX06
2/40 HI GR-RX07
2/40 LO GR-RX07
5/25 HI GR-RX07
5/25 LO GR-RX07
5/65 HI GR-RX07
5/65 LO GR-RX07
8.50/26.45/50% SH6
5/10 HI GR-RX07
5/10 LO GR-RX07
10/20 GR-RX06
5/10/20 HI GR-RX07
5/10/20 LO GR-RX07
8.50/26.70/50% SH6
7/14 HI GR-RX07
370 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
6KL
6LH
6LL
6MA
6MH
6ML
6NH
6NL
6NM
6PH
6PL
6PM
6QH
6QL
6RH
6RL
6SH
6SI
6SL
6SR
6TH
6TL
6TR
6UH
6UL
6UR
6VM
6WH
70O
710
711
712
713
714
715
716
717
718
719
71A
71B
71C
71D
71E
71F
71G
71H
71I
71J
71K
Plan / Benefit Description
7/14 LO GR-RX07
7/20/50% HI GR-RX7
7/20/50% LO GR-RX7
10/25%/40% RX-GR06
10/20 HI GR-RX07
10/20 LO GR-RX07
10/20/40 HI GR-RX7
10/20/40 LO GR-RX7
5/15/30 GR-RX06
10/20 HI GR-RX07
10/20 LO GR-RX07
5/15/30 GR-RX06
10/20/35 HI GR-RX7
10/20/35 LO GR-RX7
10/20/35 HI GR-RX7
10/20/35 LO GR-RX7
10/25/55 HI GR-RX7
10/20/40 I GR-RX06
10/25/55 LO GR-RX7
10/20/40 GR-RX06
10/40/75 HI GR-RX7
10/40/75 LO GR-RX7
10/25/40 GR-RX06
15/25/40 HI GR-RX7
15/25/40 LO GR-RX7
15/25/40 GR-RX06
5/5 GR-RX06
10/25/50 HI GR-RX7
VALUE $25/70% SG
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
371 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
71L
71M
71N
71O
71P
71Q
71R
71S
71T
71U
71V
71W
71X
71Y
71Z
720
721
722
723
724
725
726
727
728
729
72A
72B
72C
72D
72E
72F
72G
72H
72I
72J
72K
72L
72M
72N
72O
72P
72Q
72R
72S
72T
72U
72V
72W
72X
730
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
372 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
731
732
733
734
735
736
737
738
739
73A
73B
73C
73D
73E
73F
73G
73H
73I
73J
73K
73L
73M
73N
73O
73P
73Q
73R
73S
73T
73U
73V
73W
73X
73Y
73Z
740
741
742
743
744
745
746
747
748
749
74A
74B
74C
74D
74E
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
373 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
74F
74G
74H
74I
74J
74K
74L
74M
74N
74O
74P
74Q
74R
74S
74T
74U
74V
74W
74X
74Y
74Z
750
751
752
753
754
755
756
757
758
759
75A
75B
75C
75D
75E
75F
75G
75H
75I
75J
75K
75L
75M
75N
75O
75P
75Q
75R
75S
Plan / Benefit Description
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
374 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
75T
75U
75V
75W
75X
75Y
75Z
760
761
762
763
764
765
766
767
768
769
76A
76B
76C
76D
76E
76F
76G
76H
76I
76J
76K
76L
76M
76N
76O
76P
76Q
76R
76S
76T
76U
76V
7AQ
7AR
7BD
7BH
7BI
7BL
7BR
7C1
7C2
7CD
7CI
Plan / Benefit Description
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
7/20 GR-RX07
0/0 GR-RX07
7/14 GR-RX07
4/10/20 T1A H GRX7
7/14 I GR-RX07
4/10/20 T1A L GRX7
0/0 FLAT GR-RX07
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
7/14 GR-RX07
7/14 I GR-RX07
375 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
7CM
7DD
7DH
7DL
7DM
7DR
7ED
7EH
7EL
7EM
7ER
7FD
7FH
7FL
7FM
7FR
7GD
7GM
7GR
7HH
7HI
7HL
7HR
7JH
7JL
7JM
7JR
7KH
7KI
7KL
7KM
7KR
7LH
7LL
7LM
7LR
7MA
7MH
7MI
7ML
7MR
7NH
7NL
7NM
7O1
7O2
7OZ
7PH
7PI
7PL
Plan / Benefit Description
15/25/40 GR-RX07
7/20/30 GR-RX07
4/15/30 T1B H GRX7
4/15/30 T1B L GRX7
15/25/40 GR-RX07
10/10 FLAT GR-RX07
7/7 GR-RX07
4/20/40 T1C H GRX7
4/20/40 T1C L GRX7
3/3 FLAT GR-RX07
10/20 GR-RX07
7/7 C GR-RX07
4/25/50 T1D H GRX7
4/25/50 T1D L GRX7
3/3/3 GR-RX07
10/20 GR-RX07
10/20/30 GR-RX07
5/10 GR-RX07
10/20 GR-RX07
4/15/30 T2A H GRX7
10/20 I GR-RX07
4/15/30 T2A L GRX7
10/20 GR-RX07
4/28/58 T3C H GRX7
4/28/58 T3C L GRX7
5/10 GR-RX07
10/10 GR-RX07
4/28/55 T3B H GRX7
10/20/35 I GR-RX07
4/28/55 T3B L GRX7
5/10/20 GR-RX07
10/20/35 GR-RX07
4/25/45 T3A H GRX7
4/25/45 T3A L GRX7
5/15 GR-RX07
15/25/40 GR-RX07
10/25%/40% GR-RX07
4/20/40 T2B H GRX7
10/20/40 I GR-RX07
4/20/40 T2B L GRX7
10/20/40 GR-RX07
4/25/50 T2C H GRX7
4/25/50 T2C L GRX7
5/15/30 GR-RX07
$25/70% SG
$25/70% SG COBRA
VALUE $25/70% SG COBRA
4/25/50 T2C H GRX7
10/20/40 I GR-RX07
4/25/50 T2C L GRX7
376 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
7PM
7PR
7QH
7QI
7QL
7QM
7QR
7RA
7RB
7RC
7RD
7RH
7RL
7RM
7RR
7SB
7SI
7SR
7TH
7TL
7TM
7TR
7UH
7UL
7UM
7UR
7VH
7VL
7VM
7WH
7WI
7WL
7WM
7WR
7XA
7XB
7XC
7XD
7XE
7XF
7XG
7XH
7XJ
7XL
7XM
7XP
7YH
7YI
7YL
7YM
Plan / Benefit Description
5/15/30 GR-RX07
10/20/40 GR-RX07
4/20/40 T2B H GRX7
10/20/40 I GR-RX07
4/20/40 T2B L GRX7
5/15/30 GR-RX07
10/20/40 GR-RX07
10/20/35 RDS GRX7
10/20 RDS GR-RX07
10/20/35 RDS GRX7
10/20 RDS GR-RX07
4/15/30 T2A H GRX7
4/15/30 T2A L GRX7
5/15/30 GR-RX07
15/35/50/50 GR-X07
10/25%/40% GR-RX07
10/20/40 I GR-RX07
10/20/40 GR-RX07
4/28/55 T3B H GRX7
4/28/55 T3B L GRX7
5/5 GR-RX07
10/25/40 GR-RX07
4/28/58 T3C H GRX7
4/28/58 T3C L GRX7
5/5 GR-RX07
15/25/40 GR-RX07
4/25/50 T1D H GRX7
4/25/50 T1D L GRX7
5/5 GR-RX07
4/20/40 T1C H GRX7
15/25/40 I GR-RX07
4/20/40 T1C L GRX7
5/7.50 GR-RX07
15/25/40 GR-RX07
4/10/20 RDS GR-RX7
4/15/30 RDS GR-RX7
4/20/40 RDS GR-RX7
4/25/50 RDS GR-RX7
4/10/20 RDS GR-RX7
4/15/30 RDS GR-RX7
4/20/40 RDS GR-RX7
4/15/30 T1B H GRX7
4/25/50 RDS GR-RX7
4/15/30 T1B L GRX7
7/14 GR-RX07
5/29/60 N/G SH-RX7
4/10/20 T1A H GRX7
15/25/40 I GR-RX07
4/10/20 T1A L GRX7
7/14 GR-RX07
377 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
7YR
7ZH
7ZL
7ZM
7ZR
80O
810
811
812
813
814
815
816
817
818
819
820
821
822
823
824
825
826
827
828
829
830
831
832
833
834
835
836
837
838
839
840
841
842
843
844
845
846
847
848
849
84A
84B
84C
84D
Plan / Benefit Description
15/25/40 GR-RX07
4/25/45 T3A H GRX7
4/25/45 T3A L GRX7
7/14 GR-RX07
15/25/40 GR-RX07
VALUE $20/80% SG
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
VESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
378 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
84E
84F
84G
84H
84J
84K
84L
84M
84N
84P
84Q
84R
84S
84T
84U
84V
84W
84X
84Y
84Z
850
851
852
853
854
855
856
857
858
859
85A
85B
85C
85D
85E
85F
85G
85H
85J
85K
85L
85M
860
861
862
863
864
865
866
867
Plan / Benefit Description
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
379 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
868
869
881
882
8AH
8AR
8B8
8BH
8C1
8C2
8CH
8DD
8DH
8DR
8ED
8EH
8EM
8ER
8FD
8FH
8GH
8GM
8HD
8HH
8KM
8LH
8LM
8MA
8NM
8O1
8O2
8OZ
8PH
8PM
8RH
8RM
8SH
8TH
8TM
8TR
8UM
8UR
8VM
8WH
8Z1
8Z2
90O
910
911
912
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
880 PLAN
880 PLAN (2)
0/0 HI C GR-RX07
0/0 C GR-RX07
5/29/60NG RX-SH08
DO NOT USE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
2/30/60 HI C GRX07
7/20/30 C GR-RX07
2/40 HI C GR-RX07
10/10 FLAT C GRX07
7/7 C GR-RX07
5/25 HI C GR-RX07
3/3 FLAT C GR-RX07
10/20 C GR-RX07
7/7 C GR-RX07
5/65 HI C GR-RX07
510 HI C GR-RX07
5/10 C GR-RX07
10/20/30 C GR-RX07
DO NOT USE
5/10/20 C GR-RX07
7/20/50% HI C GRX7
5/15 C GR-RX07
10/25%/40% C GRX07
5/15/30 C GR-RX07
$20/80% SG
$20/80% SG COBRA
VALUE $20/80% SG COBRA
10/20 HI C GR-RX07
5/15/30 C GR-RX07
10/20/35 HI C GRX7
5/15/30 C GR-RX07
10/25/55 HI C GRX7
10/40/75 HI C GRX7
5/5 C GR-RX07
10/25/40 C GR-RX07
5/5 C GR-RX07
15/25/40 C GR-RX07
5/7.50 C GR-RX07
10/25/50 HI C GRX7
880 PLAN (COBRA)
880 PLAN (2)
VALUE $15/90% SG
RESERVED PPO
RESERVED PPO
RESERVED PPO
380 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
913
914
915
916
917
918
919
91H
920
921
922
923
924
925
926
927
928
929
92H
930
931
932
933
934
935
936
937
938
939
93H
940
941
942
943
944
945
946
947
948
949
94H
950
951
952
953
954
955
956
957
958
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
15/25/40 HI RX-GR8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/25/50 HI RX-GR8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/20/40 HI RX-GR8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/20 HI RX-GR08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
381 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
959
95H
960
961
962
963
964
965
966
967
968
969
970
971
972
974
975
976
977
978
979
980
981
982
983
984
985
986
987
988
989
990
991
992
993
994
9AN
9AQ
9AR
9AY
9BE
9BH
9BL
9C1
9C2
9CM
9DH
9DL
9DR
9EH
Plan / Benefit Description
RESERVED PPO
10/40/75 HI C XGR8
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
4/20/40 LO RX-GR08
7/20 RX-GR08
0/0 RX-GR08
4/25/50 HI RX-GR08
7/14 RX-GR08
4/10/20 T1A H XGR8
4/10/20 T1A L XGR8
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
15/25/40 RX-GR08
4/15/30 T1B H XGR8
4/15/30 T1B L XGR8
10/10 FLAT C XGR08
4/20/40 T1C H XGR8
382 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
9EL
9ER
9FD
9FH
9FL
9GE
9GM
9HD
9HH
9HK
9HL
9HN
9HP
9JH
9JL
9KH
9KL
9KS
9LH
9LL
9LM
9LP
9LV
9MA
9MH
9MI
9ML
9MR
9NH
9NL
9NM
9O1
9O2
9OZ
9PH
9PL
9QH
9QL
9RH
9RL
9RP
9RS
9RX
9TH
9TL
9UH
9UL
9VH
9VL
9VM
Plan / Benefit Description
4/20/40 T1C L XGR8
10/20 RX-GR08
7/7 C RX-GR08
4/25/50 T1D H XGR8
4/25/50 T1D L XGR8
10/20/30 RX-GR08
5/10 RX-GR08
10/20/30 C RX-GR08
4/15/30 T2A H XGR8
4/10/20 RX-GR08
4/15/30 T2A L XGR8
4/15/30 RX-GR08
5/30/45 RX-GR08
4/28/58 T3C H XGR8
4/28/58 T3C L XGR8
4/28/55 T3B H XGR8
4/28/55 T3B L XGR8
10/20/35 RX-GR08
4/25/45 T3A H XGR8
4/25/45 T3A L XGR8
5/15 C RX-GR08
5/15 RX-GR08
10/20/35 RX-GR08
10/25%/40% RX-GR08
4/20/40 T2B H XGR8
10/20/40 I RX-GR08
4/20/40 T2B L XGR8
10/20/40 RX-GR08
4/25/50 T2C H XGR8
4/25/50 T2C L XGR8
5/15/30 RX-GR08
$15/90% SG
$15/90% SG COBRA
VALUE $15/90% SG COBRA
4/25/50 T2C H XGR8
4/25/50 T2C L XGR8
4/20/40 T2B H XGR8
4/20/40 T2B L XGR8
4/15/30 T2A H XGR8
4/15/30 T2A L XGR8
5/15/30 RX-GR08
15/35/50/50 X-GR08
NO RX
4/28/55 T3B H XGR8
4/28/55 T3B L XGR8
4/28/58 T3C H XGR8
4/28/58 T3C L XGR8
4/25/50 T1D H XGR8
4/25/50 T1D L XGR8
5/5 RX-GR08
383 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
9WH
9WI
9WL
9WM
9XH
9XL
9YH
9YL
9ZH
9ZL
A1C
A1Z
A3C
A3Z
AAB
AAC
AAF
ABH
ABL
ACB
ACD
ACF
AD2
AD9
ADA
ADD
ADF
ADX
AE2
AE3
AE4
AE5
AEF
AF1
AF4
AF5
AF8
AFS
AH1
AH2
AH3
AH4
AH5
AH6
AH7
AH8
AH9
AIC
AIZ
AJ1
Plan / Benefit Description
4/20/40 T1C H XGR8
15/25/40 I RX-GR08
4/20/40 T1C L XGR8
5/7.50 RX-GR08
4/15/30 T1B H XGR8
4/15/30 T1B L XGR8
4/10/20 T1A H XGR8
4/10/20 T1A L XGR8
4/25/45 T3A H XGR8
4/25/45 T3A L ZGR8
94-AA-480
94-AA-480 COBRA
AA-480 PREFERRED
AA-480 PREFERRED COBRA
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
US BEHAVIORAL HEALTH
NOT AVAIL CLK CNTY CODE
SV 10/100% 07
SV 10/100% 07 CB
ADMIN/CONSULTANTS FEE
ADVANTAGE PLAN
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
SV 10/100% 08
SV 10/100% 08 CB
UNAVAIL USED IN WA CLARK
35/30V ACU/CHIRO/NAT/MASS
5/30V ACU/CHIRO/NAT/MASS
3/30V ACU/CHIRO/NAT/MASS
0/30V ACU/CHIRO/NAT/MASS
EXECU-FIT BENEFIT
SECURE HORIZONS B ONLY
20/12V ACU/CHIRO/NAT/MASS
SECURE HORIZONS B ONLY
SH LINN/BENTON/LANE B ONLY
ADMINISTRATIVE SERVICE FEE
$10/$1500 MAX CHIRO/ACU/NA
$15/$2500 MAX/CHIRO/ACU/NA
$10/30 CHIRO/ACU/NATU/MASS
$15/30 CHIRO/ACU/NATU/MASS
$20/30 CHIRO/ACU/NATU/MASS
$25/30 CHIRO/ACU/NATU/MASS
$0 /30 CHIRO/ACU/NATU/MASS
$3 /30 CHIRO/ACU/NATU/MASS
$5 /30 CHIRO/ACU/NATU/MASS
DO NOT USE
DO NOT USE
SV 10/100%
384 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
AJ2
AJ3
AJ4
ALF
ALH
AM0
AMD
AMF
AMR
AMZ
APC
APD
APF
APN
APQ
ART
AS1
AS5
AS8
ASA
ASB
AT1
AT2
AT3
AT4
ATA
ATB
ATD
ATF
ATJ
ATK
ATP
ATT
ATU
AW7
AW8
AWF
AZ2
AZM
AZT
B2A
B2B
B2C
B2D
B2E
B2F
B2G
B2H
B2J
B2P
Plan / Benefit Description
SV 10/100% CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
SV 20-40/300A AM MD 07
$35-30 VISITS CAM
UNAVAIL USED IN CLARK WA
AMMD RSP $20/$300 ADMT
UNAVAIL USED IN CLARK WA
AMER MED RESPONSE
AMMD RSP $20/$300 ADMT CBR
NOT AVAIL CLK CNTY CODE
ALREADY USED
10/12V 1YR ACU SH07
10/12V 1YR ACU SH08
SP 10/100% AZUSA PAC 07
RESERVED ART
SECURE HORIZONS STANDARD
SECURE HORIZONS STANDARD
SH LINN/BENTON/LANE
ALLERGY SERUM-LOW PLAN
ALLERGY SERUM - HIGH PLAN
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
SV $10-$15/$100A AT&T
SV $10-$15/$100A AT&T CB
SV 10-15/100A AT&T 06
UNAVAIL USED IN WA CLARK
SV 10-15/100A AT&T 06 CB
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
ATW-PLUS SH-WL07
AT & T CORP
ATW-PLUS WL-SH08
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
SV 20-40/300A AM MD 07 CB
STANDARD 10 PLAN (COBRA)
AMER MED RESPONSE COBRA
AT & T CORP COBRA
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
385 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
B2R
B3A
B3B
B3C
B3D
B3E
B3F
B3G
B3H
B3J
B3P
B3R
B4A
B4B
B4C
B4D
B4E
B4F
B4G
B4H
B4J
B4P
B4R
B4Z
B5A
B5B
B5C
B5D
B5E
B5F
B5G
B5H
B5J
B5P
B5R
B6A
B6B
B6C
B6D
B6E
B6F
B6G
B6H
B6J
B6R
B7A
B7B
B7C
B7D
B7E
Plan / Benefit Description
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
BOEING $15/100% COBRA
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
386 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
B7F
B7G
B7H
B7J
B7P
B7R
B8A
B8B
B8C
B8D
B8E
B8F
B8G
B8H
B8J
B8P
B8R
B9A
B9B
B9C
B9D
B9E
B9F
B9G
B9H
B9J
B9P
B9R
BA1
BA2
BAA
BAB
BAC
BAD
BC1
BC8
BDB
BDG
BDM
BEA
BEB
BEC
BEG
BEM
BFM
BGB
BGM
BH2
BH4
BH5
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
BASIC PLAN
BASIC PLAN (2)
UNAVAIL USED IN WA CLARK
SV 15/100% BUP BOEIN 06
UNAVAIL USED IN WA CLARK
SV 15/100% BUP BOEIN 06 CB
BUBB-SH-LINN/BENTON
ONLY USE SETTL&WHOLE STATE
SV 10/100% BNA SLRD 07
SV 15-25/250A BOEING 07
SV 15/100% BNA HRLY 08
SV 10/100% BOEING 06
SV 10/100% BOEING 06 CB
SV 10/100% BNA SLRD 08
SV 10/100% BNA SLRD 08 CB
SV 15/100% BNA HRLY 08 CB
SV 15-25/250A BOEING 08
SV 10/100% BNA SLRD 07 CB
SV 15-25/250A BOEING 08 CB
BOEING NA-HRLY $10 GRP RET
BOEING HOURLY $15 GRP RET
BASIC HEALTH PLAN SG
387 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
BH6
BJ1
BJ2
BJ3
BJ4
BJ5
BJ6
BJ7
BJ8
BK5
BK6
BKG
BLA
BLB
BLP
BMC
BMJ
BMP
BNC
BO1
BO4
BOE
BOF
BOG
BOZ
BP2
BP3
BP4
BP5
BP6
BP7
BP8
BP9
BPA
BPC
BPD
BPE
BPF
BPG
BPH
BPJ
BPK
BPL
BPM
BPN
BPP
BPQ
BPR
BPS
BPU
Plan / Benefit Description
BASIC HEALTH PLAN SG CBRA
SV $10/80%
SV $10/80% CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
SV $10/80% SG
SV $10/80% SG CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
BASIC HEALTH PLAN
BASIC HEALTH PLAN COBRA
SV 15-25/250A BOEING 07 CB
SV 10/100% BUP BOEIN 06
SV 10/100% BUP BOEIN 06 CB
SV 10/100% BNA HRLY 08
SV 10/80% 07
SV 10/80% 07 CB
SV 10/100% BNA HRLY 08 CB
****** OK TO USE THIS CODE
BOEING $10/100%
BOEING $15/100%
SV $15-$25/$250A VEBA
SV $15-$25/$250A VEBA CB
UNAVAIL USED IN WA CLARK
BOEING $10/100% COBRA
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVE PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
388 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
BPV
BPW
BPX
BPY
BPZ
BR2
BR3
BR4
BR5
BR6
BR7
BR8
BR9
BRB
BRC
BRD
BRJ
BU1
BU2
BU3
BU4
BU5
BU6
BU7
BU8
BU9
BUC
BUD
BUE
BUF
BUG
BUH
BUI
BUJ
BUK
BUL
BUM
BUN
BVA
BVB
BVC
BVD
BVF
BVK
BVM
BW7
BWA
BWB
BWC
BWF
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
SV 15/100% BNA HRLY 07
UNAVAIL USED IN WA
UNAVAIL USED IN WA
UNAVAIL USED IN WA CLARK
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
SV 15-25/250A BOEING 06
SV 15-25/250A BOEING 06 CB
SV 10/80% 08
15/100A BOEING VEBA GR07
15 BO-VEBA NON-AARP GR08
UNAVAIL USED IN WA CLARK
SV 10/100% BOEING 07
SV 15/100% BNA HRLY 07 CB
SV 10/100% BOEING 07 CB
SV 10/80% 08 CB
389 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
BX2
BX3
BX4
BX5
BX6
BX7
BX8
BX9
BXA
BXB
BXC
BXD
BXE
BXF
BXG
BXH
BXJ
BXK
BXL
BXM
BXN
BXP
BXR
BXS
BXT
BXU
BXV
BXW
BXX
BXY
BXZ
BYA
BYB
BYC
BYD
BYE
BYF
BYG
BYH
BYJ
BYK
BYL
BYM
BYN
BYP
BYR
BYS
BZ1
BZ2
BZ3
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
BASIC PLAN (COBRA)
BASIC PLAN (2) COBRA
RESERVED RX PPO
390 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
BZ4
BZ5
BZ6
BZ7
BZ8
BZ9
BZA
BZB
BZC
BZD
BZE
BZG
BZH
BZJ
BZK
BZL
BZM
BZN
BZP
BZR
BZS
BZT
BZV
BZW
BZX
BZY
BZZ
C1C
C1Z
C27
C2C
C2K
C2N
C2Z
C71
C72
C7A
C7D
C7E
C7F
C7G
C7H
C7J
C7K
C7L
C7M
C7P
C7R
C7S
C7U
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
94-BA-480
94-BA-480 COBRA
SC 90 ELIGIBILITY ONLY
BA-480 STANDARD
SV 15/250A CREDENCE 07
SV 15/250A CREDENCE 07 CB
BA-480 STANDARD COBRA
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
5/12V 1YR GR-CH07
50%/$250MAX 1YR GR-CH07
10/12V 1YR GR-CH07
10/20V 1YR GR-CH07
10/30V 1YR GR-CH07
15/12V 1YR GR-CH07
15/20V 1YR GR-CH07
0/20V 1YR GR-CH07
15/30V 1YR GR-CH07
20/12V 1YR GR-CH07
5/10V 1YR GR-CH07
10/1500MAX GR-CH07
30/12V 1YR GR-CH07
5/20V 1YR GR-CH07
391 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
C7W
C7Y
C81
C82
C91
C92
CAA
CAB
CAD
CAR
CAV
CAX
CAY
CBA
CBB
CBD
CBF
CBQ
CCS
CDA
CDZ
CE1
CE3
CE5
CE7
CEL
CEO
CF1
CF2
CF3
CFA
CFD
CFE
CFF
CFQ
CG8
CG9
CGD
CGF
CGG
CGI
CGL
CGO
CGP
CGS
CGV
CGX
CH0
CH1
CHA
Plan / Benefit Description
5/30V 1YR GR-CH07
5/40 1YR GR-CH07
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
20/12V CH06
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
CHIRO $20/20 VISITS
10/30V ACU/CHIRO/NAT/MASS
15/30V ACU/CHIRO/NAT/MASS
20/30V ACU/CHIRO/NAT/MASS
SV 15/100A COMCAST 06
SV 15/80% SG07
SV 15/100A COMCAST 06 CB
SV 15/80% SG07 CB
25/30V ACU/CHIRO/NAT/MASS
OOA 5/1500D CHIRO 07
SV 15/250A C SCHWAB 06
SV 15/250A C SCHWAB 06 CB
SECURE HORIZONS PLUS
SH PLUS 3 LINN BENTON
SH PLUS 5 LINN BENTON
SH PLUS 7 LINN BENTON
SV 10/250A 08
15/30V CH 07
SECURE HORIZONS B ONLY
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
SV 15-25/100A COMCST 07
10/20V CH 07
15/20V CH 07
SV 15/250A CSWB 07
SV 15/250A CSWB 07 CB
CAREGIVER-SH GOLD
CAREGIVER-SH INDIV
CAREGIVER LITE SH06
CHIRO RET $10/$1500 MAX
CAREGIVER PROGRAM
CAREGIVER PROGRAM
CAREGIVER CG-GR08
CAREGIVER ENHANCED
CHIROPRACTIC CARE
PEBB - CHIROCARE
$10/20VISIT PEBB CHIRO1-99
392 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
CHB
CHD
CHE
CHF
CHG
CHH
CHI
CHK
CHO
CHQ
CHT
CHU
CHW
CJ3
CJ4
CJ5
CJ6
CJ8
CL3
CL4
CL5
CL6
CMA
CMC
CMO
CN4
CN6
CN7
CN8
CNC
CNL
CNZ
CP5
CPA
CPO
CQ1
CR3
CR4
CR5
CR6
CRE
CRG
CRX
CRY
CS1
CS2
CS3
CS9
CSE
CT1
Plan / Benefit Description
CHIROCARE $35/30 VISITS
CHIROCARE $10
CHIROCARE $15
CHIROCARE $20/30 VISITS
CHIRO $25/30 VISITS
CHIRO $0 /30 VISIT
CHIRO $3 /30 VISITS
CHIRO $10/40V
CHIRO OUT-OF-AREA
FED $15/30V ACU/CHIRO 2005
15/30V ACU/CH 06
10/12V 1YR SH-CH07
10/12V 1YR SH-CH08
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
SV $15/80% BASIC PLAN
SV $15/80% BASIC PLAN CB
OOA ACU/CHIRO/NAT/MASS 07
20/30V CH 07
25/30V CH 07
NOT USED--SEE OLD CODE CHK
FEDS 15/30V ACU/CHIRO 07
SV 10/250A 07
SV 10/250A 07 CB
CAM OUT-OF-AREA
5/30V CH 07
35/30V CH 07
0/30V CH 07
3/30V CH 07
UWAA (CUSTOM 94-BA-480)
SV 10/250A 08 CB
UWAA-CUSTOM BA-480 (COBRA)
$5G/$15BR RETIREE
RESERVED PFFS
PEBB CH RET 50%/$250MAX1YR
10/30V CH 07
GRP RET CHIRO $5/12VISITS
GRP RET CHIRO $10/12VISITS
GRP RET CHIRO $15/12VISITS
GRP RET CHIRO $20/12VISITS
SV 15/250A CREDENCE 08
CUSTOM PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
SH STANDARD - CORVALLIS
C SCHWAB $15/100A
C.SCHWAB $15/100 COBRA
SV $15/$100A C SCHWAB CB
SV $15/$100A C SCHWAB
CHIROCARE $10/20 VISITS
393 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
CT2
CT3
CT4
CT5
CT6
CTE
CTL
CUC
CUL
CUZ
CW7
CW8
CXK
CXQ
CZK
D00
D05
D10
D1C
D1P
D1Y
D1Z
D20
D2C
D2Z
D50
D6V
D8E
D8M
DBA
DBO
DC1
DC2
DC6
DCA
DDA
DDG
DDP
DDR
DDS
DFA
DFC
DFJ
DIR
DJ1
DJ2
DJ3
DJ4
DJP
DJY
Plan / Benefit Description
CHIROCARE $15/20 VISITS
CHIROCARE $15/30 VISITS
CHIROCARE $5/30 VISITS
CHIROCARE $10/30 VISITS
30/12V GR-CH07
SV 15/250A CREDENCE 08 CB
SV 20/250A SCHWAB 08
94-BA-480 UNOCAL
SV 20/250A SCHWAB 08 CB
94-BA-480 UNOCAL COBRA
DO NOT USE
DO NOT USE
SV 15/80% SG 08
SV 15-25/100A COMCST 07 CB
SV 15/80% SG 08 CB
DURABLE MED EQUIP $0
DURABLE MED EQUIP 5%(SEBB)
DME 10%
94-CA-480
94-CA-480 (OPTION)
94-CA-480 (OPTION) COBRA
94-CA-480 COBRA
DME 20%
CA-480
CA-480 COBRA
DME 50%
DENTAL - VISION GR06
$20 469 DN-SH08
$0 466 DN-SH08
100%/70% DISCOUNT GR-DN07
DNTL DISC PRGRM - OREGON
PREMIER $5/100%
PREMIER $5/100% COBRA
$0 466 SH-DN06
SV 15/100% 08
SV 15/100% 08 CB
DENTAL DISCOUNT RETIREES
DENTAL DISCOUNT PROGRAM
DENTAL DISCOUNT RETIREE
DENTAL DISCOUNT PROGRAM
SV 15/100% 07
FEDERAL EMPLOYEE PLAN
SV 15/100% 07 CB
DUMMY-USED FOR VRU CODING
SV 10/250A
SV 10/250A CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
JOSEPHINE COUNTY
JOSEPHINE COUNTY (COBRA)
394 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
DK1
DK2
DK3
DK4
DM3
DM4
DN2
DN3
DNC
DNP
DNT
DP1
DPO
DPP
DPY
DQ6
DQP
DQY
DRC
DT1
DTC
DTO
DTS
DTZ
DW7
DW8
DZ2
EA3
EA5
EAP
ECE
ECN
ECP
EE6
EE7
EE9
EEE
EEN
EEP
EH6
EH7
EH9
EHA
EHE
EHJ
EHN
EHP
EUC
EVC
EW7
Plan / Benefit Description
PREMIER $5/100%
PREMIER $5/100% COBRA
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
DO NOT USE
RESERVED PPO GRP RET DEN
RESERVED PPO GRP RET DEN
INACTIVE PLAN CODE-NOT USE
INDEMNITY DENTAL
DENTAL-ORIG. EFF 1/88
DEPENDENT LIFE BENE
DOMESTIC PARTNERS COVERAGE
POS-CA-480
POS-CA-480 COBRA
$20 469 SH-DN06
CA-480 POS (IN-NETWK1&2)
CA-480 POS(IN-NETWK1&2)CBR
FEDERAL RETIRE PLAN 1994
DENTAL ONLY
94-CA-480 NATIONWIDE
INDEMNITY DNTL ONLY (EOFF)
PREV. DENTAL CHRN 3-12
94-CA-480 NATIONWIDE COBRA
DO NOT USE
DO NOT USE
ADVANTAGE PLAN COBRA
EAP-3 VISITS (PBHI)
EAP-5 VISITS (PBHI)
PBHI - EAP BENEFIT
10-20 NORTH C SH06 EPO
10-20 NORTH C SH06
10-20 NORTH C SH06 ODP
MCC NO PP-PL SH07
MCC NO EP-PL SH07
MCC NO PLUS SH07
MCC NO EP SH07
MC COMP NO SH07
MCC NO PP SH07
MCC ESS NO PP-PL SH07
MCC ESS NO EP-PL SH07
MCC ESS NO PLUS SH07
SV 10-20/100A 07
MCC ESS NO EP SH07
SV 10-20/100A 07 CB
MC COMP ESS NO SH07
MCC ESS NO PP SH07
SV 10-20/100A 08
SV 10-20/100A 08 CB
DO NOT USE
395 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
EW8
F01
F02
F03
F04
F05
F06
F07
F08
F09
F10
F11
F12
F13
F14
F15
F16
F17
F18
F19
F1C
F1M
F1P
F1X
F1Y
F1Z
F20
F21
F22
F23
F24
F25
F26
F27
F28
F29
F2C
F2Z
F30
F31
F32
F33
F34
F35
F36
F37
F38
F39
F40
F41
Plan / Benefit Description
UNAVAIL USED IN WA CARK
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
$10G/$10B
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
94-DA-480
94-DA-480 IPGB
94-DA-480 (OPTION)
94-DA-480 IPGB
94-DA-480 (OPTION) COBRA
94-DA-480 COBRA
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
DA-480 STANDARD 10 PLAN
DA-480 STANDARD 10 PLAN CB
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
396 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
F42
F43
F44
F45
F46
F47
F48
F49
F50
F51
F52
F53
F54
F55
F56
F57
F58
F59
F60
F9C
F9Z
FAA
FAC
FAD
FAE
FAH
FAK
FAL
FAM
FAZ
FB2
FB3
FB6
FC1
FC2
FC5
FC6
FC8
FC9
FCA
FCB
FCE
FCF
FCI
FCJ
FCL
FCM
FCN
FD4
FD5
Plan / Benefit Description
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDUEL PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
DA-480 SMALL GROUP
DA-480 SMALL GROUP COBRA
BOEING $10/100% EFF 1-00
SV 10-15/250A FIDLTY 06
UNAVAIL USED IN WA CLARK
SV 10-15/250A FIDLTY 06 CB
SV 25/240A FIDLTY 07
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
SV 25/240A FIDLTY 07 CB
BOEING $10/100% EF 1-00CBR
BOEING ERET 15/100
BOEING ERET 15/100 COBRA
NOT AVAIL CLK CNTY CODE
PREMIER $10/$100%
PREMIER $10 100% COBRA
PREMIER $10/100% SG
PREMIER $10/100% SG COBRA
RESERVED FOR RX PPO
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
FORD $20/100%
SV $15-$45/$250D FEDS
397 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
FD6
FD7
FDA
FDD
FDE
FDG
FDZ
FE1
FE2
FE3
FE4
FEC
FEZ
FF1
FF2
FFC
FFF
FFG
FFS
FFV
FGC
FH6
FHC
FHD
FHG
FHJ
FHR
FI3
FI4
FID
FJD
FK1
FK2
FK3
FK4
FK5
FK6
FK7
FK8
FM6
FMC
FMM
FMN
FMV
FMW
FMX
FMZ
FN1
FN2
FNA
Plan / Benefit Description
SV 20/100% FORD 05
SV 20/100% FORD 05 CB
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
SV 35/240A FID IN SV 06
SV 35/240A FID IN SV 06 CB
FORD $20/100% COBRA
FEDERAL EMPLOYEES
FEDERAL EMPLOYEES (2)
FEDERAL EMPLOYEES 1991
FEDERAL EMPLOYEES 1993
STANDARD 10 PLAN
STANDARD 10 PLAN COBRA
FIREMAN FUND
FIREMAN FUND
COBRA
FEDERAL EMPLOYEE PLAN FEH
ADMINISTRATIVE RETENTION
SV 35/240A FIDELITY 07
FITNESS SH/GR-WL07
FITNESS SH/GR-WL08
FEDERAL EMPLOYEES PLAN1-99
SV 15-30/200D FEDS 06
FEDS 2001
FEDS 2003
SV 35/240A FIDELITY 07 CB
SV 15-30/250A 07
SV 15-30/250A 07 CB
DO NOT USE
NOT AVAIL CLK CNTY CODE
FEDS INDEMNITY DENTAL 2001
FEDS 2004
PREMIER $10/100%
PREMIER $10/100% COBRA
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
PREMIER $10/100% SG
PREMIER $10/100% SG COBRA
DO NOT USE CLK CNTY CODE
DO NOT USE CLK CNTY CODE
SV 20/100% FORD 06 CB
SV 20/100% FORD 06
NOT AVAILABLE
SV $15-30/250A FARMERS
SV 20/100% FORD 07
SV 15-30/250A 08
SV 20/100% FORD 07 CB
NOT AVAILABLE
FIDELITY NATL FINANCIAL
FIDELITY NAT FINANCE COBRA
UNAVAIL USED IN WA CLARK
398 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
FND
FNE
FNZ
FP1
FP2
FPA
FPB
FPC
FPD
FPP
FPY
FQP
FQY
FR1
FR2
FR3
FR4
FRA
FRM
FRS
FW7
FWW
FZM
G1C
G1P
G1Y
G1Z
G2C
G2Z
GC1
GC2
GC3
GC4
GCB
GCJ
GJ1
GJ2
GLB
GLC
GRC
GW7
GZ2
H01
H02
H03
H04
H05
H06
H07
H08
Plan / Benefit Description
SV 10-15/250A FIDELITY
SV 10-15/250A FIDELITY CB
SV $15-30/250A FARMERS CB
POS $10/100%/75%
POS $10/100%/75% COBRA
POS $10/100%/75%
POS $10/100%/75% COBRA
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
POS-DA-480
POS-DA-480 COBRA
DA-480 POS(IN-NETWK3&4)
DA-480 POS(IN-NETWK3&4)CBR
FEDERAL RETIREES PLAN
FEDERAL RETIREES PLAN (2)
FEDERAL EMPL. RETIREES
FEDERAL EMP. RETIREES 1993
RISK CHARGE - AGGREGATE
FARMERS INS
RISK CHARGE - SPECIFIC
UNAVAIL USED IN WA CLARK
SV 15-30/250A 08 CB
FARMERS INS COBRA
94-EA-480
94-EA-480 (OPTION)
94-EA-480 (OPTION) COBRA
94-EA-480 COBRA
EA-480
EA-480
COBRA
CORVALLIS $20/$500
CORVALLIS $20/$500 COBRA
CORVALIS CLINIC $20/90%
COR CLINIC $20/90% COBRA
SV 20-40/400A 07
SV 20-40/400A 07 CB
SV 15/100%
SV 15/100% CB
SV 20-40/400A 08
SV 20-40/400A 08 CB
DUMMY
DO NOT USE
THE BASIC HEALTH PLAN CBR
DOMESTIC PARTNERSHIP PPO
VISION CARE BENEFIT PPO
FAMILY PLANING BENEFIT PPO
24/HOUR HEALTH INFO PPO
HEARING AID BENEFIT PPO
MENTAL NON-SMI PPO 90/70
RESERVED FOR PPO PRODUCT
RESERVED FOR PPO PRODUCT
399 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
H09
H10
H11
H12
H13
H14
H15
H16
H17
H18
H19
H1Z
H20
H21
H22
H23
H24
H25
H26
H27
H28
H29
H2Z
H30
H31
H32
H33
H34
H35
H36
H37
H38
H39
H3Z
H40
H41
H42
H43
H44
H45
H46
H47
H48
H49
H50
H51
H52
H53
H54
H55
Plan / Benefit Description
MENTAL NON-SMI 80/60
MENTAL NON-SMI PPO 80/50
MENTAL NONSMI INDEMNITY 80
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
PREFERRED $10/$20/$100 CBR
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
PREFERRED $15/$30/$250 CBR
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
20-40/400A COBRA
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
400 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
H56
H57
H58
H59
H60
H61
H62
H63
H64
H65
H66
H67
H68
H69
H6P
H70
H71
H72
H73
H74
H75
H76
H77
H78
H79
H80
H81
H82
H83
H84
H85
H86
H87
H88
H89
H8A
H90
H91
H92
H93
H94
H95
H96
H97
H98
H99
HA1
HA2
HAJ
HAN
Plan / Benefit Description
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
15-25/100A GR06
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
0/500A 3YRS PL HA-SH08
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
HEARING AIDS SEBB
$500 HEARING AID PEBB1-99
HEARING AID $500 EVERY 3YR
300A/24M GR-HA07
401 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
HAO
HB1
HB2
HB3
HCE
HCN
HCP
HDC
HDE
HDN
HEP
HEQ
HFC
HFQ
HFR
HG1
HG2
HG3
HG4
HG6
HG7
HG9
HGC
HGE
HGI
HGN
HGO
HGP
HGQ
HGU
HGV
HGW
HGY
HHE
HIH
HIZ
HJ1
HJ2
HJ3
HJ4
HJ6
HJ7
HJ9
HJE
HJN
HJP
HK1
HK2
HK3
HK4
Plan / Benefit Description
HEARING AID BENEFIT
RESERVED FPR PPO PRODUCT
RESERVED FOR PPO PRODUCT
RESERVED FOR PPO PRODUCT
15-30 SOUTH C SH06 EPO
15-30 SOUTH C SH06
15-30 SOUTH C SH06 ODP
SV 15/300D 07
300A 2YRS HA-GR08
SV 15/300D 07 CB
UNAVAILABLE IN WA CLARK
UNAVAILABLE IN WA CLARK
SV 15/300D 08
SV 20-40/500A HP 07
SV 20-40/500A HP 07 CB
SV 10-20/100A
SV 10-20/100A CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
MCC SO PP-PL SH07
MCC SO EP-PL SH07
MCC SO PLUS SH07
SV 15/300D 08 CB
MCC SO EP SH07
ARP MCC SO EP-PL SH08
MC COMP SO SH07
HRING AID RET $1000/MAX3YR
MCC SO PP SH07
ARP MCC SO PP-PL SH08
ARP MCC SO PP SH08
ARP MCC SO PLUS SH08
ARP MCC SO SH08
ARP MCC SO EP SH08
500A 3YRS HA-GR08
HINES HORT $20/$300D
HINES HORT $20/$300D COBRA
SV 15-30/250A
SV 15-30/250A CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
MCC ESS SO PP-PL SH07
MCC ESS SO EP-PL SH07
MCC ESS SO PLUS SH07
MCC ESS SO EP SH07
MC COMP ESS SO SH07
MCC ESS SO PP SH07
SV 20-40/400A
SV 20-40/400A CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
402 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
HM1
HM2
HM3
HME
HMN
HMP
HOA
HOE
HOI
HP1
HP2
HP3
HPA
HPB
HPC
HPD
HPE
HPF
HPH
HPJ
HPN
HPO
HPS
HPZ
HQC
HR2
HR3
HRP
HSH
HTC
HTH
HW7
HZ2
I01
I02
I03
I04
I05
I06
I07
I0V
I1C
I1P
I1Y
I1Z
I24
I2C
I2Z
I81
I82
Plan / Benefit Description
PREFERRED $10/$20/$100
PREFERRED $15/$30/$250
20-40/400A
15-30 SOUTH M SH06 EPO
15-30 SOUTH M SH06
15-30 SOUTH M SH06 ODP
RESERVED HEARING PFFS
RESERVED HEARING PFFS
RESERVED HEARING PFFS
HP $15/$300A
550 PLAN
HP $15/$300A COBRA
SV $15-$30/$500A HP
SV $15-$30/$500A HP CB
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
RESERVED PFFS
SV 15-30/500A HP 06
20-40/500A HP GR07
UNAVAIL USED IN WA CLARK
20-40/500A HP NO-AARP GR08
PEBB HRING AID $300MAX3YRS
UNAVAIL USED IN WA CLARK
SV 15-30/500A HP 06 CB
$300 MAX 3YRS PEBB HA-GR08
HRING AID $500 ALLOWANCE
HRING AID $300 ALLOWANCE
0/500A 3YRS PL SH-HA07
SV 20-40/90% HP 08
500A 2YRS HA-GR08
SV 20-40/90% HP 08 CB
UNAVAIL USED IN WA CLARK
550 PLAN
COBRA
INDEMNITY COVERAGE PLAN
EOFF ELECTRIC INDEMNITY
INDEMNITY PPO
INDEMNITY OOA (DEPENDENT)
INDEMNITY OOA (SUBS)
OOA SUBSCRIBER PLAN I
OOA SUBSCRIBER PLAN II
VISION PLAN /STAND ALONE
94-CB-800
94-CB-800 OPTION
94-CB-800 OPTION COBRA
94-CB-800 COBRA
INPUT ERROR
CB-800 VALUE PLAN
CB-800 VALUE PLAN COBRA
IND. CONV. PLAN -880
IND. CONV. PLAN -880 (2)
403 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
IC2
ICI
ICP
IGJ
IGL
IOA
IOC
IPI
IS1
IZ1
IZ2
IZ3
IZ4
IZ5
IZ6
IZ7
IZA
IZC
IZV
JAA
JAJ
JCA
JCB
JJ1
JJ2
JJA
JJB
JJF
JJN
JJY
JJZ
JKG
JLG
JW7
K1C
K1P
K1Y
K1Z
K2C
K2P
K2Y
K2Z
K3P
K3Y
K4C
K4Z
K5C
K5Z
K9C
K9P
Plan / Benefit Description
INDIVIDUAL CONVERSION 7/90
SV 15-30/100% ICI PNTS
SV 15-30/100% ICI PNTS CB
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
INDEMNITY OUT-OF-AREA
INDEMNITY SG OUT-OF-AREA
UNAVAIL USED IN WA CLARK
IND. CONV. PLAN - SHARE
INDEMNITY PLAN
COBRA
EOFF ELECTRIC INDEMNITY CB
INDEMNITY PPO
INDEMNITY OOA (DEPENDENT)
INDEMNITY OOA (SUBS) COBRA
OOA SUBSCRIBER PLAN I COBR
OOA SUBSCRIBER PLAN II CBR
INDEMNITY OUT-OF-AREA CBRA
INDEMNITY SG OOA COBRA
VISION PLAN / STAND ALONE
SV 15-35/250A J&J-NE 06
SV 15-35/250A J&J-NE 06 CB
SV 15/70% 08
SV 15/70% 08 CB
SV 15/300D
SV 15/300D CB
SV 15/70% 07
SV 15-35/250A J&J 06
SV 15-35/250A J&J 06 CB
SV JOHN&JOHN 15-35/250A
SV 15/70% 07 CB
SV JOHN&JOHN 15-35/250A CB
SV 15-35/250A J&J 08
SV 15-35/250A J&J 08 CB
UNAVAIL USED IN WA CLARK
94-DB-1000
SHARE PLAN 10-20 POS
SHARE PLAN 10-20 COBRA POS
94-DB-1000 COBRA
DB-1000 IPGB
94-DB-1000-OPTION
94-DB-1000-OPTION COBRA
DB-1000 IPGB COBRA
DB-1000 POS ORE-MET UNION
DB-1000-POS ORE MET COBRA
DB-1000 SHARE PLAN
DB-1000 SHARE PLAN COBRA
00-DB-1000
00-DB-1000 COBRA
DB-1000 20% PLAN SMALL GRP
DB-1000 POS SMALL GROUP
404 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
K9Y
K9Z
KA2
KA3
KA4
KA5
KA6
KA7
KA8
KA9
KAC
KAP
KAY
KAZ
KB2
KB3
KB4
KB5
KB6
KB7
KB8
KB9
KBB
KBJ
KC1
KC2
KC5
KC6
KCG
KD2
KD3
KD4
KD5
KD6
KD7
KD8
KD9
KE2
KE3
KE4
KE5
KE6
KE7
KE8
KE9
KF2
KF3
KF4
KF5
KF6
Plan / Benefit Description
DB-1000 POS SMALL GROUP CB
DB-1000 20% SMALL GRP COBR
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
00-DB 1000 SMALL GROUP
00-DB 1000 POS SMALL GRP
00-DB 1000 POS SMALL COBRA
00-DB 1000 SMALL GRP COBRA
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 20/500D 07
SV 20/500D 07 CB
PREMIER $10/80%
PREMIER $10/80% COBRA
PREMIER $10/80% SG
PREMIER $10/80% SG COBRA
SV 5/100% KRAFT FDS 07
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
405 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
KF7
KF8
KF9
KFA
KFB
KFC
KFD
KG2
KG3
KG4
KG5
KG6
KG7
KG8
KG9
KH8
KH9
KJ2
KJ3
KJ4
KJ5
KJ6
KJ7
KJ8
KJ9
KK1
KK2
KK3
KK4
KK5
KK6
KK7
KK8
KKA
KL2
KL3
KL4
KL5
KL6
KL7
KL8
KL9
KM2
KM3
KM4
KM5
KM6
KM7
KM8
KM9
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 5/100% KRAFT FDS 06
SV 5/100% KRAFT FDS 06 CB
SV 3/100% KRAFT FDS 06
SV 3/100% KRAFT FDS 06 CB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
PREMIER $10/80%
PREMIER $10/80% COBRA
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
PREMIER $10/80% SG
PREMIER $10/80% SG COBRA
DO NOT USE CLK CNTY CODE
DO NOT USE CLK CNTY CODE
UNAVAIL USED IN WA CLARK
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
406 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
KMA
KMG
KNA
KP1
KP2
KPC
KPD
KPP
KPY
KQ1
KQ2
KQA
KQB
KQC
KQD
KQP
KQY
KR2
KR3
KR4
KR5
KR6
KR7
KR8
KR9
KRF
KRP
KRY
KS2
KS3
KS4
KS5
KS6
KS7
KS8
KS9
KT2
KT3
KT4
KT5
KT6
KT7
KT8
KT9
KU2
KU3
KU4
KU5
KU6
KU7
Plan / Benefit Description
SV 5/100% KRAFT FDS 08
SV 5/100% KRAFT FDS 07 CB
SV 5/100% KRAFT FDS 08 CB
POS $10/100%/60%
POS $10/100%/60% COBRA
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
POS-DB-1000
POS-DB-1000 COBRA
POS $10/80%/60%
POS $10/80%/60% COBRA
POS $10/80%/60%
POS $10/80%/60% COBRA
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
DB-1000 POS(IN-NETWK5)
DB-1000 POS (IN-NETWK5)CBR
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 3/100% KRAFT 07
00-DB 1000 POS(IN-NETWK5)
00-DB 1000POS(IN-NETWK5)CB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
407 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
KU8
KU9
KUH
KV2
KV3
KV4
KV5
KV6
KV7
KV8
KV9
KVH
KW2
KW3
KW4
KW5
KW6
KW7
KW8
KW9
KWA
KWH
KX2
KX3
KX4
KX5
KX6
KX7
KX8
KX9
KXF
KY2
KY3
KY4
KY5
KY6
KY7
KY8
KY9
L01
L02
L03
L04
L05
L06
L07
L08
L09
L1I
LCG
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
SV 20/500D 08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 20/500D 08 CB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 3/100% KRAFT FDS 08
SV 3/100% KRAFT FDS 08 CB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 3/100% KRAFT 07 CB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
LIFE W/SEATBELT (LARGE)
LIFE W/SEATBELT (LARGE)
LIFE PLAN - SMALL GROUP
LIFE PLAN - SMALL GROUP
LIFE PLAN - SG INTERNET
LIFE PLAN - SG INTERNET
LIFE PLAN - LARGE GROUP
LIFE PLAN - LARGE GROUP
LIFE PLAN - LARGE GROUP
94-FB-1200
SV 20/250A 08
408 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
LDA
LDB
LDG
LEA
LEJ
LF1
LL3
LO6
LO7
LOW
LOZ
LPA
LPB
LPC
LPD
LPE
LPF
LTD
LTM
LW7
LW8
M03
M10
MA1
MA2
MA3
MA4
MA5
MA6
MA7
MA8
MBA
MBH
MBZ
MDA
MDC
MDJ
MF5
MF8
MFF
MGA
MH0
MHK
MHO
MJ1
MJ2
MJ5
MJ6
MJ7
MJ8
Plan / Benefit Description
SV 20/85% LOWE'S 06
SV 20/85% LOWE'S 06 CB
SV 20/250A 08 CB
SV 20/250A 07
SV 20/250A 07 CB
LIFE W/SEATBELT (SMALL)
LIFELINK- MEN. AND CHEM
SV LOWES $20/85%
SV LOWES $20/85% CB
$20/85% LOWES
$20/85% LOWES COBRA
POS $20/80%/60%
POS $20/80%/60% COBRA
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
POS $20/80%/60% SG
POS $20/80%/60% SG COBRA
RESERVED FOR PPO LIFE
$2MILLION LIFETIME MAXIMUM
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
MEDICAID
$10 MAN GEN
OHP - MEDICAL COVERAGE
OHP-MEDI-CAL PART B ONLY
0HP - 133 FPL CHILD
OHP - GENERAL ASSIST
OHP-100 FPL (MENTAL ONLY)
OHP-FPL ADULT MENTAL ONLY
OHP-FPL CHILD MENTAL ONLY
OHP-GEN. ASST. MENTAL ONLY
MULTNOMAH BAR ASSOC
SV 20-30/90% MCKSON 07
MULTNOMAH BAR ASSOC COBRA
SV 10/200D 07
MEDICAID PLAN
SV 10/200D 07 CB
SECURE HORIZONS B ONLY
SH JACKSON B ONLY
SV 10/200D 08
ENTERED IN ERROR OK TO USE
OHP - MENTAL HEALTH ONLY
30/200D FEDS MH06
USE ONLY FOR ALL STATE MH
SV $15/70%
SV $15/70% CB
SV $15/70% SG
SV $15/70% SG CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
409 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
MJF
MK5
MK6
MKY
MKZ
MM1
MM2
MMF
MR1
MS1
MS5
MS8
MTK
MTM
MW6
MW7
MZ1
N01
N02
N03
N04
N05
N06
N07
N08
N09
N0H
N10
N11
N12
N13
N14
N15
N16
N17
N18
N19
N1B
N1H
N1I
N1N
N1Z
N20
N21
N22
N23
N24
N25
N26
N27
Plan / Benefit Description
SV 10/200D 08 CB
SV 20-30/90 MCKESSON
SV 20-30/90% MCKSN 06
SV 20-30/90% MCKSN 06 CB
SV 20-30/90 MCKESSON CB
SECURE HORIZONS OHP
SECURE HORIZONS OHP B ONLY
SV 20-30/90% MCKSON 07 CB
MARRIOTT PLAN
$10 MAN GEN
SECURE HORIZONS STANDARD
SH JACKSON
10/5V 1YR MSG THRPY SH07
10/5V 1YR MSG THRPY SH08
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
MARRIOTT PLAN COBRA
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
NOT AVAIL CLK CNTY CODE
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
NAT $10/$100 MH BUYUP CBRA
NATL $10/$20/$100 COBRA
NATL$10/$20/$100W/BUYUP CO
SV 5/100% NAT'L 06 CB
NATL PLAN $10/100 COBRA
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
410 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
N28
N29
N2B
N2H
N2I
N2J
N2N
N2Z
N30
N3B
N3H
N3I
N3J
N3N
N3Z
N4B
N4H
N4I
N4J
N4N
N4Z
N5B
N5H
N5I
N5J
N5N
N5Z
N6H
N6J
N6N
N7H
N7J
N7N
N8H
N8J
N8N
N9H
N9J
N9N
NA1
NA2
NA3
NA4
NA5
NA6
NA8
NAA
NAB
NAC
NAD
Plan / Benefit Description
INDEMNITY PLANS
INDEMNITY PLANS
NAT $15/$250 MH BUYUP CBRA
NATL $15/$30/$250 COBRA
NATL$15/$30/$250W/BUYUP CO
SV 5/100% NATL 07 AB
SV 10/100% NAT'L 06 CB
NATL PLAN $15/$250 COBRA
INDEMNITY PLANS
NAT $15/$400 MH BUYUP CBRA
NATL $15/$30/$400 COBRA
NATL$15/$30/$400W/BUYUP CO
SV 10/100% NATL 07 CB
SV 15/100% NAT'L 06 CB
NATL PLAN $15/$400 COBRA
NAT $20/$250 MH BUYUP CBRA
NATL $20/$40/$250 COBRA
NATL$20/$40/$250W/BUYUP CO
SV 15/100% NATL 07 CB
SV 10-20/100A NATL 06 CB
NATL PLAN $20/$250 COBRA
NAT $20/$400 MH BUYUP CBRA
NATL $20/$40/$400 COBRA
NATL$20/$40/$400WBUYUP COB
SV 10/100A NATL 07 CB
SV 15-30/250A NATL 06 CB
NATL PLAN $20/$400 COBRA
NOT AVAIL CLK CNTY CODE
SV 10/250A NATL 07 CB
SV 15-30/400A NATL 06 CB
NOT AVAIL CLK CNTY CODE
SV 15/250A NATL 07 CB
SV 20-40/250D NATL 06 CB
NOT AVAIL CLK CNTY CODE
SV 15/100A NATL 07 CB
SV 10/250A NATL 06 CB
NOT AVAIL CLK CNTY CODE
SV 35/500D NATL 07 CB
SV 15/250A NATL 06 CB
PHS NATL $5/100% CBRA
PHS NATL $10/100% CBRA
PHS NATL $10/$100/100%CBRA
PHS NATL $10/$250/100%CBRA
PHS NATL $15/$250/100%CBRA
PHS NAT'L $15/100% COBRA
PHS NATL $15/$100/100% CBR
PHS NATL $5/100%
PHS NATL $10/100%
PHS NATL $10/$100/100%
PHS NATL $10/$250/100%
411 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
NAE
NAF
NAG
NAH
NAI
NAJ
NAK
NAL
NB0
NB1
NB2
NB3
NB4
NB5
NB6
NB7
NB8
NB9
NBA
NBB
NBC
NBD
NBE
NBF
NBG
NBH
NBJ
NBK
NBL
NBM
NBN
NBP
NBQ
NBR
NC1
NC2
NC3
NC4
NC5
NC6
NC7
NCA
NCJ
NCK
NCL
ND1
ND2
ND3
ND4
ND5
Plan / Benefit Description
PHS NATL $15/$250/100%
PHS NAT'L $15/100%
NATL POS $10/100%/70%
NATL POS $10/90%/70%
PHS NATL $15/$100/100%
NATL POS $10/$250/100%
NATL POS $15/80%/60%
NATL POS $15/$150/70%
NOT AVAIL CLK CNTY CODE
NAT $10/$100 MH BUYUP
NAT $15/$250 MH BUYUP
NAT $15/$400 MH BUYUP
NAT $20/$250 MH BUYUP
NAT $20/$400 MH BUYUP
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN CA CLARK
UNAVAIL USED IN WA CLARK
SV 5/100% NATL 07
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVIAL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
$15/$250/WSUPP RITE AIDCBR
DO NOT USE C COUNTY CODE
DON'T USE CLK COUNTY CODE
DON'T USE CLK COUNTY CODE
DON'T USE CLK COUNTY CODE
DON'T USE CLK COUNTY CODE
DON'T USE CLK COUNTY CODE
$15/$250/WSUPP RITE AID
SV 10/100% NATL 07
SV 10-20/100A NATL 08
SV 5/100% NATL 08
NATL POS $10/100%/70% CBRA
NATL POS $15/$150/70% CBRA
NATL POS $10/90%/70% COBRA
NATL POS $10/$250/60% CBRA
NATL POS $15/80%/60% COBRA
412 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
NDA
NDB
NDC
NDD
NDE
NDF
NDG
NDJ
NDK
NDL
NE1
NE2
NE3
NE4
NE5
NE6
NE7
NE8
NEA
NEB
NEC
NED
NEE
NEF
NEG
NEH
NEJ
NEK
NEL
NEP
NEY
NF4
NF5
NF6
NF7
NF8
NFD
NFE
NFF
NFG
NFH
NFJ
NFK
NFL
NFM
NFN
NFP
NFQ
NFR
NFS
Plan / Benefit Description
NATL POS $10/100%/70%
NATL POS $15/$150/70%
NATL POS $10/90%/70%
NATL POS $10/$250/60%
NATL POS $15/80%/60%
SV 10-20/100A NATL 07
SV 10-20/100A NATL 07 CB
SV 15/100% NATL 07
SV 10-20/100A NATL 08 CB
SV 5/100% NATL 08 CB
NATL $5/100% COBRA
NATL $10/100% COBRA
NATL $15/100% COBRA
NATL $10/$100/100% COBRA
NATL $10/$250/100% COBRA
NATL $15/$250/100% COBRA
NATL $15/$100/100% COBRA
NATL $35/$500D COBRA
NATL $5/100%
NATL $10/100%
NATL $15/100%
NATL $10/$100/100%
NATL $10/$250/100%
NATL $15/$250/100%
NATL $15/$100/100%
NATL $35/$500D
SV 10/100A NATL 07
SV 15-30/250A NATL 08
SV 10/100% NATL 08
NEC AMERICA CUSTOM POS
NEC AMERICA CUSTOM POS CBR
SV 10-20/100A NATL CB
SV 15-30/250A NATL CB
SV 15-30/400A NATL CB
SV 20-40/250D NATL CB
SV 20-40/400D NATL CB
SV 10-20/100A NATL
SV 15-30/250A NATL
SV 15-30/400A NATL
SV 20-40/250D NATL
SV 20-40/400D NATL
SV 10/250A NATL 07
SV 15-30/250A NATL 07
SV 15-30/250A NATL 07 CB
SV 15-30/400A NATL 07
SV 20-40/250D NATL 07
SV 15-30/400A NATL 07 CB
SV 20-40/250D NATL 07 CB
SV 20-40/400D NATL 07
SV 20-40/400D NATL 07 CB
413 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
NGA
NGC
NGJ
NGK
NGL
NGZ
NH0
NH1
NH2
NH3
NH4
NH5
NH6
NH7
NH8
NH9
NHG
NHJ
NHK
NHL
NHZ
NI1
NI2
NI3
NI4
NI5
NJ1
NJ2
NJ3
NJ4
NJ5
NJ6
NJ7
NJ8
NJ9
NJA
NJB
NJC
NJD
NJE
NJF
NJG
NJH
NJJ
NJK
NJL
NJM
NJN
NJP
NJQ
Plan / Benefit Description
NAT'L PLN 2C $20 GRP RET
NAT'L PLN 2D $20 GRP RET
SV 15/250A NATL 07
SV 15-30/250A NATL 08 CB
SV 10/100% NATL 08 CB
NATL POS $10/100%/70% CBRA
NOT AVAIL CLK CNTY CODE
NATL $10/$20/$100
NATL $15/$30/$250
NATL $15/$30/$400
NATL $20/$40/$250
NATL $20/$40/$400
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
SV 15/100% NATL 08
SV 15/100A NATL 07
SV 15-30/400A NATL 08
SV 15/100% NATL 08 CB
NATL POS $10/90%/70% COBRA
NATL $10/$20/$100 W/ BUYUP
NATL $15/$30/$250 W/BUYUP
NATL $15/$30/$400 W BUY UP
NATL $20/$40/$250 W/BUYUP
NATL $20/$40/$400 W BUY UP
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
UNAVAIL USED IN WA CLARK
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
414 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
NJR
NJS
NJT
NJU
NJV
NJW
NJX
NJY
NJZ
NK1
NK2
NK3
NK4
NK5
NK6
NK7
NKA
NKB
NKC
NKD
NKE
NKF
NKG
NKJ
NKK
NKL
NKZ
NL1
NL2
NL3
NL4
NL5
NL8
NLA
NLB
NLC
NLD
NLE
NLK
NLL
NLZ
NM1
NM2
NM3
NM4
NM5
NN1
NN2
NN3
NN4
Plan / Benefit Description
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
NATL POS $10/$250/100% CBR
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
SV 35/500D NATL 07
SV 15-30/400A NATL 08 CB
SV 10/100A NATL 08
NATL POS $15/80%/60% COBRA
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
24HR NURSLINE WL-SH/GR08
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
SV 20-40/250D NATL 08
SV 10/100A NATL 08 CB
NATL POS $15/$150/70% CBRA
NATL PLAN $10/$100
NATL PLAN $15/$250
NATL PLAN $15/$400
NATL PLAN $20/$250
NATL PLAN $20/$400
SV 5/100% NATL CB
SV 10/100% NATL CB
SV 15/100% NATL CB
SV 10/100A NATL CB
415 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
NN5
NN6
NN7
NN8
NNA
NNB
NNC
NND
NNE
NNF
NNG
NNH
NNK
NNL
NNM
NNN
NNP
NNQ
NNR
NNS
NNT
NNU
NNV
NNW
NNY
NO1
NO2
NO3
NO4
NO5
NO6
NO7
NP1
NP2
NP3
NP4
NP5
NP6
NP8
NPA
NPB
NPC
NPD
NPE
NPF
NPI
NQ1
NQ2
NQ3
NQ4
Plan / Benefit Description
SV 10/250A NATL CB
SV 15/250A NATL CB
SV 15/100A NATL CB
SV 35/500D NATL CB
SV 5/100% NATL
SV 10/100% NATL
SV 15/100% NATL
SV 10/100A NATL
SV 10/250A NATL
SV 15/250A NATL
SV 15/100A NATL
SV 35/500D NATL
SV 10/250A NATL 06
SV 15/100A NATL 06
SV 10/100% NAT'L 06
SV 5/100% NAT'L 06
SV 15/250A NATL 06
SV 10-20/100A NATL 06
SV 10/100A NAT'L 06
SV 15-30/400A NATL 06
SV 20-40/250D NATL 06
SV 15/100% NAT'L 06
SV 15-30/250A NATL 06
SV 35/500D NATL 06
SV 20-40/400D NAT'L06
NAT'L PLN 1 $5 GRP RET
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 3 $15 GRP RET
NAT'L PLN 2A $10 GRP RET
NAT'L PLN 2B $10 GRP RET
NAT'L PLN 3A $15 GRP RET
NAT'L PLN 3B $15 GRP RET
PHS NATL $5/100%W/SUPP CBR
PHS NATL $10/100%W/SUPPCBR
PHS NATL$10/$100/WSUPP CBR
PHS NATL$10/$250/100SUPPCB
PHS NATL$15/$250/100SUPPCB
PHS NATL $15/100%W/SUPPCBR
PHS NATL15/$100/100WSUPCBR
PHS NATL $5/100% W/SUPP
PHS NATL $10/100%W/SUPP
PHS NATL$10/$100/100%WSUPP
PHS NATL$10/$250/100WSUPP
PHS NATL$15/$250/100WSUPP
PHS NATL $15/100%W/SUPP
PHS NATL $15/$100/100WSUPP
SV 5/100% NATL BU CB
SV 10/100% NATL BU CB
SV 15/100% NATL BU CB
SV 10/100A NATL BU CB
416 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
NQ5
NQ6
NQ7
NQ8
NQ9
NQA
NQB
NQC
NQD
NQE
NQF
NQG
NQH
NQJ
NQK
NQL
NQM
NQN
NQP
NQQ
NQR
NQS
NQT
NQU
NQV
NQW
NQX
NQY
NQZ
NS1
NS2
NS3
NS4
NS5
NS6
NS7
NS8
NSA
NSB
NSC
NSD
NSE
NSF
NSG
NSH
NTK
NTL
NTN
NU1
NU2
Plan / Benefit Description
SV 10/250A BH NATL CB
SV 15/250A NATL BU CB
SV 15/100A NATL BU CB
SV 35/500D NATL BU CB
SV 35/500D B-UP NATL 06
SV 5/100% NATL BU
SV 10/100% NATL BU
SV 15/100% NATL BU
SV 10/100A NATL BU
SV 10/250A BH NATL
SV 15/250A NATL BU
SV 15/100A NATL BU
SV 35/500D NATL BU
SV 5/100% NATL BU06
SV 5/100% NATL BU06 CB
SV 10/100% NATL BU06
SV 10/100% NATL BU06 CB
SV 10/100A NAT'L 06 CB
SV 15/100% NATL BU06
SV 15/100% NATL BU06 CB
SV 10/100A NATL BU06
SV 10/100A NATL BU06 CB
SV 10/250A B-UP NATL 06
SV 10/250A B-UP NATL 06 CB
SV 15/250A B-UP NATL 06
SV 15/250A B-UP NATL 06 CB
SV 15/100A B-UP NATL 06
SV 15/100A B-UP NATL 06 CB
SV 35/500D B-UP NATL 06 CB
NATL $5/100% W/BUYUP COBRA
NATL $10/100%W/BUYUP COBRA
NATL $15/100% W BYUP COBRA
NAT $10/$100/100% BYUP CBR
NATL$10/$250/100%WBUYUP CO
NAT $15/$250/100% BYUP CBR
NAT $15/$100/100% BYUP CBR
NATL $35/$500D BUYUP CBRA
NATL $5/100% W/ BUY UP
NATL $10/100% WITH BUY-UP
NATL $15/100% W BUYUP
NATL $10/$100/100% BUYUP
NATL $10/$250/100% W BUYUP
NATL $15/$250/100% BUYUP
NATL $15/$100/100% BUYUP
NATL $35/$500D BUYUP
SV 20-40/250D NATL 08 CB
SV 10/250A NATL 08
SV 15/100A NATL 06 CB
SV 10-20/100A NATL BU CB
SV 15-30/250A NATL BU CB
417 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
NU3
NU4
NU5
NUA
NUB
NUC
NUD
NUE
NUF
NUG
NUH
NUK
NUL
NUM
NUN
NUP
NUQ
NUR
NWG
NWI
NWL
NWN
NWZ
NXK
NXL
NYK
NYL
NYN
NZC
NZG
NZK
NZL
O1U
O1V
O1X
O22
O2H
O2U
O2V
O2X
O3U
O3V
O3X
O4U
O4V
O4X
O5U
O5V
O5X
O6U
Plan / Benefit Description
SV 15-30/400A NATL BU CB
SV 20-40/250D NATL BU CB
SV 20-40/4OOD NATL BU CB
SV 10-20/100A NATL BU
SV 15-30/250A NATL BU
SV 15-30/400A NATL BU
SV 20-40/250D NATL BU
SV 20-40/4OOD NATL BU
SV 10-20/100A NATL BU06
SV 10-20/100A NATL BU06 CB
SV 15-30/250A NATL BU06
SV 15-30/250A NATL BU06 CB
SV 15-30/400A NATL BU06
SV 15-30/400A NATL BU06 CB
SV 20-40/250D NAT BU 06
SV 20-40/250D NAT BU 06 CB
SV 20-40/400D NAT BU 06
SV 20-40/400D NAT BU 06 CB
UNAVAIL USED IN WA CLARK
SV $15-30/250D NATIONWD
SV 10/250A NATL 08 CB
SV 35/500D NATL 06 CB
SV $15-30/250D NATIONWD CB
SV 35/500D NATL 08
SV 15/100A NATL 08
SV 35/500D NATL 08 CB
SV 15/100A NATL 08 CB
SV 20-40/400D NAT'L06 CB
SV 15/250A NATL 08
SV 15/250A NATL 08 CB
SV 20-40/400D NATL 08
SV 20-40/400D NATL 08 CB
15-25/200D T3A GR07
10-20/750A T2A GR07
10-15/50A T1A GR07
NAT'L PLN 2 $10 GRP RET
BOEING NA-HRLY $10 GRP RET
15-25/200D T3A GR07
10-20/750A T2A GR07
10-15/50A T1A GR07
15-25/200D T3A GR07
10-20/750A T2A GR07
10-15/50A T1A GR07
15-30/220D T3B GR07
15-25/130D T2B GR07
5-20/100A T1B GR07
15-30/220D T3B GR07
15-25/130D T2B GR07
5-20/100A T1B GR07
15-30/220D T3B GR07
418 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
O6V
O6X
O70
O71
O72
O7U
O7V
O7X
O7Z
O80
O81
O82
O8U
O8V
O8X
O8Z
O90
O91
O92
O9U
O9V
O9X
O9Z
OA1
OA2
OA4
OAN
OAV
OB1
OB2
OB4
OBH
OBP
OCU
OCY
OD1
OD2
OD4
OE1
OE2
OE4
OF1
OF2
OF3
OF4
OF5
OF6
OF7
OF8
OF9
Plan / Benefit Description
15-25/130D T2B GR07
5-20/100A T1B GR07
VALUE $25/70%
$25/70%
$25/70%
COBRA
20-35/250D T3C GR07
10-25/150D T2C GR07
10-20/200A T1C GR07
VALUE $25/70% COBRA
VALUE $20/80%
$20/80%
$20/80% COBRA
20-35/250D T3C GR07
10-25/150D T2C GR07
10-20/200A T1C GR07
VALUE $20/80% COBRA
VALUE $15/90%
$15/90%
$15/90% COBRA
20-35/250D T3C GR07
10-25/150D T2C GR07
10-20/200A T1C GR07
VALUE $15/90% COBRA
NAT'L PLN 2C $20 GR 06
NAT'L PLN 2C $20 GR 06
NAT'L PLN 2C $20 GR 06
NATIONAL ACCT EXTENDED OOA
OUT OF AREA VISION
NAT'L PLN 2D $20 GR 06
NAT'L PLN 2D $20 GR 06
NAT'L PLN 2D $20 GR 06
BOEING HOURLY $15 GRP RET
15 BO HRLY-F NO-AARP GR08
OSU POS $10/100%/75%
OSU POS $10/100%/75% COBRA
NAT'L PLN 2B $10 GR 06
NAT'L PLN 2B $10 GR 06
NAT'L PLN 2B $10 GR 06
NAT'L PLN 3A $15 GR 06
NAT'L PLN 3A $15 GR 06
NAT'L PLN 3A $15 GR 06
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
419 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
OFA
OFB
OFC
OFD
OFE
OG1
OG2
OG4
OH1
OH2
OH3
OH4
OH7
OH8
OHP
OIT
OJ2
OJO
OK1
OK2
OK4
OK8
OL2
OL4
OLB
OMP
ON1
ON2
ONN
OO1
OO2
OO3
OO4
OO5
OO6
OO7
OO8
OOA
OON
OOZ
OP1
OP2
OP3
OP4
OP5
OP6
OP7
OP8
OPA
OPB
Plan / Benefit Description
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
NAT'L PLN 3B $15 GR 06
NAT'L PLN 3B $15 GR 06
NAT'L PLN 3B $15 GR 06
SH-OREGON METRO AREA BASIC
SH-OREGON METRO PRT B ONLY
SH-OR BENT/LINN/LANE BASIC
SH-OR BENT/LINN/LANE PRT B
SH-OREGON MARION/PLK BASIC
SH-OREGON MARION/PLK PRT B
OHP MENTAL HEALTH BENEFIT
OR INFERTILITY TREATMENT
NAT'L PLN 2 $10 GR 06
10/100% NON-AARP GR08
NAT'L PLN 2A $10 GR 06
NAT'L PLN 2A $10 GR 06
NAT'L PLN 2A $10 GR 06
10-20/250A NON-AARP GR08
NAT'L PLN 1 $5 GRP RET
NAT'L PLN 1 $5 GR 06
15/250A NON-AARP GR08
10 BO HRLY NO-AARP GR08
TEST CODE
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 1 $5 GRP RET
NAT'L PLN 1 $5 GRP RET
NAT'L PLN 2 $10 GRP RET
10/100% NON-AARP GR08
NAT'L PLN 2A $10 GRP RET
10-20/250A AARP GR08
NAT'L PLN 3A $15 GRP RET
NAT'L PLN 3B $15 GRP RET
15-25/500A AARP GR08
OUT OF AREA PLAN
POS - OUT OF AREA
OUT OF AREA PLAN (COBRA)
OHP - 100 FPL
OHP - 133 FPL ADULT
OHP - 133 FPL CHILD
OHP - GENERAL ASSIST
OHP-100 FPL (MENTAL ONLY)
OHP-MEDICAL COVERAGE
OHP-FPL CHILD MENTAL ONLY
OHP-GEN. ASST. MENTAL ONLY
OPEIU $0
OPEIU $0 COBRA
420 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
OPC
OPD
OPE
OPZ
OR1
OR2
OR3
OR4
OR5
OR6
OR7
OR8
ORA
ORX
OS1
OS2
OS3
OS4
OS5
OS6
OS7
OS8
OSA
OSB
OSC
OSD
OSE
OSF
OSG
OSH
OSJ
OSK
OSL
OSU
OSY
OTO
OTZ
OUB
OUZ
OWA
OWM
P1C
P1Z
P2C
P2P
P2Z
P3C
P3P
P3Z
P4P
Plan / Benefit Description
OPEIU
OPEIU COBRA
OPEIU LOCAL 11
OPEIU LOCAL 11 COBRA
SH-OREGON METRO AREA BASIC
SH-OREGON METRO PRT B ONLY
SH-0REGON BENT/LINN BASIC
SH-OREGON BENT/LINN PRT B
SH-OREGON LANE BASIC
SH-OREGON LANE PRT B ONLY
SH-OREGON MARION/PLK BASIC
SH-OREGON MARION/PLK PRT B
5/100% AARP GR08
OTHR RX NOT THRU RX SOL
SH-OREGON METRO AREA BASIC
SH-OREGON METRO PRT B ONLY
SH-OR BENT/LINN/LANE BASIC
SH-OR BENT/LINN/LANE PRT B
OR-SH STD PLN
OR-SH STD PLN PART B
SH-OREGON MARION/PLK BASIC
SH-OREGON MARION/PLK PRT B
OR - SH STD PLAN
OR - SH STD PLAN PART B
NORTHERN SH $10/$20/$100
SOUTHERN SH $15/$30/$200
SH INDIVIDUAL PART B
OR SH SOUTHERN STD PLAN 05
OR SH NORTHERN STD PLAN
OR SH SOUTHERN STD PLAN
OR SH NORTHERN STD PLAN 05
OR SH STANDARD PART B 05
OR SH VALUE PLAN 05
OSU POS $10/100%/75%
OSU POS $10/100%/75% CBRA
10/100% AARP GR08
20-40/250A AARP GR08
5/100% AARP GR08
5/100% NON-AARP GR08
OR PEBB-GR
10/150D PEBB NO-AARP GR08
94-CF-500
94-CF-500 COBRA
CF500 (REVISED)
RESERVED PPO
CF500 COBRA (REVISED)
CF-500
RESERVED PPO
CF-500
COBRA
RESERVED PPO
421 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
P5P
P6H
P6P
P7H
P7P
P8L
P8P
P9P
PA2
PA3
PA4
PA5
PA6
PA7
PA8
PA9
PAA
PAB
PAC
PAD
PAE
PAF
PAG
PAH
PAJ
PAK
PAM
PAN
PB1
PB4
PB6
PBH
PBI
PBL
PBR
PC1
PC7
PCF
PCG
PCH
PCI
PCJ
PCK
PCL
PCM
PCQ
PD6
PDQ
PED
PEP
Plan / Benefit Description
RESERVED PPO
UNAVAIL USED IN WA CLARK
RESERVED PPO
15-30/200A PEBB V GR07
RESERVED PPO
15-30/200A PB NON-AARP GR8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
PPO - PFFS
PPO - PFFS
PPO ADMINISTRATIVE CHARGE
PPO - PFFS
PPO - PFFS
RESERVED PFFS
RESERVED PFFS
RESERVED PFFS
SV 20-30/200A PEPSI 06
RESERVED PFFS
SV 20-30/200A PEPSI 06 CB
PERSONAL ASSIST. NETWORK
$7G/$7BR BOEING RE
$10G/$20BR/$30NF
$5G/$5B TRI-MET
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
$10G/$25B/$40NF
SH-PERS LINN/BENTON
SH PERS 7 LINN BENTON
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
SV $15-$30/$100A PHS
SV $15-$30/$100A PHS CB
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
SV 20-40/200A PHS 06
SV 20-40/200A PHS 06 CB
SV 30/500A PRINT S&P 08
PDV CUSTOM DENTAL & VISION
SV 30/500A PRINT S&P 08 CB
UNAVAILABLE USED IN WA
$5/$15/$30 PEPSI CUSTOM RX
422 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
PF2
PF3
PF4
PF5
PF6
PF7
PF8
PF9
PFC
PFD
PH2
PH3
PH4
PH5
PH6
PH7
PH8
PH9
PIA
PIB
PIC
PID
PIE
PIF
PIG
PIH
PII
PIK
PIL
PIN
PIO
PJ7
PJ8
PJL
PJP
PK7
PK8
PKA
PKB
PLP
PLW
PNA
PNB
POA
POC
POM
PP1
PP7
PPA
PPB
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SH MARION/POLK B ONLY
SH MARION/POLK B ONLY
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SP 10/80%-60%
SP 10/80%-60% CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
SV 20-30/200A PEPSI 07
SV 20-30/100D PBG 07
DO NOT USE CLK CNTY CODE
DO NOT USE CLK CNTY CODE
SP 10/100%
SP 10/100% CB
PAYMENT LAG PREMIUM ALLOC
25% PORTABILITY
SP 10/200D-60%
SP 10/200D-60% CB
POS OUT OF AREA
POS OUT OF AREA SM GRP
PCOR OPMH REIMBURSEMENT
SH-PERS PORTLAND
SH PERS 7
RESERVED PPO
RESERVED PPO
423 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
PPC
PPD
PPE
PPF
PPG
PPH
PPJ
PPK
PPL
PPM
PPQ
PPR
PPS
PPT
PPU
PPV
PPW
PPX
PPY
PPZ
PQ7
PQ8
PQK
PR1
PR2
PRD
PRE
PRK
PRP
PRT
PRY
PS1
PS2
PS5
PS6
PS7
PS8
PS9
PSC
PSI
PSK
PSP
PSQ
PSZ
PTK
PTL
PVA
PVE
PVG
PVK
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
PP&L MOD STAND 10 PLAN
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
PP&L MOD STAND 10 COBRA
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
SP 10/80% 08
PREFERRED PLAN
PREFERRED PLAN
PREMIUM DELAY
PREFERRED PLAN $O ER COPAY
SP 10/80% 08 CB
PREFERRED PLAN-POS
$10G/$20B PORT
PREFERRED PLAN-POS (COBRA)
SV 30/500A PRINT SPEC
SV 30/500A PRINT SPEC CB
SV 30/500A PRINT SPC 05
SV 30/500A PRINT SPC 05 CB
PERS-MEDICARE ELIGIBLE
SH MARION/POLK
SH MARION/POLK
SEBB PLAN - 94
$20/$200 PEPSI
SP 10/100% 08
SV $20/$200A PEPSICO
SV $20/$200A PEPSICO CB
$20/$200 PEPSI COBRA
SP 10/100% 08 CB
SV 20-30/200A PEPSI 07 CB
SP 10/100% 07
SP 10/200D 07
SP 10/80% 07
SP 10/80% 07 CB
424 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
PVL
PVY
PW5
PW8
PW9
PWA
PXK
PYI
PYK
PYQ
PZ1
PZ2
PZA
PZC
PZE
PZK
Q1A
Q1Z
Q2A
Q2C
Q2Z
Q3C
Q4C
Q5C
Q5D
Q5E
Q5F
Q6C
Q7C
QAC
QC1
QC2
QC5
QC6
QCC
QD3
QD4
QE1
QE2
QE3
QE4
QE5
QE6
QE7
QE8
QF1
QF2
QF3
QF4
QH1
Plan / Benefit Description
SP 10/200D 07 CB
SP 10/100% 07 CB
PEBB-WA SECURE HORIZONS
PEBB SH
SH-PEBB $10
OR PEBB-GR
SP 10/200D 08
RESERVED PFFS
SV 30/500A PRINT SPEC 07
SV 30/500A PRINT SPEC 07CB
PREFERRED PLAN (COBRA)
PREFERRED PLAN (2) COBRA
POS OUT OF AREA COBRA
POS OUT OF AREA SMGRP CBRA
PREFERRED $0ER COPAY COBRA
SP 10/200D 08 CB
00-FB 2500 SMALL GROUP
00-FB 2500 SMALL GRP COBRA
00-FB 2500
INDIVIDUAL PLAN I
00-FB 2500 COBRA
PORTABILITY LOW COST PLAN
INDIVIDUAL PLAN I 1998
PORTABILITY LOW COST 1-99
2002 LOW COST PORTABILITY
PORTABILITY LOW COST
RESERVED SIGVALUE25/500DC
INDIVIDUALPLAN I 2000-2001
INDIVIDUAL PLAN I
SV 30/100D 06
ADVANTAGE $20/$500
ADVANTAGE $20/$500 COBRA
ADVANTAGE $20/$500 SG
ADVANTAGE $20/$500 SG CBRA
SV 30/500D 06
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
SV $20/$500D
SV $20/$500D CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
SV $20/$500D SG
SV $20/$500D SG CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
SV 20/250A
SV 20/250A CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
PREFERRED $20/$250
425 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
QH2
QI3
QI4
QIC
QJ3
QJ4
QK1
QK2
QK3
QK5
QK6
QK7
QK8
R10
R15
R1C
R1Z
R3C
R3Z
R4C
R4Z
R50
R5C
R5Z
R6C
R6Z
RA1
RA3
RA4
RB3
RB5
RB7
RB8
RBA
RBB
RBC
RC1
RC2
RC5
RC6
RCM
RFA
RFF
RFH
RG0
RG1
RG2
RG3
RG4
RG5
Plan / Benefit Description
PREFERRED $20/$250 COBRA
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
INDIVIDUAL PLAN I
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
ADVANTAGE $20/$500
ADVANTAGE $20/$500 COBRA
NOT AVAIL CLK CNTY CODE
ADVANTAGE $20/$500 SG
ADVANTAGE $20/$500 SG CBR
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
O/P PRESCR DRUGS $100 DED
$15 OR 50%
94-DE-3000 PLAN
94-DE-3000 PLAN COBRA
CUSTOM DE3000
CUSTOM DE3000
$10/250 HMO TCI/PRIMESTAR
$10/250 HMO TCI COBRA
O/P PRESCRIP DRUGS $50 DED
$10/250 NAT'L ACT PLAN
$10/250 NAT'L ACCT PLANCBR
DE-3000
DE-3000
COBRA
RITE AID
UNAVAIL USED IN WA CLARK
SV 20/250A RITE AID 05
$3/$8/$23
$5/$10/$25
$7/$12/$27
$8/$13/$28
$10/$15/$30
$15/$25/$40
$15/$25/$40
ADVANTAGE $10/$200
ADVANTAGE $10/$200 COBRA
ADVANTAGE $10/$200 SG
ADVANTAGE $10/$200 SG CBRA
$10 MAIL
UNAVAIL USED IN WA CLARK
SV 20/250A RITE AID 06
SV 20/250A RITE AID 06 CB
$10G/$15B/$30NF RE
$10G/$20B RETIREE
$10G/$35B RETIREE
$15G/$25B/$40NF $200 DED
$15G/$25B/$40NF RE
$5G/$10B
426 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
RG6
RG7
RG8
RG9
RH8
RHD
RHJ
RJ1
RJ2
RK1
RK2
RK5
RK6
RKI
RKQ
RKU
RKV
RKW
RKY
RM3
RM5
RM7
RM8
RMA
RMI
RMQ
RMR
RMU
RMV
RMW
RMY
RN1
RN2
RN3
RN4
RN5
RN6
RNG
RNH
RNJ
RNK
RNL
RNP
RNY
RP5
RP8
RPA
RPB
RPC
RPE
Plan / Benefit Description
$5G/$15B RETIREE
$5G/$25B RETIREE
$7G/$12B/$27NF RE
$5G/$10B/$25NF RET
$8 MAN GEN
SV 15/90% 07
SV 15/90% 07 CB
SV 10/200D
SV 10/200D CB
ADVANTAGE $10/$200
ADVANTAGE $10/$200 COBRA
ADVANTAGE $10/$200 SG
ADVANTAGE $10/$200 SG CBR
ARP MCC NO EP-PL SH08
ARP MCC NO PP-PL SH08
ARP MCC NO PP SH08
ARP MCC NO PLUS SH08
ARP MCC NO SH08
ARP MCC NO EP SH08
$3 MAN GEN
$5 MAN GEN
$7/$7+DIF
$8 MAN GEN
$10 MAN GENERIC
ARP MCC ES NO EP-PL SH08
ARP MCC ES NO PP-PL SH08
$15G/$20B/$30NF
ARP MCC ES NO PP SH08
ARP MCC ES NO PLUS SH08
ARP MCC ES NO SH08
ARP MCC ES NO EP SH08
$7G/$14B GRP RET
$10G/$20B GRP RET
$10G/$25B GRP RET
$10G/$20B/$40NF
$10G/$20B/$50NF
$15G/$25B/$40NF
$7G/$14B
$10G/$20B
$10G/$25B
$10G/$20B/$40NF
$15G/$25B/$40NF
NEC AMERICA OPTION PLAN
NEC AMERICA OPTION PLAN CB
$5G/$15B
$8G/$13B
POS $10/100%/60%
POS $10/100%/60% COBRA
THRIFTY PAYLESS PLAN
RESPITE/PERS CARE SH07
427 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
RPX
RPZ
RR0
RSC
RSZ
RT3
RT5
RT7
RT8
RTA
RTB
RTC
RTL
RUC
RUZ
RVC
RVZ
RW7
RX0
RX1
RX2
RX3
RX4
RX5
RX8
RXA
RXG
RXH
RXN
RXP
RZ1
RZ4
RZA
RZH
S10
S12
S52
SA2
SA3
SA4
SAF
SAZ
SBO
SC1
SC2
SE0
SE1
SE3
SE5
SE7
Plan / Benefit Description
RESPITE/PERS CARE WL-SH08
THRIFY PAYLESS PLAN COBRA
$5G/$10B/$25NF 1X MO RET
SEBB
SEBB COBRA
$3G/$8B
$5G/$10B
$7G/$12B
$8G/$13B
$5G/$10B
$10G/$20B
$5G/$10B
DUMMY
OHSU CUSTOM PLAN EFF 1-00
OHSU CUSTOM PLAN CBR 1-00
PEBB
PEBB COBRA
EFF 1-99
UNAVAIL USED IN WA CLARK
$0
$1
$2
$3
$4
$5
$8
25%
50% TO $25
50% UPTO $25
%50
50% TO $50
RITE AID
COBRA
SV 20/250A RITE AID 05 CB
SV 15/90% 08
SV 15/90% 08 CB
SHARE PLAN 10-20
SHARE PLAN (PACIFICARE EE)
STANDARD 5 PLAN
STANDARD 10 PLAN
AGILENT $20/100A
AGILENT $20/100A COBRA
SAFEWAY/VONS
SAFEWAY/VONS COBRA
SH BOEING NORTH AMERICAN
PREMIER $15/100%
PREMIER $15/100% COBRA
SECURE HORIZONS PLUS
SECURE HORIZONS PLUS
SH PLUS 3
SH PLUS 5
SH PLUS 7
428 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
SE9
SEB
SED
SEJ
SER
SF0
SF1
SF3
SF5
SF8
SF9
SFC
SFD
SFW
SFZ
SG1
SG2
SG3
SG5
SG7
SGC
SGJ
SGL
SGM
SHE
SHF
SHP
SHS
SJ1
SJ3
SJ5
SJ7
SJE
SJG
SJM
SK1
SK2
SKM
SOC
SOD
SP1
SP3
SP5
SP7
SP9
SR0
SR1
SR3
SR5
SR7
Plan / Benefit Description
SEC.HORIZONS-EMPLOYER
SEBB PLAN
SV 20/80% 07
SV 20/80% 07 CB
SUPP ELIGIBILITY RIDER
SECURE HORIZONS B ONLY
SECURE HORIZONS B ONLY
SH METRO AREA B ONLY
SECURE HORIZONS B ONLY
SH METRO AREA B ONLY
SECURE HORIZ. B ONLY PLAN
SPLIT FAMILY COVERAGE
$10/$30/$60 SF
SAFEWAY/VONS $20/250A
SAFEWAY/VONS $20/250A CBRA
SECURE HORIZONS PLUS 10
THE BASIC HEALTH PLAN
SECURE HORIZONS PLUS 3
SECURE HORIZONS PLUS 5
SECURE HORIZONS PLUS 7
SV 20/250A SAFEWAY 06
SV 20/250A SAFEWAY 06 CB
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
SECURE HORIZ. PLUS B ONLY
SECURE HORIZ. B ONLY PLAN
SECURE HORIZONS PLUS PLAN
SECURE HORIZONS PLAN
SECURE HORIZONS RET GRP 10
SECURE HORIZONS RET GRP 3
SECURE HORIZONS RET GRP 5
SECURE HORIZONS RET GRP 7
SV 20/250A SAFEWAY 07
SV 20/250A SAFEWAY 07 CB
SV 20/250A SAFEWAY 08
PREMIER $15/100%
PREMIER $15/100% COBRA
SV 20/250A SAFEWAY 08 CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
SUPPLEMENTAL LIFE BENE
SECURE HORIZONS PLUS 3
SECURE HORIZONS PLUS 5
SECURE HORIZONS PLUS 7
SECURE HORIZONS PLUS PLAN
SH GRP RETIREE $10
SEARS PLAN
SH-GRP RETIREE $3
SH-GRP RETIREE $5
SH GRP RETIREE $7
429 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
SRS
SRZ
SS0
SS1
SS3
SS5
SS8
SS9
SSP
SSR
ST1
ST2
STD
STF
STM
STX
SW1
SW2
SW3
SW4
SW7
SX1
SX3
SX5
SX7
SYN
SZ0
SZ1
SZ2
SZB
SZN
SZR
T10
T1C
T2C
T2D
T2E
T2F
T3P
T4P
TAX
TCS
TCU
TD1
TD2
TK1
TK2
TK3
TK4
TL1
Plan / Benefit Description
SEARS
SEARS PLAN (COBRA)
SECURE HORIZONS STANDARD
SECURE HORIZONS STANDARD
SH METRO AREA
SECURE HORIZONS STANDARD
SH METRO AREA
SECURE HORIZONS STANDARD
SH SILVER SNEAKERS
SLV SNEAK/FITNESS BEN GR06
STANDARD PLAN
STANDARD PLAN (2)
RESERVED FOR PPO LIFE
STATE FARM 20-30/250A
SH TRI-MET RET GRP $5
STATE FARM 20-30/250A CBRA
UNAVAIL USE IN WA CLARK
UNAVAIL USE IN WA CLARK
SV 20/250A SAFEWAY
SV 20/250A SAFEWAY CB
UNAVAIL USED IN WA CLARK
SECURE HORIZONS RET GRP 10
SECURE HORIZONS RET GRP 3
SECURE HORIZONS RET GRP 5
SECURE HORIZONS RET GRP 7
SV 20/80% 08
SHARE PLAN 10-20 COBRA
STANDARD PLAN (COBRA)
STANDARD PLAN (2) COBRA
SEBB PLAN
COBRA
SV 20/80% 08 CB
SEARS COBRA
$10G/$15B
PORTABILITY PREVAIL PLAN
OREGON PREVAILING PORTAB
2002 PREVAILING PORTABILTY
PORTABILITY PREVAILING
RESERVED SIGVALUE15/100DC
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
PCOR PREMIUM TAX
SV 25/70% 07
SV 25/70% 07 CB
PREFERRED $10/$250
PREFERRED $10/$250 COBRA
PREFERRED $10/$250
PREFERRED $10/$250 COBRA
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
VALUE PLAN ($1600 FAM MAX)
430 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
TL2
TL3
TM1
TM2
TM6
TM7
TNC
TP1
TP2
TP3
TP5
TP6
TPA
TPB
TPE
TPF
TPH
TPL
TS1
TS2
TSA
TSB
TSE
TSF
TTH
TTL
TW7
TW8
TYB
TZ1
TZ2
TZ3
TZB
U01
U02
U03
U04
U05
U06
U07
U08
U09
U10
U11
U12
U13
U14
U15
U16
U17
Plan / Benefit Description
TELEDYNE WAH CHANG PLAN
$5/50 HMO ORE-MET WAH CHAN
CREDENCE SYS $15/$250A
CREDENCE SYS $15/$250A CBR
SV $15/$250A CREDENCE
SV $15/$250A CREDENCE CB
UNAVAI DON'T USE WA CODE
POS $10/$200/60%
POS $10/$200/60% COBRA
TOWERS PERRIN $15 PLAN
POS $10/$200/60% SG
POS $10/$200/60% SG COBRA
POS $10/$200/60%
POS $10/$200/60% COBRA
RESERVED
RESERVED
5-10/100% GR06
15-20/100A GR06
POS $10/$200/75%
POS $10/$200/75% COBRA
POS $10/$200/75%
POS $10/$200/75% COBRA
POS $10/$200/75% SG
POS $10/$200/75% SG COBRA
DUMMY
DUMMY
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
SV 25/70% 08
VALUE (COBRA)(2X FAM MAX)
TELEDYNE WAH CHANG COBRA
$5/50 HMO ORE-MET WAH COBR
SV 25/70% 08 CB
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
431 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
U18
U19
U20
U21
U22
U23
U24
U25
U26
U27
U28
U29
U30
U31
U32
U33
U34
U35
U36
U37
U38
U39
U40
U41
U42
U43
U44
U45
U46
U47
U48
U49
U50
U51
U52
U53
U54
U55
U56
U57
U58
U59
U60
UCW
UCZ
UHC
UM0
UM3
UNA
UNC
Plan / Benefit Description
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
VSUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PP
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
DUAL-OPTION - UHC 06
UMTA $10/100%
UMTA $3/100%
UNAVAIL USED IN WA CLARK
UWAA (CUSTOM $5 PLAN)
432 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
UNZ
UPC
UPZ
UTC
UZ0
UZ3
V00
V05
V07
V0A
V12
V15
V1C
V1M
V1P
V1X
V1Y
V1Z
V25
V27
V2C
V2F
V2P
V2Y
V2Z
V3C
V3Z
V8P
V8Q
V8R
V8S
V8T
V8U
V8V
V8W
V8X
V9C
V9Z
VA2
VA3
VAA
VAB
VAC
VAD
VAE
VAF
VAG
VAH
VAI
VAJ
Plan / Benefit Description
UWAA (CUSTOM $5 PLAN)COBRA
UWAA $5 CUSTOM PLAN
UWAA $5 CUSTOM PLAN COBRA
TAKING CHARGE OF YOU
UMTA $10/100% COBRA
UMTA $3/100% COBRA
VISION CARE $0 VSP
VISION CARE $10.00(SEBB)
VISION CARE $7 (VSP)
VISIONCARE $10 PEBB 1-99
VISION CARE $12 (VSP)
VISION CARE $15 (VSP)
94-EB-1500
94-EB-1500 IPGB
ADVANTAGE PLAN OPTION
94-EB-1500 IPGB
ADVANTAGE PLAN OPTION CBR
94-EB-1500 COBRA
VISION - THRIFTY/PAYLESS
SC 20 ELIGIBILITY ONLY
EB-1500 20% PLAN
25/70A TOWERS GR-VN06 VSP
94-EB-1500-OPTION
94-EB-1500-OPTION COBRA
EB-1500 20% PLAN COBRA'
00-EB-1500
00-EB-1500 COBRA
0 REFRAC 1/V YR VN-GR08
5 REFRAC 1/V YR VN-GR08
10 REFRAC 1/V YR VN-GR08
15 REFRAC 1/V YR VN-GR08
20 REFRAC 1/V YR VN-GR08
25 REFRAC 1/V YR VN-GR08
30 REFRAC 1/V YR VN-GR08
35 REFRAC 1/V YR VN-GR08
40 REFRAC 1/V YR VN-GR08
EB-1500 20% SMALL GROUP
EB-1500 20% SMALL GRP COBR
VALUE PLAN
$10 VISION OHSU
$10 OPTION A EXAM/HRDWARE
$10 OPTION B EXAM/HRDWARE
VSP $10 EXAM ONLY
VISION CARE $15 1-99
VSP $35 EXAM ONLY
VSP $5 EXAM ONLY
VSP $15 EXAM ONLY
VSP $20 EXAM ONLY
VSP $25 EXAM ONLY
$5 OPTION A EXAM/HARDWARE
433 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
VAK
VAL
VAM
VAN
VAO
VAP
VAQ
VAR
VB6
VBC
VBH
VBJ
VBK
VBL
VBM
VBN
VBO
VBZ
VC0
VC1
VC2
VC5
VC6
VCB
VCC
VDA
VE1
VE3
VE7
VEO
VEP
VEY
VFA
VFD
VFP
VFQ
VG6
VGC
VGP
VGQ
VGS
VGZ
VI3
VI4
VI7
VI8
VJQ
VK3
VK4
VKP
Plan / Benefit Description
$15 OPTION A EXAM/HRDWARE
$20 OPTION A EXAM/HRDWARE
$25 OPTION A EXAM/HRDWARE
$0 OPTION A EXAM/HARDWARE
$3 OPTION A EXAM/HARDWARE
VSP $0 EXAM ONLY
30/70A 2YRS SH-VN07
VSP $3 EXAM ONLY
25/150A 2 YRS SH-VN06
00-EB 1500 SMALL GROUP
$15/$75 BOEING HRLY GP RET
$5 OPTION B EXAM/HRDWARE
$15 OPTION B EXAM/HRDWARE
$20 OPTION B EXAM/HRDWARE
$25 OPTION B EXAM/HRDWARE
$0 OPTION B EXAM/HARDWARE
$3 OPTION B EXAM/HARDWARE
00-EB 1500 SMALL GRP COBRA
VSP $15 EXAM ONLY CHILD
ADVANTAGE $15/$300
ADVANTAGE $15/$300 COBRA
ADVANTAGE $15/$300 SG
ADVANTAGE $15/$300 SG CBRA
BOEING ERET VISN $15 (VSP)
BOEING ERET VISN $10 (VSP)
15/70A GR-VN07
UNAVAIL USED IN WA CLARK
SH PLUS 3
SECURE HORIZONS PLUS 7
35 EXAM ONLY VSP
ADVANTAGE PLAN - EOFF
ADVANTAGE PLAN EOFF COBRA
30 EXAM FEDS VN06-PDV
PDV $40 EXAM ONLY FED 2005
0/75A 2YRS VN-GR08
0/125A 2YRS VN-GR08
25/75A VN-GR06
GOOD SAMARITAN HOS PLAN
5/75A 2YRS VN-GR08
5/125A 2YRS VN-GR08
VISION CARE - EUGENE SCHLS
GOOD SMRTN HOS PLAN COBRA
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
NOT AVAIL. C CNTY CODE
NOT AVAIL. C CNTY CODE
10/75A 2YRS VN-GR08
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
10/125A 2YRS VN-GR08
434 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
VL6
VMQ
VMU
VMZ
VN1
VN2
VN5
VNQ
VOA
VOB
VOC
VOD
VOE
VOF
VPA
VPE
VPP
VPS
VPV
VPZ
VQD
VQP
VSQ
VVP
VVQ
VWP
VYP
VZ2
VZC
W1C
W1Z
W2C
W3C
W4C
W4Z
W5C
W6C
WAB
WAC
WAD
WAJ
WAL
WAP
WBJ
WBL
WC1
WC2
WCE
WCH
WCJ
Plan / Benefit Description
ADV WELLNESS LITE SH-WL06
15/125A 2YRS VN-GR08
MULTNOMAH BAR ASSOC
MULTNOMAH BAR ASSOC COBRA
GRP RET $5OV/$125 ALLOWNCE
GRP RET $10OV/$75 ALLOWNCE
GRP RET $20V/$75 ALLOWANCE
20/75A 2YRS VN-GR08
POS $15/90%/65%
POS $15/90%/65% COBRA
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
POS $15/90%/65% SG
POS $15/90%/65% SG COBRA
VISION PREMIUM ALLOCATION
RESERVED PFFS
20/125A 2YRS VN-GR08
$30 PRINT SPEC VSP
10/150A 2YRS PEBB GR-VN07
25/150A 2YRS PEBB GR-VN07
30/70A 2YRS VN-SH08
25/70A 2YRS VN-GR08
30/70A 2YRS SH-VN07
15/75A 2YRS VN-GR08
25/75A 2YRS VN-GR08
25/125A 2YRS VN-GR08
10/150A 2YRS PEBB VN-GR08
VALUE PLAN (COBRA)
25/150A 2YRS PEBB VN-GR08
94-EE-3000 PLAN
94-EE-3000 PLAN COBRA
INDIVIDUAL PLAN II
INDIVIDUAL PLAN II
EE-3000
EE-3000 COBRA
INDIVIDUALPLANII 2000-2001
INDIVIDUAL PLAN II
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL DON'T USE WA CODE
WEIGHT ALTERATION PROGRAMS
SV 25/70% SG07
UNAVAIL DON'T USE WA CODE
PREMIER $15/70%
PREMIER $15/70% COBRA
UNAVAIL USED IN WA CLARK
SP 15/90% WILLAMETTE 05
SV 25/70% SG07 CB
435 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
WCK
WCL
WCM
WCN
WCP
WD1
WD2
WD3
WD4
WE1
WE2
WE3
WE4
WE5
WE6
WE7
WE8
WEC
WEZ
WF1
WF2
WF3
WF4
WF5
WF6
WF7
WF8
WFB
WFD
WFE
WFJ
WFX
WFZ
WG7
WG8
WGC
WGZ
WH7
WH8
WHA
WHG
WHZ
WIC
WJ1
WJ2
WJ5
WJ6
WJP
WJY
WK1
Plan / Benefit Description
SP 15/90% WILLAMETTE 05 CB
SP 20/80% WILLAMETTE 05
SP 20/80% WILLAMETTE 05 CB
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
SV 15/90%
SV 15/90% CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
SV $20/80%
SV $20/80% CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
SV $20/80% SG
SV $20/80% SG CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
EUGENE PUBLIC SCHOOLS
EUGENE PUBLIC SCHOOLS
SV $25/70%
SV $25/70% CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
SV $25/70% SG
SV $25/70% SG CB
NOT AVAIL CLK CNTY CODE
NOT AVAIL CLK CNTY CODE
WELLS FARGO BANK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
WELLS FARGO BANK COBRA
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
EUGENE PUBLIC SCHOOLS
EUGENE SCHLS - COBRA
UNAVIL USED IN WA CLARK
UNAVIL USED IN WA CLARK
KUNI $15/$200
SV 15-30/100D OPEIU 08
KUNI $15/$200 COBRA
INDIVIDUAL PLAN
ADVANTAGE $15/$300
ADVANTAGE $15/$300 COBRA
ADVANTAGE $15/$300 SG
ADVANTAGE $15/$300 SG CBR
JOSEPHINE COUNTY
JOSEPHINE COUNTY (COBRA)
PREMIER $15/70%
436 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
WK2
WK5
WK6
WK7
WK8
WLA
WME
WMG
WMN
WMP
WNC
WNF
WPA
WPC
WPY
WUR
WUS
WUT
WVR
WVS
WVT
WWF
WXR
WXS
WXT
X10
X15
X1A
X1B
XAV
XAY
XAZ
XJA
XJB
XJC
XM1
XM3
XM5
XM7
XM8
XS1
XS5
XS7
XS8
XXX
Z2X
Z5V
Z8X
ZA2
ZA3
Plan / Benefit Description
PREMIER $15/70% COBRA
PREMIER $15/70% SG
PREMIER $15/70% SG COBRA
DO NOT USE CLK CNTY CODE
DO NOT USE CLK CNTY CODE
36AVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
SV 15-30/100D OPEIU 08 CB
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
INDIVIDUAL PLAN II
SV 25/70% SG 08
KUNI $15/$200/75%
IPGB - BASIC PLAN
KUNI $15/$200/75% COBRA
15-25/200D T3A GR07
15-30/220D T3B GR07
20-35/250D T3C GR07
10-20/750A T2A GR07
15-25/130D T2B GR07
10-25/150D T2C GR07
SV 25/70% SG 08 CB
10-15/50A T1A GR07
5-20/100A T1B GR07
10-20/200A T1C GR07
$10
$15
$10
$10 PPO
DUMMY
DUMMY
DUMMY
$5 MAND. GENERIC
$10 MAND. GENERIC
$15
$10/10+DIF
$3/$3 + DIFF
$5/$5+DIF
$7/$7+DIF
$8/$8+DIF
$10
$5
$7
$8
NO BENEFIT
10-15/50A T1A NON-AARP GR8
15-25/130D T2B NO-AARP GR8
10-20/200A T1C NO-AARP GR8
RESERVED PPO
RESERVED PPO
437 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
ZA4
ZA5
ZA6
ZA7
ZA8
ZA9
ZB2
ZB3
ZB4
ZB5
ZB6
ZB7
ZB8
ZB9
ZBL
ZC2
ZC3
ZC4
ZC5
ZC6
ZC7
ZC8
ZC9
ZCE
ZCN
ZCP
ZD2
ZD3
ZD4
ZD5
ZD6
ZD7
ZD8
ZD9
ZE2
ZE3
ZE4
ZE5
ZE6
ZE7
ZE8
ZE9
ZF2
ZF3
ZF4
ZF5
ZF6
ZF7
ZF8
ZF9
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
NOT AVAIL CLK CNTY CODE
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
UNAVAIL USED IN WA CLARK
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
438 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
ZG2
ZG3
ZG4
ZG5
ZG6
ZG7
ZG8
ZG9
ZH2
ZH3
ZH4
ZH5
ZH6
ZH7
ZH8
ZH9
ZJ2
ZJ3
ZJ4
ZJ5
ZJ6
ZJ7
ZJ8
ZJ9
ZK2
ZK3
ZK4
ZK5
ZK6
ZK7
ZK8
ZK9
ZM2
ZM3
ZM4
ZM5
ZM6
ZM7
ZM8
ZM9
ZN2
ZN3
ZN4
ZN5
ZN6
ZN7
ZN8
ZN9
ZP2
ZP3
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
439 of 640
Plan Benefit - OR
State
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR
Plan / Benefit
ZP4
ZP5
ZP6
ZP7
ZP8
ZP9
ZR2
ZR3
ZR4
ZR5
ZR6
ZR7
ZR8
ZR9
ZZZ
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
HISTORICAL PLAN
440 of 640
Plan Benefit - TX
Cap/Eligibility CP7810
Assigned Plan Benefit Codes & Descriptions
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
0AZ
0BZ
0CZ
0DZ
0HM
13A
1AZ
1BZ
1CZ
1DZ
1EZ
1HM
1JZ
1LZ
1RZ
1SA
1U5
1UA
1UB
203
2AN
2AY
2AZ
2BL
2BZ
2C1
2C2
2C3
2C5
2CG
2CH
2CJ
2CK
2CZ
2DZ
2FH
2FL
2G1
2G2
2G3
2GH
2HH
Plan / Benefit Description
PPO PLAN10 15 80/60 250 CB
PPO PLAN10 15 80/60 250 CB
PPO PLAN10 15 80/60 250 CB
PPO PLAN10 15/80/60 250 CB
FLEX PREF 99
DUMMY
PPO PLAN1 15 90/70 250 CBR
PPO PLAN1 15 90/70 250 CBR
PPO PLAN1 15 90/70 250 CBR
PPO PLAN1 15 90/70 250 CBR
PPO PLAN11 20 80/60 250 CB
FLEX P10 99
PPO PLAN11 20 80/60 250 CB
PPO PLAN11 20 80/60 250 CB
PPO PLAN11 20 80/60 250 CB
$5
$5
$10
$5
PLAN 20
4/20/40 LO GR-RX07
4/25/50 HI GR-RX07
PPO PLAN2 20 90/70 250 CBR
10/25/50 RX-GR08
PPO PLAN2 20 90/70 250 CBR
$5G/$10B
$10G/$15B
$5G/$10B
$7.50G/$15B
$2G/$2B
$7G / $15B
$5G/$15B FEDS RX
$10G/$20B
PPO PLAN2 20 90/70 250 CBR
PPO PLAN2 20 90/70 250 CBR
4/15/30 RX-GR08
5/20/45 RX-GR08
$7G/$14B
$10G/$20B
$10G/$25B
4/20/40 RX-GR08
4/15/30 RX-GR08
441 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
2HM
2I5
2IA
2IB
2JH
2KH
2MH
2NH
2PH
2QH
2S2
2S3
2S4
2SA
2U1
2U2
2U5
2U6
2UB
2UF
2UH
2UJ
2VH
2WH
2XH
2YH
2Z3
2ZA
2ZB
2ZC
2ZD
2ZE
2ZF
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
Plan / Benefit Description
FLEX 1-10 99
$10G/$20B INDIVIDUAL PLAN
$5G/$10B S GOLD
$5G $15B SECURE GOLD
4/20/40 RX-GR08
4/25/50 RX-GR08
4/25/45 RX-GR08
4/28/55 RX-GR08
4/28/58 RX-GR08
4/25/50 RX-GR08
$10G/$30B SH
$10G/$30B SH
$10G/$30B
$5G/$15B
$5G/$10B
$5G/$15B
$10G/$20B
$10G/$25B
$5G/$15B
$10G/$25B
10/25/50 RX-GR08
$5G/$15B
10/25/50 RX-GR08
5/20/45 RX-GR08
5/20/45 RX-GR08
4/10/20 RX-GR08
PLAN 20 - COBRA
0/0 GR-RX07
2/40 GR-RX07
5/25 GR-RX07
5/65 GR-RX07
5/10 GR-RX07
10/20 GR-RX07
MANDATED OFFER RIDERS PPO
INFERTILITY INVITRO PPO
SPEECH & HEARING PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
442 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
317
318
319
320
321
322
323
324
325
326
327
328
329
330
382
383
38H
3AZ
3BZ
3C1
3C2
3C3
3C4
3C5
3C6
3C7
3C8
3CA
3CB
3CC
3CD
3CF
3CT
3CZ
3DZ
3E1
3E2
3E3
3E4
3E5
3FA
3FC
3FD
3G1
3G2
3G3
3GA
3GB
3HM
3PC
Plan / Benefit Description
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
380 PLAN (2)
380 PLAN (3)
$7G/15B
PPO PLAN3 10 90/70 250 CBR
PPO PLAN3 10 90/70 250 CBR
$5/$20/$35
$5/$15/$25
$10/$20/$35
$5/$10/$10
$10/$20/$35 FT WORTH RET
$5/$15/$30
$5/$10/$25
$5G/$10B/$10NF
$15G/$20B/$30NF
$5/$15/$25
$10/$30/$50
$5/$15/$30
$20G/$40B/$50NF
$10G/$20B/$40NF
PPO PLAN3 10 90/70 250 CBR
PPO PLAN3 10 90/70 250 CBR
10/20/45 E
10/30/50 E
15/25/50 E
15/30/50E 1HD
15/35/60E 2HD
10/30/50 RX06
10/40/50 RX05
15/30/60 RX06
$15G/$25B/$40NF
$10G/$20B/$50NF
$10G/$20B/$40NF
$15G/$25B/$40NF
15G/25B/40NF W/INJ
FLEX PLAN 1 99
10/30/40 PHS
443 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
3PH
3QL
3TA
3U5
3U7
3U8
3U9
3UG
3UI
3UK
3UL
3Z2
3Z3
3ZE
3ZF
3ZG
3ZH
3ZJ
3ZK
3ZL
3ZM
40A
40B
40C
40D
40E
40F
40G
40H
40I
40J
40K
40L
40M
40N
40O
40P
40Q
40R
40S
40T
40U
40V
40W
40X
40Y
40Z
41A
41B
41C
Plan / Benefit Description
10/30/50 RX06
5/15/30 RX 08
$10G/$30B/$55NF
$5/$10/$25
$5/$15/$30
$5/$15/$35
$10/$20/$35
$5/$15/$30
$10/$20/$35
$5G/$10B/$25NF
$10G/$15B/$25NF
380 PLAN (COBRA 2)
380 PLAN (COBRA 3)
5/10/20 GR-RX07
10/20/35 GR-RX07
10/20/35 GR-RX07
10/25/55 GR-RX07
10/40/75 GR-RX07
7/20/50% GR-RX07
2/30/60 GR-RX07
10/25/50 GR-RX07
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
444 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
41D
41E
41F
41G
41H
41I
41J
41K
41L
41M
41N
41O
41P
41Q
41R
41S
41T
41U
41V
41W
41X
41Y
41Z
42I
43I
440
44I
45I
46A
46I
47A
47I
48I
49I
49P
49Q
4A0
4A1
4AI
4AO
4AZ
4B0
4B1
4BI
4BO
4BZ
4C0
4C1
4CI
4CO
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
MCC 1 CC GR08
RESERVED RX PPO
MCC 1 SA GR08
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
MCC 1 DFW GR08
MCC 1 DFW DLX GR08
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
PPO PLAN4 20 90/70 500 CBR
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
PPO PLAN4 20 90/70 500 CBR
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
445 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
4CZ
4D0
4D1
4DZ
4E0
4E1
4EI
4EO
4F0
4F1
4FI
4FO
4G0
4G1
4GI
4H0
4H1
4HI
4HM
4HO
4I0
4I1
4IA
4IB
4IC
4ID
4IE
4IF
4IG
4IH
4II
4IJ
4IK
4IL
4IN
4IO
4IP
4IQ
4IR
4IS
4IT
4IU
4IV
4IW
4IX
4IY
4IZ
4J0
4J1
4JI
Plan / Benefit Description
PPO PLAN4 20 90/70 500 CBR
RESERVED RX PPO
RESERVED RX PPO
PPO PLAN4 20 90/70 500 CBR
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
FLEX 10/0/800
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
446 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
4JO
4K0
4K1
4KI
4KO
4L0
4L1
4LI
4M0
4M1
4MI
4MO
4N0
4N1
4NI
4NO
4O0
4O1
4OA
4OB
4OC
4OD
4OF
4OH
4OI
4OJ
4OK
4OL
4OM
4OO
4OP
4OQ
4OS
4OT
4OU
4OV
4OW
4OX
4OY
4OZ
4P0
4P1
4PI
4PO
4Q0
4Q1
4QI
4QO
4R0
4R1
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
447 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
4RO
4S0
4S1
4T0
4T1
4TI
4U0
4U1
4UI
4UO
4V0
4V1
4VI
4VO
4W0
4W1
4WI
4WO
4X0
4X1
4XI
4XO
4Y0
4Y1
4YI
4YO
4Z0
4Z1
4ZI
4ZO
50A
50B
50C
50D
50E
50F
50G
50H
50I
50J
50K
50L
50M
50N
50O
50P
50Q
50R
50S
50T
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
448 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
50U
50V
50W
50X
50Y
50Z
51A
51B
51C
51D
51E
51F
51G
51H
51I
51J
51K
51L
51M
51N
51O
51P
51Q
51R
51S
51T
51U
51V
51W
51X
51Y
51Z
52I
535
536
537
538
539
53I
540
541
542
543
544
545
546
547
548
549
54I
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
449 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
550
551
552
553
554
555
556
557
558
559
55I
560
561
562
563
564
565
566
567
568
569
56I
570
571
572
573
574
575
576
577
578
579
57I
580
581
582
583
584
585
586
587
588
589
58I
590
591
592
593
594
59I
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
450 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
5A0
5A1
5AA
5AI
5AO
5AX
5AZ
5B0
5BA
5BI
5BO
5BX
5BZ
5C0
5C1
5CA
5CI
5CO
5CX
5CZ
5D0
5D1
5DA
5DX
5DZ
5E0
5E1
5EI
5F0
5F1
5FI
5FO
5G0
5G1
5GI
5H0
5H1
5HI
5HM
5HO
5I0
5I1
5IA
5IB
5IC
5ID
5IE
5IF
5IG
5IH
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
HMO 5
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
PPO PLAN5 15 80/60 500 CBR
HMO 5 COBRA
RESERVED BENEFIT PPO
HMO 5
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
PPO PLAN5 15 80/60 500 CBR
HMO 5 COBRA
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
HMO 5
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
PPO PLAN5 15 80/60 500 CBR
HMO 5 COBRA
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
HMO 5
PPO PLAN5 15 80/60 500 CBR
HMO 5 COBRA
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
FLEX 10/100/1000
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
451 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
5II
5IJ
5IK
5IL
5IN
5IO
5IP
5IQ
5IR
5IS
5IU
5IV
5IW
5IX
5IY
5IZ
5J0
5J1
5JI
5JO
5K0
5K1
5KI
5KO
5L0
5L1
5LI
5M0
5M1
5MI
5N0
5N1
5NI
5NO
5O0
5O1
5O2
5O3
5O4
5O5
5O6
5O7
5O8
5O9
5OA
5OB
5OD
5OF
5OH
5OI
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
452 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
5OJ
5OK
5OL
5OM
5ON
5OO
5OQ
5OS
5OT
5OU
5OV
5OW
5OX
5OY
5OZ
5P0
5P1
5PI
5PO
5Q0
5Q1
5QI
5QO
5R0
5RO
5S0
5S1
5S2
5S3
5SA
5SB
5SC
5T0
5T1
5TI
5U0
5U1
5UI
5UO
5V0
5V1
5VI
5VO
5W0
5W1
5WI
5WO
5X0
5X1
5XI
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
$5/100% HMO SMALL GRP CBRA
$5/100% HMO SMALL GRP CBRA
$5/100% HMO SMALL GRP CBRA
$5/100% HMO SMALL GRP
$5/100% HMO SMALL GROUP
$5/100% HMO SMALL GROUP
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
453 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
5XO
5Y0
5Y1
5YI
5YO
5Z0
5Z1
5ZI
5ZO
635
636
637
638
639
640
641
642
643
644
645
646
647
648
649
650
651
652
653
654
655
656
657
658
659
660
661
662
663
664
665
666
667
668
669
670
671
672
673
674
675
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
454 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
676
677
678
679
680
681
682
683
684
685
686
687
688
689
690
691
692
693
694
6AH
6AL
6AZ
6BH
6BL
6BZ
6CP
6CZ
6DH
6DL
6DM
6DP
6DZ
6EH
6EL
6FH
6FL
6FR
6HH
6HL
6HM
6JH
6JL
6KH
6KL
6LH
6LL
6MA
6MH
6ML
6NH
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
0/0 HI GR-RX07
0/0 LO GR-RX07
PPO PLAN6 20 90/70 500 CBR
2/30/60 HI GR-RX07
2/30/60 LO GR-RX07
PPO PLAN6 20 90/70 500 CBR
8.50/26.15/50% SH6
PPO PLAN6 20 90/70 500 CBR
2/40 HI GR-RX07
2/40 LO GR-RX07
15/25/40 GR-RX06
8.50/26.15/50% SH6
PPO PLAN6 20 90/70 500 CBR
5/25 HI GR-RX07
5/25 LO GR-RX07
5/65 HI GR-RX07
5/65 LO GR-RX07
10/20 GR-RX06
5/10 HI GR-RX07
5/10 LO GR-RX07
FLEX 10/200/1000
5/10/20 HI GR-RX07
5/10/20 LO GR-RX07
7/14 HI GR-RX07
7/14 LO GR-RX07
7/20/50% HI GR-RX7
7/20/50% LO GR-RX7
10/25%/40% RX-GR06
10/20 HI GR-RX07
10/20 LO GR-RX07
10/20/40 HI GR-RX7
455 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
6NL
6PH
6PL
6PR
6QH
6QL
6QM
6RH
6RL
6SC
6SH
6SL
6TH
6TL
6UH
6UL
6VM
6VP
6WH
6ZM
710
711
712
713
714
715
716
717
718
719
71A
71B
71C
71D
71E
71F
71G
71H
71I
71J
71K
71L
71M
71N
71O
71P
71Q
71R
71S
71T
Plan / Benefit Description
10/20/40 LO GR-RX7
10/20 HI GR-RX07
10/20 LO GR-RX07
10/20/40 GR-RX06
10/20/35 HI GR-RX7
10/20/35 LO GR-RX7
5/15/30 GR-RX06
10/20/35 HI GR-RX7
10/20/35 LO GR-RX7
10/25%/40% RX-GR06
10/25/55 HI GR-RX7
10/25/55 LO GR-RX7
10/40/75 HI GR-RX7
10/40/75 LO GR-RX7
15/25/40 HI GR-RX7
15/25/40 LO GR-RX7
5/5 GR-RX06
25%/25%/25% SH6
10/25/50 HI GR-RX7
7/14 GR-RX06
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
456 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
71U
71V
71W
71X
71Y
71Z
720
721
722
723
724
725
726
727
728
729
72A
72B
72C
72D
72E
72F
72G
72H
72I
72J
72K
72L
72M
72N
72O
72P
72Q
72R
72S
72T
72U
72V
72W
72X
730
731
732
733
734
735
736
737
738
739
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVE PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
457 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
73A
73B
73C
73D
73E
73F
73G
73H
73I
73J
73K
73L
73M
73N
73O
73P
73Q
73R
73S
73T
73U
73V
73W
73X
73Y
73Z
740
741
742
743
744
745
746
747
748
749
74A
74B
74C
74D
74E
74F
74G
74H
74I
74J
74K
74L
74M
74N
Plan / Benefit Description
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
VESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
458 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
74O
74P
74Q
74R
74S
74T
74U
74V
74W
74X
74Y
74Z
750
751
752
753
754
755
756
757
758
759
75A
75B
75C
75D
75E
75F
75G
75H
75I
75J
75K
75L
75M
75N
75O
75P
75Q
75R
75S
75T
75U
75V
75W
75X
75Y
75Z
760
761
Plan / Benefit Description
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED RX PPO
RESERVED RX PPO
459 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
762
763
764
765
766
767
768
769
76A
76B
76C
76D
76E
76F
76G
76H
76I
76J
76K
76L
76M
76N
76O
76P
76Q
76R
76S
76T
76U
76V
7AQ
7AR
7AZ
7BD
7BH
7BI
7BL
7BR
7BZ
7CD
7CI
7CM
7CZ
7DD
7DH
7DL
7DM
7DR
7DZ
7ED
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
7/20 GR-RX07
0/0 GR-RX07
PPO PLAN7 10 80/60 500 CBR
7/14 GR-RX07
4/10/20 T1A H GRX7
7/14 I GR-RX07
4/10/20 T1A L GRX7
0/0 FLAT GR-RX07
PPO PLAN7 10 80/60 500 CBR
7/14 GR-RX07
7/14 I GR-RX07
15/25/40 GR-RX07
PPO PLAN7 10 80/60 500 CBR
7/20/30 GR-RX07
4/15/30 T1B H GRX7
4/15/30 T1B L GRX7
15/25/40 GR-RX07
10/10 FLAT GR-RX07
PPO PLAN7 10 80/60 500 CBR
7/7 GR-RX07
460 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
7EH
7EL
7EM
7ER
7FD
7FH
7FL
7FM
7FR
7GD
7GM
7GR
7HH
7HI
7HL
7HM
7HR
7JH
7JL
7JM
7JR
7KH
7KI
7KL
7KM
7KR
7LH
7LL
7LM
7LR
7MA
7MH
7MI
7ML
7MR
7NH
7NL
7NM
7PH
7PI
7PL
7PM
7PR
7Q2
7Q3
7QH
7QI
7QL
7QM
7QR
Plan / Benefit Description
4/20/40 T1C H GRX7
4/20/40 T1C L GRX7
3/3 FLAT GR-RX07
10/20 GR-RX07
7/7 C GR-RX07
4/25/50 T1D H GRX7
4/25/50 T1D L GRX7
3/3/3 GR-RX07
10/20 GR-RX07
10/20/30 GR-RX07
5/10 GR-RX07
10/20 GR-RX07
4/15/30 T2A H GRX7
10/20 I GR-RX07
4/15/30 T2A L GRX7
FLEX 10/250/1000
10/20 GR-RX07
4/28/58 T3C H GRX7
4/28/58 T3C L GRX7
5/10 GR-RX07
10/10 GR-RX07
4/28/55 T3B H GRX7
10/20/35 I GR-RX07
4/28/55 T3B L GRX7
5/10/20 GR-RX07
10/20/35 GR-RX07
4/25/45 T3A H GRX7
4/25/45 T3A L GRX7
5/15 GR-RX07
15/25/40 GR-RX07
10/25%/40% GR-RX07
4/20/40 T2B H GRX7
10/20/40 I GR-RX07
4/20/40 T2B L GRX7
10/20/40 GR-RX07
4/25/50 T2C H GRX7
4/25/50 T2C L GRX7
5/15/30 GR-RX07
4/25/50 T2C H GRX7
10/20/40 I GR-RX07
4/25/50 T2C L GRX7
5/15/30 GR-RX07
10/20/40 GR-RX07
5/29/56.25W/G SHX7
5/29/55.40W/G SHX7
4/20/40 T2B H GRX7
10/20/40 I GR-RX07
4/20/40 T2B L GRX7
5/15/30 GR-RX07
10/20/40 GR-RX07
461 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
7RA
7RB
7RC
7RD
7RH
7RL
7RM
7SB
7SI
7SR
7TH
7TL
7TM
7TR
7UH
7UL
7UM
7UR
7VH
7VL
7VM
7WH
7WI
7WL
7WM
7WR
7XA
7XB
7XC
7XD
7XE
7XF
7XG
7XH
7XJ
7XL
7XM
7XP
7XU
7XV
7XW
7YH
7YI
7YL
7YM
7YR
7ZH
7ZL
7ZM
7ZR
Plan / Benefit Description
10/20/35 RDS GRX7
10/20 RDS GR-RX07
10/20/35 RDS GRX7
10/20 RDS GR-RX07
4/15/30 T2A H GRX7
4/15/30 T2A L GRX7
5/15/30 GR-RX07
10/25%/40% GR-RX07
10/20/40 I GR-RX07
10/20/40 GR-RX07
4/28/55 T3B H GRX7
4/28/55 T3B L GRX7
5/5 GR-RX07
10/25/40 GR-RX07
4/28/58 T3C H GRX7
4/28/58 T3C L GRX7
5/5 GR-RX07
15/25/40 GR-RX07
4/25/50 T1D H GRX7
4/25/50 T1D L GRX7
5/5 GR-RX07
4/20/40 T1C H GRX7
15/25/40 I GR-RX07
4/20/40 T1C L GRX7
5/7.50 GR-RX07
15/25/40 GR-RX07
4/10/20 RDS GR-RX7
4/15/30 RDS GR-RX7
4/20/40 RDS GR-RX7
4/25/50 RDS GR-RX7
4/10/20 RDS GR-RX7
4/15/30 RDS GR-RX7
4/20/40 RDS GR-RX7
4/15/30 T1B H GRX7
4/25/50 RDS GR-RX7
4/15/30 T1B L GRX7
7/14 GR-RX07
5/29/60 N/G SH-RX7
5/28/65 N/G SH-RX7
5/35/65 NGB SH-RX7
0/28/64 N/G SH-RX7
4/10/20 T1A H GRX7
15/25/40 I GR-RX07
4/10/20 T1A L GRX7
7/14 GR-RX07
15/25/40 GR-RX07
4/25/45 T3A H GRX7
4/25/45 T3A L GRX7
7/14 GR-RX07
15/25/40 GR-RX07
462 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
810
811
812
813
814
815
816
817
818
819
820
821
822
823
824
825
826
827
828
829
82A
82B
82C
82D
82E
82F
82G
82H
82J
82K
82L
82M
82N
82P
82Q
82R
82S
82T
82U
82V
82W
82X
82Y
82Z
830
831
832
833
834
835
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
463 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
836
837
838
839
83A
83B
83C
83D
83E
83F
83G
83H
83J
83K
83L
83M
840
841
842
843
844
845
846
847
848
849
84A
84B
84C
84D
84E
84F
84G
84H
84J
84K
84L
84M
84N
84P
84Q
84R
84S
84T
84U
84V
84W
84X
84Y
84Z
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
464 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
850
851
852
853
854
855
856
857
858
859
85A
85B
85C
85D
85E
85F
85G
85H
85J
85K
85L
85M
860
861
862
863
864
865
866
867
868
869
86A
86B
86C
86D
86E
86F
86G
86H
86J
86K
86L
86M
86N
86P
86Q
86R
86S
86T
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX POO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
465 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
86U
86V
86W
86X
86Y
86Z
87A
87B
87C
87D
87E
87F
87G
87H
87J
87K
87L
87M
882
883
88H
8AH
8AR
8AZ
8B8
8BH
8BZ
8CH
8CZ
8DD
8DH
8DP
8DR
8DZ
8ED
8EH
8EM
8ER
8FD
8FH
8G8
8GH
8GM
8H8
8HD
8HH
8HM
8HR
8KM
8L8
Plan / Benefit Description
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
880 PLAN (2)
880 PLAN (3)
$5G/$20B POS
0/0 HI C GR-RX07
0/0 C GR-RX07
PPO PLAN8 20 80/60 500 CBR
5/29/60NG RX-SH08
DO NOT USE
PPO PLAN8 20 80/60 500 CBR
2/30/60 HI C GRX07
PPO PLAN8 20 80/60 500 CBR
7/20/30 C GR-RX07
2/40 HI C GR-RX07
3/20/40/40 GR-RX07
10/10 FLAT C GRX07
PPO PLAN8 20 80/60 500 CBR
7/7 C GR-RX07
5/25 HI C GR-RX07
3/3 FLAT C GR-RX07
10/20 C GR-RX07
7/7 C GR-RX07
5/65 HI C GR-RX07
6/42/85NG RX-SH08
5/10 HI C GR-RX07
5/10 C GR-RX07
6/43/92NG RX-SH08
10/20/30 C GR-RX07
DO NOT USE
FLEX 10/300/1200
3/20/40/40 RX-GR08
5/10/20 C GR-RX07
5/34/79NG RX-SH08
466 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
8LH
8LM
8M8
8MA
8N8
8NM
8PH
8PM
8Q8
8R8
8RH
8RM
8SH
8TH
8TM
8TR
8UM
8UR
8VM
8WH
8Z2
8Z3
910
911
912
913
914
915
916
917
918
919
91H
920
921
922
923
924
925
926
927
928
929
92H
930
931
932
933
934
935
Plan / Benefit Description
7/20/50% HI C GRX7
5/15 C GR-RX07
5/36/82NG RX-SH08
10/25%/40% C GRX07
5/29/60G RX-SH08
5/15/30 C GR-RX07
10/20 HI C GR-RX07
5/15/30 C GR-RX07
5/37/71G RX-SH08
5/37/71G RX-SH08
10/20/35 HI C GRX7
5/15/30 C GR-RX07
10/25/55 HI C GRX7
10/40/75 HI C GRX7
5/5 C GR-RX07
10/25/40 C GR-RX07
5/5 C GR-RX07
15/25/40 C GR-RX07
5/7.50 C GR-RX07
10/25/50 HI C GRX7
880 PLAN (COBRA 2)
880 PLAN (COBRA 3)
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
15/25/40 HI RX-GR8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/25/50 HI RX-GR8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
467 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
936
937
938
939
93H
940
941
942
943
944
945
946
947
948
949
94H
950
951
952
953
954
955
956
957
958
959
95H
960
961
962
963
964
965
966
967
968
969
970
971
972
973
974
975
976
977
978
979
980
981
982
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/20/40 HI RX-GR8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/20 HI RX-GR08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/40/75 HI C XGR8
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
468 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
983
984
985
986
987
988
989
990
991
992
993
994
9AN
9AQ
9AR
9AY
9AZ
9BE
9BH
9BL
9BZ
9CM
9CZ
9DH
9DL
9DP
9DR
9DZ
9EH
9EL
9ER
9FD
9FH
9FL
9GE
9GM
9HD
9HH
9HK
9HL
9HM
9HN
9JH
9JL
9KH
9KL
9KS
9KU
9LH
9LL
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
4/20/40 LO RX-GR08
7/20 RX-GR08
0/0 RX-GR08
4/25/50 HI RX-GR08
PPO PLAN9 25 80/60 500 CBR
7/14 RX-GR08
4/10/20 T1A H XGR8
4/10/20 T1A L XGR8
PPO PLAN9 25 80/60 500 CBR
15/25/40 RX-GR08
PPO PLAN9 25 80/60 500 CBR
4/15/30 T1B H XGR8
4/15/30 T1B L XGR8
3/20/40/40 RX-GR08
10/10 FLAT C XGR08
PPO PLAN9 25 80/60 500 CBR
4/20/40 T1C H XGR8
4/20/40 T1C L XGR8
10/20 RX-GR08
7/7 C RX-GR08
4/25/50 T1D H XGR8
4/25/50 T1D L XGR8
10/20/30 RX-GR08
5/10 RX-GR08
10/20/30 C RX-GR08
4/15/30 T2A H XGR8
4/10/20 RX-GR08
4/15/30 T2A L XGR8
FLEX 15/100A/1000
4/15/30 RX-GR08
4/28/58 T3C H XGR8
4/28/58 T3C L XGR8
4/28/55 T3B H XGR8
4/28/55 T3B L XGR8
10/20/35 RX-GR08
10/20/40 RX-GR08
4/25/45 T3A H XGR8
4/25/45 T3A L XGR8
469 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
9LM
9LP
9LV
9MA
9MH
9MI
9ML
9MR
9NH
9NL
9NM
9PH
9PL
9PX
9PY
9QH
9QL
9RH
9RL
9RP
9RX
9TH
9TL
9UH
9UL
9VH
9VL
9VM
9WH
9WI
9WL
9WM
9XH
9XL
9YH
9YL
9ZH
9ZL
A10
A38
A88
AAA
AAF
AAI
AAZ
AB4
ABA
ABN
ABZ
AC2
Plan / Benefit Description
5/15 C RX-GR08
5/15 RX-GR08
10/20/35 RX-GR08
10/25%/40% RX-GR08
4/20/40 T2B H XGR8
10/20/40 I RX-GR08
4/20/40 T2B L XGR8
10/20/40 RX-GR08
4/25/50 T2C H XGR8
4/25/50 T2C L XGR8
5/15/30 RX-GR08
4/25/50 T2C H XGR8
4/25/50 T2C L XGR8
5/29/60 P RX-GR08
ALREADY USED
4/20/40 T2B H XGR8
4/20/40 T2B L XGR8
4/15/30 T2A H XGR8
4/15/30 T2A L XGR8
5/15/30 RX-GR08
NO RX
4/28/55 T3B H XGR8
4/28/55 T3B L XGR8
4/28/58 T3C H XGR8
4/28/58 T3C L XGR8
4/25/50 T1D H XGR8
4/25/50 T1D L XGR8
5/5 RX-GR08
4/20/40 T1C H XGR8
15/25/40 I RX-GR08
4/20/40 T1C L XGR8
5/7.50 RX-GR08
4/15/30 T1B H XGR8
4/15/30 T1B L XGR8
4/10/20 T1A H XGR8
4/10/20 T1A L XGR8
4/25/45 T3A H XGR8
4/25/45 T3A L XGR8
STANDARD 10 PLAN
380 PLAN
880 PLAN
HMO 10
ADVANTAGE PLAN - FAMILY
ADVANTAGE PLAN-INDIVIDUAL
HMO 10 COBRA
MCC ESS SA PP SH07
HMO 10
MC COMP ESS SA SH07
HMO 10 COBRA
ACU/CHIRO/MESSAGE S GOLD
470 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
AC7
ACA
ACE
ACF
ACN
ACV
ACZ
AE7
AEE
AEN
AER
AFA
AFE
AFF
AFR
AFS
AFZ
AG4
AGG
AGN
AGW
AH3
AH4
AH5
AHF
AHZ
AI2
AI3
AI8
AM1
AM7
AME
AMN
AMZ
AO4
AO9
AOI
AOV
AOW
AOY
APF
APN
APR
AQ4
AQ7
AQ8
AQ9
AQE
AQN
AR1
Plan / Benefit Description
5/15 SANANT C SH06 D467
HMO 10
5/15 SANANT C SH06 EPO
BROKER/CONSULTANT FEE
5/15 SANANT C SH06
SV 15-30/250D ATT 07
HMO 10 COBRA
5/10 SANANT CE SH06 D467
5/10 SANANT CE SH06 EPO
5/10 SANANT CE SH06
EMP. RETIRE. SYS.
HMO 10
FEDERAL EMPLOYEES-AUSTIN
SV 15-30/250D ATT 07
FEDERAL RETIREES PLAN - AT
ADMINISTRATIVE SERVICE FEE
HMO 10 COBRA
ARP MCC ES SA PP SH08
SV 15-30/250D ATT 07
0 SANANT G SH06
ARP MCC ES SA SH08
ALLERGY SERUM 50%
ALLERGY SERUM 100%
ALLERGY SERUM $10 COPAY
SV 15-30/250D ATT 07 CB
AUSTIN ISD HIGH OPTION CBR
ADVANAGE PLAN-INDIVIDUAL
ADVANTAGE PLAN-INDIVIDUAL
IND. CONVERSION PLAN 880
TEXAS A&M PLAN
0 SANANT M SH06 D467
0 SANANT M SH06 EPO
0 SANANT M SH06
TEXAS A&M PLAN
ARP MCC 1 SA PP SH08
ARP MCC 1 SA PP-PL SH08
ARP MCC 1 SA EP-PL SH08
ARP MCC 1 SA PLUS SH08
ARP MCC 1 SA SH08
ARP MCC 1 SA EP SH08
10/12V 1YR ACU SH07
10/12V 1YR ACU SH08
PREFERRED PLAN
MCC 1 SA PP SH07
MCC 1 SA EP-PL SH07
MCC 1 SA PP-PL SH07
MCC 1 SA PLUS SH07
MCC 1 SA EP SH07
MC COMP 1 SA SH07
AMR 2002 $20-$40/$300
471 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
AR2
AR3
AR4
AR5
AR6
AR7
AR8
ARG
ART
ARV
AS0
AS1
AS2
AS3
AS4
AS5
AS6
AS7
ASH
AST
AT7
ATP
ATQ
ATU
ATV
AU4
AU7
AU8
AU9
AUE
AUN
AUT
AWD
AWE
AZ0
AZ1
AZ2
AZ3
AZ8
AZE
AZF
AZI
AZR
AZT
AZU
B2A
B2B
B2C
B2D
B2E
Plan / Benefit Description
AMR 2002 $20-$40/$300 CBRA
AMR 2002 $20-$40/$300
AMR 2002 $20-$40/$300 CBRA
AMR 2002 $20-$40/$300
AMR 2002 $20-$40/$300 CBRA
AMR 2002 $20-$40/$300
AMR 2002 $20-$40/$300 CBRA
SV 15-30/250D ATT 07 CB
RESERVED
SV 15-30/250D ATT 07 CB
ALLERGY SERUM- 100%
ALLERGY SERUM
ALLERGY SERUM
ALLERGY SERUM 80%
ALLERGY SERUM $20 COPAY
$5 COPAY ALLERGY SERUM SMG
$10 COPAY ALLERGY SERUM SG
ALLERGY SERUM 90%
AUSTIN ISD HIGH OPTION
STANDARD PLAN
ATW-STD SH-WL07
ATW-PLUS SH-WL07
ATW ENHANCED SH08
ATW-PLUS WL-SH08
ATW-STD WL-SH08
MCC 2 SA PP SH07
MCC 2 SA EP-PL SH07
MCC 2 SA PP-PL SH07
MCC 2 SA PLUS SH07
MCC 2 SA EP SH07
MC COMP 2 SA SH07
UNIVERSITY OF TEXAS
SV 15-30/250D ATT 07
SV 15-30/250D ATT 07 CB
STANDARD 10 PLAN COBRA
ADVANTAGE PLAN-IND.(COBRA)
ADVANTAGE PLAN-INDV (COBRA
380 PLAN COBRA
880 PLAN (COBRA)
EMP. RETIRE. SYS COBRA
ADVANTAGE PLAN-FAM.(COBRA)
ADVANTAGE PLAN-INDIVIDUAL
PREFERRED PLAN (COBRA)
STANDARD PLAN
UNIVERS. OF TEXAS (COBRA)
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
472 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
B2F
B2G
B2H
B2J
B2P
B2R
B3A
B3B
B3C
B3D
B3E
B3F
B3G
B3H
B3J
B3P
B3R
B4A
B4B
B4C
B4D
B4E
B4F
B4G
B4H
B4J
B4P
B4R
B5A
B5B
B5C
B5D
B5E
B5F
B5G
B5H
B5J
B5P
B5R
B6A
B6B
B6C
B6D
B6E
B6F
B6G
B6H
B6J
B6P
B6R
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVE PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
473 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
B7A
B7B
B7C
B7D
B7E
B7F
B7G
B7H
B7J
B7P
B7R
B8A
B8B
B8C
B8D
B8E
B8F
B8G
B8H
B8J
B8P
B8R
B9A
B9B
B9C
B9D
B9E
B9F
B9G
B9H
B9J
B9P
B9R
BA1
BA2
BA3
BA4
BAA
BAB
BAC
BAD
BB1
BB2
BB3
BB4
BB5
BBH
BC5
BC6
BCA
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
BANK AMER $10/250/100% CBR
BANK AMER $10/250/100% CBR
BANK AMER $10/250/100% CBR
BANK AMER $10/250/100% CBR
BANK OF AMER $10/$250/100%
BANK OF AMER $10/$250/100%
BANK OF AMER $10/$250/100%
BANK OF AMER $10/$250/100%
BELL (SMI/CD/IPMH)PLAN1-7
BELL (SMI/CD/IPMH)PLN348-1
BELL (SMI/CD/IPMH)PLAN1-8
BELL (SMI/CD/IPMH)PLAN1-10
CORNING (SMI/CD/IPMH)189-3
20-30/100A BH 07
SMI/CD/MH PACIFICARE
SMI/CD/MH LOCKHEED
GM SALARIED 2003 $15/100%
474 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
BCB
BCC
BCD
BCE
BCF
BCG
BCH
BCI
BCK
BCM
BE4
BEB
BED
BEH
BET
BEU
BH1
BH2
BH3
BH6
BH9
BHA
BHB
BHC
BHD
BHE
BHF
BHG
BHH
BHJ
BHK
BHL
BHM
BHN
BHP
BHQ
BHR
BHS
BHT
BHU
BHV
BHW
BHX
BHY
BKH
BN2
BN3
BN4
BN5
BN6
Plan / Benefit Description
FIREMANS FUND $20/$40/$250
GM HOURLY 2003 $0/100%
BELL HMO/POS $0/100%
REED ELSEVIER $10-$20/$250
PEPSI BOTTLING $20/$200
LOCKHEED $20/100%
CHEVRON TEXACO $20/100%
LOCKHEED $0/100%
AT&T $10-$15/$100
SW RESRCH SMI $10-$40-$100
BELL HMO $0/100% COBRA
*** OK TO USE ***
BELL HMO $0/100%
15-30/250D BH 07
SV 0/100% BELL HELICOP
SV 0/100% BELL HELICOP CB
BELL 2001 (SMI/CD/IPMH)
BOEING NA-HRLY $10 GRP RET
BOEING NA-HRLY $10 GRP RET
20/100A LOCKHEED MART MH06
35/240A MH06
NA SMI/CD/MH $10/$20/$100D
NA SMI/CD/MH $15/$30/$250D
NA SMI/CD/MH $15/$30/$400D
NA SMI/CD/MH $20/$40/$250D
NA SMI/CD/MH $20/$40/$400D
20-40/250D BH 06
RE SMI/CD/MH $20/$40/$250D
20-40/200A BH 06
NA SMI/CD/MH $5/100%
NA SMI/CD/MH $10/100%
NA SMI/CD/MH $10/$100
NA SMI/CD/MH $10/$250
NA SMI/CD/MH $15/$100
NA SMI/CD/MH $15/$250
RE SMI/CD/MH $5/100%
RE SMI/CD/MH $10/100%
RE SMI/CD/MH $15/10%
RE SMI/CD/MH $20/100%
RE SMI/CD/MH $20/$400
RE SMI/CD/MH $20/20%
RE SMI/CD/MH $25/$600
NA SMI/CD/MH $15/100%
NA SMI/CD/MH $10/$15/$250
15-20/75A BH 08
BELO $15-$30/$250
BELO $15-$30/$250 COBRA
BELO $15-$30/$250
BELO $15-$30/$250 COBRA
BELO $15-$30/$250
475 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
BN7
BN8
BN9
BND
BNP
BNS
BNU
BO1
BO2
BO3
BO4
BO5
BO6
BO7
BO8
BOP
BP1
BP2
BP3
BP4
BP5
BP6
BP7
BP8
BP9
BPA
BPB
BPC
BPD
BPE
BPF
BPG
BPH
BPJ
BPK
BPL
BPM
BPN
BPP
BPQ
BPR
BPS
BPT
BPU
BPV
BPW
BPX
BPY
BPZ
BR2
Plan / Benefit Description
BELO $15-$30/$250 COBRA
BELO $15-$30/$250
BELO $15-$30/$250 COBRA
15/100A BH07
20 BP AMOCO NON-AARP GR08
20 BP AMOCO NON-AARP GR08
20 BP AMOCO NON-AARP GR08
BOEING HRLY $10/100%
BOEING HRLY $10/100% COBRA
BOEING HRLY $10/100%
BOEING HRLY $10/100% COBRA
BOEING HRLY $10/100%
BOEING HRLY $10/100% COBRA
BOEING HRLY $10/100%
BOEING HRLY $10/100% COBRA
20/100% BP AMOCO GR06
20/100% BP AMOCO CC GR06
RESERVED RX PPO
RESERVED RX PPO
BELL POS $0/$100/70% CBRA
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
BELL POS $0/100%/70%
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
20/100% BP AMOCO GR06
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVE PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
476 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
BR3
BR4
BR5
BR6
BR7
BR8
BR9
BS1
BS2
BS3
BSA
BSB
BSC
BSD
BSE
BSF
BSG
BSH
BSI
BSJ
BSK
BSL
BSM
BTH
BU1
BU2
BU3
BU4
BU5
BU6
BU7
BU8
BU9
BUC
BUD
BUE
BUF
BUG
BUH
BUI
BUJ
BUK
BUL
BUM
BUN
BUO
BUP
BUQ
BUR
BUS
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
$10/100% HMO SMALL GRP CBR
$10/100% HMO SMALL GRP CBR
$10/100% HMO SMALL GRP CBR
$10/100% HMO SMALL GROUP
$10/100% HMO SMALL GROUP
$10/100% HMO SMALL GROUP
SG CD/MH $10/$200
SG CD/MH $15/$300
SG CD/MH $20/$400
SG CD/MH $25/$600
SG SMI/CD/MH $20-$40/$250D
SG SMI/CD/MH $10/$200
SG CD/MH $15/$300
SG CD/MH $20/$400
SG CD/MH $25/$600
SG CD/MH $20/$40/$250D
20-40/250A BH 08
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
NA SMI/CD/MH $10/$20/$100
NA SMI/CD/MH $15/$30/$250
NA SMI/CD/MH $15/$30/$400
NA SMI/CD/MH $20/$40/$250
NA SMI/CD/MH $20/$40/$400
477 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
BUT
BUU
BUV
BUW
BUX
BUY
BUZ
BVE
BVG
BVK
BVL
BVN
BVP
BVQ
BX2
BX3
BX4
BX5
BX6
BX7
BX8
BX9
BXA
BXB
BXC
BXD
BXE
BXF
BXG
BXH
BXJ
BXK
BXL
BXM
BXN
BXP
BXR
BXS
BXT
BXU
BXV
BXW
BXX
BXY
BXZ
BYA
BYB
BYC
BYD
BYE
Plan / Benefit Description
NA SMI/CD/MH $5/100%
NA SMI/CD/MH $10/100%
NA SMI/CD/MH $10/$100
NA SMI/CD/MH $10/$250
NA SMI/CD/MH $15/100%
NA SMI/CD/MH $15/$100
NA SMI/CD/MH $15/$250
15/100A BOEING VEBA GR07
25/240A BH07
15/100A BOEING VEBA GR07
15 BO-VEBA NON-AARP GR08
15 BO-VEBA NON-AARP GR08
15 BO-VEBA NON-AARP C GR08
15/100A BOEING VEBA GR07
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
478 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
BYF
BYG
BYH
BYJ
BYK
BYL
BYM
BYN
BYP
BYR
BYS
BZ3
BZ4
BZ5
BZ6
BZ7
BZ8
BZ9
BZA
BZB
BZC
BZD
BZE
BZG
BZH
BZJ
BZK
BZL
BZM
BZN
BZP
BZR
BZS
BZT
BZV
BZW
BZX
BZY
BZZ
C27
C2C
C2Z
C7A
C7E
C7F
C7G
C7H
C7J
C7K
C7L
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
SC 90 ELIGIBILITY ONLY
STANDARD $3 MFP
STANDARD $3 MFP
5/12V 1YR GR-CH07
10/12V 1YR GR-CH07
10/20V 1YR GR-CH07
10/30V 1YR GR-CH07
15/12V 1YR GR-CH07
15/20V 1YR GR-CH07
0/20V 1YR GR-CH07
15/30V 1YR GR-CH07
479 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
C7M
C7P
C7S
C7U
C7W
C7Y
CBZ
CC1
CC2
CC3
CC4
CC5
CC6
CC7
CC8
CC9
CCE
CCN
CCO
CD1
CD2
CD5
CD6
CDD
CDJ
CDW
CDZ
CEO
CEZ
CF1
CF2
CF3
CFA
CFD
CFE
CFF
CFZ
CG8
CG9
CGG
CGI
CGL
CGP
CGR
CGS
CGT
CGU
CGV
CGX
CGZ
Plan / Benefit Description
20/12V 1YR GR-CH07
5/10V 1YR GR-CH07
30/12V 1YR GR-CH07
5/20V 1YR GR-CH07
5/30V 1YR GR-CH07
5/40 1YR GR-CH07
HALLIBURTON ENERGY 99 COBR
NAT'L 1 $5 CC GR06
NAT'L 2 $10 CC GR06
NAT'L 2A $10 CC GR06
NAT'L 2B $10 CC GR06
NAT'L 2C $20 CC GR06
NAT'L 2D $20 CC GR06
5/15 CORCHR C SH06 D467
NAT'L 3A $15 CC GR06
NAT'L 3B $15 CC GR06
5/15 CORCHR C SH06 EPO
5/15 CORCHR C SH06
5/100% AARP GR08
SECURE HORIZONS
SECURE HORIZONS
SECURE HORIZONS GP RETIREE
SH RETIREE $6 OV
STANDARD PLAN
CHEM DEP IP $250 OP $20
STANDARD PLAN COBRA
KMART 1999 COBRA
15/30V CH 07
15/200/1200 THR 2000 COBRA
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
LOCKHEED PLAN M P1-99 COBR
10/20V CH 07
15/20V CH 07
CAREGIVER-SH GOLD
CAREGIVER-SH INDIV
CAREGIVER LITE SH06
CAREGIVER PROGRAM
CAREGIVER-RESPITE SH-06
CAREGIVER PROGRAM
CAREGIVER STD CG-SH08
CAREGIVER-RESPITE CG-SH08
CAREGIVER CG-GR08
CAREGIVER ENHANCED
LOCKHEED SALARIED 2000 COB
480 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
CH1
CH2
CH5
CH6
CHA
CHB
CHC
CHD
CHQ
CHU
CHW
CHZ
CIZ
CJZ
CKZ
CMZ
CN4
CP2
CP3
CP4
CP9
CPA
CQ1
CQZ
CR1
CR2
CR3
CR4
CR5
CR6
CRG
CRR
CRX
CRY
CRZ
CS1
CS2
CS6
CT1
CT2
CT3
CT4
CT5
CTZ
CU1
CU3
CU4
CUE
CUN
CV1
Plan / Benefit Description
SECURE HORIZONS - CORRIDOR
SH B-ONLY - CORRIDOR
SECURE HORIZON GP RETIREE
SH RETIREE $6 OV
CHIROCARE $0/10 VISITS TX
CHIROCARE $5/10 VISITS TX
CHIROCARE $10/10 VISITS TX
CHIROCARE $15/10 VISITS TX
FEDS 20/20V ACU/CHIRO 05
10/12V 1YR SH-CH07
10/12V 1YR SH-CH08
LOCKHEED HOURLY 2000 COBRA
IND PROD 20/20%/2000 COBRA
MILLER 1999 COBRA
TEXAS A&M 2000 COBRA
THOMSON CORP 2000 COBRA
5/30V CH 07
CHIRO $10/10 VISIT CFW
CHIRO $5/10 VISIT CFW
CHIRO $0COPAY/10 VISIT
FEDS 20/20V ACU/CHIRO 07
RESERVED PFFS
10/30V CH 07
TEXAS UTILITIES 2000 COBRA
HRS SENIOR CHIRO $10 SELF
HRS SENIOR CHIRO $5/10 OV
GRP RET CHIRO $5/12VISITS
GRP RET CHIRO $10/12VISITS
GRP RET CHIRO $15/12VISITS
GRP RET CHIRO $20/12VISITS
CUSTOM PPO
10/12V GR-CH07
RESERVED FOR RX PPO
RESERVED FOR RX PPO
IND PROD 15/20%/2000 COBRA
SECURE HORIZONS-CORRIDOR
SECURE HORIZONS ONLY
SH RETIREE $6 OV
NAT'L CHIRO $10/20 VISITS
NAT'L CHIRO $15/20 VISITS
NAT'L CHIRO $15/30 VISITS
NAT'L CHIRO $5/30 VISITS
NAT'L CHIRO $10/30 VISITS
CORNING FLEX COBRA
15/10V CH 07
10/10V CH 07
MCC CC PP SH07
MCC CC EP SH07
MC COMP CC SH07
CHEVRON TEX $20/100%
481 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
CV2
CV3
CV4
CV5
CV6
CV7
CV8
CX4
CXW
CXY
D00
D1C
D1D
D1F
D1H
D1K
D1L
D1M
D1P
D1T
D1V
D1W
D1X
D1Y
D1Z
D20
D2D
D2H
D2L
D2M
D2N
D2P
D2U
D2X
D2Y
D30
D3D
D4D
D5D
D6V
D8A
D8B
D8D
D8E
D8P
DA1
DA2
DAE
DAF
DAG
Plan / Benefit Description
CHEVRON TEX $20/100% COBRA
CHEVRON TEX $20/100%
CHEVRON TEX $20/100% COBRA
CHEVRON TEX $20/100%
CHEVRON TEX $20/100% COBRA
CHEVRON TEX $20/100%
CHEVRON TEX $20/100% COBRA
ARP MCC CC PP SH08
ARP MCC CC SH08
ARP MCC CC EP SH08
DURABLE MED EQUIP $0
STANDARD 5 CUSTOM
STANDARD 5 CUSTOM
STANDARD 5 CUSTOM
STANDARD 5 POS COBRA
STANDARD 5 CUSTOM
STANDARD 5 POS
STANDARD 5 POS
STANDARD 5 POS
STANDARD 5 CUSTOM COBRA
STANDARD 5 CUSTOM -COBRA
STANDARD 5 CUSTOM -COBRA
STANDARD 5 POS COBRA
STANDARD 5 POS COBRA
STANDARD 5 CUSTOM -COBRA
DURABLE MED EQUIP 20%
DOD FEDS $10 CUSTOM 1-00
$5 POS COBRA
$5 POS
$5 POS
$5 POS
$5 POS
$5 POS COBRA
$5 POS COBRA
$5 POS COBRA
DURABLE MED EQUIP $1000 YR
DOD FEDS $10 CUSTOM 1-00
DOD FEDS $10 CUSTOM 1-00
DOD FEDS $10 CUSTOM 1-00
DENTAL - VISION GR06
DELUXE OPTION DN-SH08
PREVENTIVE DN-SH08
$0 467 DN-SH08
$20 469 DN-SH08
EC PREVENT 250 1YR DN-SH08
SH DALLAS BASIC
SH DALLAS PRT B ONLY
10-20/200A DART GR07
10-20/200A DART GR07
10-20/200A DART CC GR07
482 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
DBA
DBB
DC7
DCB
DCE
DCN
DDB
DDD
DDW
DE7
DEC
DED
DEE
DEK
DEN
DEV
DEW
DEZ
DGN
DH1
DH2
DH5
DH6
DHK
DHL
DHM
DHN
DIR
DKK
DKV
DL4
DLD
DLE
DLN
DM6
DM7
DME
DMN
DN2
DN3
DNA
DNE
DNF
DNT
DNY
DP1
DP6
DPA
DPB
DPC
Plan / Benefit Description
100%/70% DISCOUNT GR-DN07
10-20 DART NON-AARP GR08
5/25 DALLAS C SH06 D467
10-20 DART NON-AARP GR08
5/25 DALLAS C SH06 EPO
5/25 DALLAS C SH06
10-20 DART NON-AARP C GR08
STANDARD 5 PLAN
STANDARD 5 PLAN COBRA
5/10 DALLAS CE SH06 D467
ERS-STATE OF TEXAS SAN ANT
ERS-STATE OF TEXAS DALLAS
5/10 DALLAS CE SH06 EPO
ERS-STATE OF TEXAS (HSTN)
5/10 DALLAS CE SH06
ERS-STATE OF TEXAS COBRA
ERS-STATE OF TEXAS COBRA
ERS-STATE OF TEXAS COBRA
0 DALLAS G SH06
SECURE HORIZONS - DALLAS
SH-DALLAS-B ONLY
SECURE HORIZON GP RETIREE
SH RETIREE $6 OV
FEDS DOD EMPLOYEES 2001
FEDS DOD EMPLOYEES 2001
FEDS DOD EMPLOYEES 2001
FEDS DOD EMPLOYEES 2001
DUMMY-USED FOR VRU CODING
STANDARD 10-KROGER
STANDARD 10 KROGER-COBRA
MCC 1 DFW PP SH07
MCC 1 DFW DELUXE SH07
MCC 1 DFW EP SH07
MC COMP 1 DFW SH07
$0 467 SH-DN06
5/10 DALLAS M SH06 D467
5/10 DALLAS M SH06 EPO
5/10 DALLAS M SH06
RESERVED PPO GRP RET DEN
RESERVED PPO GRP RET DEN
PREVENTIVE SH-DN07
EVERCARE $5 SH-DN07
EVERCARE $0 SH-DN07
PREVENTIVE DENTAL PLAN
DELUXE OPTION SH-DN07
DEPENDENT LIFE BENE
$5 PREVENTIVE SH-DN06
SAME SEX DOMESTIC PARTNER
OPPOSITE DOMESTIC PARTNER
DOMESTIC PARTNER SAME/OPPO
483 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
DQ6
DR1
DR2
DR3
DR4
DR5
DR6
DRD
DRR
DRW
DS1
DS2
DSR
DT2
DTC
DTD
DTO
DTP
DTR
DTW
DTX
DU4
DUD
DUE
DUN
DV4
DVW
DVX
DVY
DX4
DXD
DXE
DXN
DY4
DYW
DYX
DYY
EC0
EC1
EC2
EC3
EC7
ECF
ECG
ECI
ECK
ENC
ENZ
ER2
ER3
Plan / Benefit Description
$20 469 SH-DN06
DRUG REHABILITATION
DRUG REHABILITATION (50%)
DRUG REHABILITATION - UT
DRUG REHABILITATION - ERS
SH GRP RET $5/100% 2001
SH GRP RET $6/100% 2001
EMP RETIREE SYSTEM PLAN
10-20/200A DERP GR07
EMP RETIREE SYS PLAN COBRA
DALLAS AREA-SH INDIVIDUAL
DALLAS-SH INDIV.PRT B ONLY
10-20/200A DERP GR07
TX SH OPT DENTAL
DENTAL - FHP
TEXAS A&M PLAN
DENTAL ONLY (INDEMNITY)
PREVENTIVE DENTAL
10-20/200A DERP GR07
TEXAS A&M PLAN (COBRA)
DENTAL ONLY (INDEMNITY)
MCC 2 DFW PP SH07
MCC 2 DFW DELUXE SH07
MCC 2 DFW EP SH07
MC COMP 2 DFW SH07
ARP MCC 1 DFW PP SH08
ARP MCC 1 DFW SH08
ARP MCC 1 DFW DLX SH08
ARP MCC 1 DFW EP SH08
MCC ESS DFW PP SH07
MCC ESS DFW DELUXE SH07
MCC ESS DFW EP SH07
MC COMP ESS DFW SH07
ARP MCC ES DFW PP SH08
ARP MCC ES DFW SH08
ARP MCC ES DFW DLX SH08
ARP MCC ES DFW EP SH08
EVERCARE DH DAL SH07
EVERCARE DH CC SH07
STAND 10 - NO REFRACTION
STAND 10 - NO REFRACTION
EVERCARE IH DAL SH07
EVERCARE DH SA SH07
EVERCARE IH SA SH07
EARLY CHILDHOOD INTERVENTN
EVERCARE BH SA SH07
SONY STANDARD PLAN
SONY STANDARD PLAN (COBRA)
EMP. RET. SYS. PLAN STATE
EMP RET SYS PLAN
484 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
ERS
ESA
ESB
ESC
ESD
ESE
ESZ
ETD
ETE
ETF
ETG
ETJ
ETK
ETM
ETP
EUO
EVO
EWO
EXO
EYO
EZ2
EZ3
EZO
EZS
F01
F02
F03
F04
F05
F06
F07
F08
F09
F10
F11
F12
F13
F14
F15
F16
F17
F18
F19
F1A
F1B
F1C
F1H
F1K
F1L
F1M
Plan / Benefit Description
EMP. RETIRE. SYS. PLAN
$10F/$25NF
$12F/$27NF
$15F/$30NF
$6F/$21NF
$5F/$10NF
EMP RET SYS PLAN (COBRA)
EVERCARE DFW DH SH08
EVERCARE SA DH SH08
EVERCARE SA IH SH08
EVERCARE CC DH SH08
EVERCARE DFW IH SH08
EVERCARE DFW MH SH08
EVERCARE SA MH SH08
EVERCARE CC MH SH08
EVERCARE DFW DH-D SH08
EVERCARE SA DH-D SH08
EVERCARE CC DH-D SH08
EVERCARE DFW MH-D SH08
EVERCARE CC MH-D SH08
STAND 1- NO REFRAC.(COBRA)
STND 10-NO REFRAC. (COBRA)
EVERCARE SA MH-D SH08
EMP. RETIRE. SYS. COBRA
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
STANDARD $10 POS PLAN
STANDARD $10 POS PLAN CBRA
CUSTOM STANDARD 10 PLAN
STANDARD 10 POS COBRA
FEHB
STANDARD 10 POS
STANDARD 10 POS
485 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
F1P
F1X
F1Y
F1Z
F20
F21
F22
F23
F24
F25
F26
F27
F28
F29
F2H
F2K
F2L
F2M
F2N
F2P
F2U
F2V
F2X
F30
F31
F32
F33
F34
F35
F36
F37
F38
F39
F3A
F3B
F3Y
F40
F41
F42
F43
F44
F45
F46
F47
F48
F49
F4A
F4B
F50
F51
Plan / Benefit Description
STANDARD 10 POS
STANDARD 10 POS COBRA
STANDARD 10 POS COBRA
CUSTOM STANDARD 10 - COBRA
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
$10 POS COBRA
STANDARD 10 MFP
$10 POS
$10 POS
$10 POS
$10 POS
$10 POS COBRA
STANDARD 10 MFP COBRA
$10 POS COBRA
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
PIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
STANDARD $10 POS PLAN SMAL
STANDARD $10 POS SMALL CBR
$10 POS COBRA
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
STANDARD $10 POS PLAN SMAL
STANDARD $10 POS SMALL CBR
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
486 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
F52
F53
F54
F55
F56
F57
F58
F59
F5C
F5D
F5R
F60
F6C
F6D
F7A
F7B
F7C
F7D
F8C
F8D
FA2
FA3
FA4
FA5
FA6
FA7
FA8
FA9
FB6
FBB
FBD
FBE
FBF
FBH
FBJ
FC8
FC9
FCA
FCB
FCE
FCF
FCI
FCJ
FCL
FCM
FCN
FDA
FDB
FDC
FDD
Plan / Benefit Description
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
IMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
POS 10/90/70
POS 10/90/70 COBRA
RESERVED LG HMO $15/90%
LIMITED FEE SCHEDULE PPO
POS 10/90/70
POS 10/90/70 COBRA
STANDARD $10 POS PLAN
STANDARD $10 POS PLAN COB
POS 10/90/70
POS 10/90/70 COBRA
POS 10/90/70
POS 10/90/70 COBRA
AT&T NATL $10-$15/$100
AT&T NATL $10-$15/$100 CBR
AT&T NATL $10-$15/$100
AT&T NATL $10-$15/$100 CBR
AT&T NATL $10-$15/$100
AT&T NATL $10-$15/$100 CBR
AT&T NATL $10-$15/$100
AT&T NATL $10-$15/$100 CBR
SV 20-40/250D FEDS 06
FITNESS BENEFIT SH06
SV 25/240A FIDELITY 07
SV 25/240A FIDELITY 07
SV 25/240A FIDELITY 07
FEDS 2003 I/P BH/MH 100%
FEDS 2004 I/P MH/CD
RESERVED FOR RX PPO
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
SV 20-40/400D FEDS
SV 20-40/400D FEDS
ERS STATE OF TEXAS
STANDARD 10 PLAN
487 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
FDE
FDF
FDG
FDH
FDI
FDJ
FDK
FDL
FDM
FDN
FDO
FDP
FDR
FDS
FDT
FDU
FDV
FDW
FDX
FDZ
FE1
FE2
FE3
FE4
FEC
FED
FEK
FEV
FEW
FEZ
FF1
FF2
FF3
FF4
FF5
FF6
FF7
FF8
FFC
FFD
FFE
FFF
FFH
FFK
FFL
FFM
FG1
FG3
FG4
FGE
Plan / Benefit Description
ERS STATE OF TEXAS
ERS STATE OF TEXAS
ERS - STATE OF TEXAS
ERS - STATE OF TEXAS
ERS - STATE OF TEXAS
ERS - STATE OF TEXAS
ERS STATE OF TEXAS
ERS STATE OF TEXAS COBRA
ERS-STATE OF TX.
ERS-STATE OF TX COBRA
ERS-STATE OF TX
ERS-STATE OF TX COBRA
ERS - STATE OF TEXAS COBRA
ERS - STATE OF TEXAS COBRA
ERS - STATE OF TEXAS COBRA
ERS - STATE OF TEXAS COBRA
ERS STATE OF TEXAS COBRA
STANDARD 10 PLAN COBRA
ERS STATE OF TEXAS COBRA
ERS STATE OF TEXAS COBRA
FEDERAL EMPLOYEES PLAN
FEDERAL EMPLOYEES PLAN
FEDERAL EMPLOYEES 1991
FEDERAL EMPLOYEE PLAN 1992
ERS-STATE OF TEXAS
ERS-STATE OF TEXAS
ERS-STATE OF TEXAS
ERS-STATE OF TEXAS COBRA
ERS-STATE OF TEXAS
ERS-STATE OF TEXAS COBRA
TX FF $20-$40/$250
TX FF $20-$40/$250 COBRA
TX FF $20$40/$250
TX FF $20-$40/$250 COBRA
TX FF $20-$40/$250
TX FF $20-$40/$250 COBRA
TX FF $20-$40/$250
TX FF $20-$40/$250 COBRA
FEDERAL EMPLOYEE PLAN
FEDERAL EMPLOYEE PLAN
SV 25/240A FIDELITY 07
ADMINISTRATIVE RETENTION
FEDERAL EMPLOYEE PLAN
FEHB PLAN EFF 1-99
FEHB PLAN EFF 1-99
FEHB PLAN EFF 1-99
GM RETIREE $10/100%
GM RETIREE $10/100%
GM RETIREE $10/100%
SV 25/240A FIDELITY 07 CB
488 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
FGK
FGL
FGM
FGN
FH1
FH2
FH3
FH6
FHE
FHK
FHL
FHM
FHN
FHP
FHQ
FHR
FHS
FHU
FHV
FHW
FHZ
FID
FJF
FL1
FL2
FL3
FL4
FL5
FL6
FL7
FL8
FLA
FLB
FLC
FLD
FLE
FLF
FLG
FLH
FMH
FN1
FN2
FN3
FN4
FN5
FN6
FN7
FN8
FNA
FNB
Plan / Benefit Description
FEDS $10 CUSTOM EFF 1-00
CEDS $10 CUSTOM EFF 1-00
FEDS $10 CUSTOM EFF 1-00
FEDS $10 CUSTOM EFF 1-00
HMO IVF RIDER IN-VITRO
ART SUPP RIDER $150 COPAY
ART SUPP RIDER $100 COPAY
SV 20-40/250D FEDS 06
SV 25/240A FIDELITY 07 CB
FEDS 2001
FEDS 2001
FEDS 2001
FEDS 2001
FEDS 2003
FEDS 2003
FEDS 2003
FEDS 2003
FEDS 2004
FEDS 2004
FEDS 2004
FEDS 2004
FEDS DENTAL INDEMNITY 2001
SV 25/240A FIDELITY 07 CB
TX LG HMO $15/90% COBRA
TX LG HMO $15/90% COBRA
TX LG HMO $15/90% COBRA
TX LG HMO $15/90% COBRA
TX LG HMO $25/$600 COBRA
TX LG HMO $25/$600 COBRA
TX LG HMO $25/$600 COBRA
TX LG HMO $25/$600 COBRA
TX LG HMO $15/90%
TX LG HMO $15/90%
TX LG HMO $15/90%
TX LG HMO $15/90%
TX LG HMO $25/$600
TX LG HMO $25/$600
TX LG HMO $25/$600
TX LG HMO $25/$600
I/P MH 100% FEDS
FNF $10 - $15 /$250
FNF $10 - $15 /$250 COBRA
FNF $10 - $15 / $250
FNF $10 - $15 / $250 COBRA
FNF $10 - $15 / $250
FNF $10 - $15 / $250 COBRA
FNF $10 - $15 / $250
FNF $10 - $15 / $250 COBRA
SV 10-15/250A FIDELITY
SV 10-15/250A FIDELITY CB
489 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
FND
FNE
FNF
FNG
FNH
FNI
FR1
FR9
FRA
FRC
FRS
FS1
FS2
FS3
FS4
FS5
FS6
FS7
FS8
FSA
FSB
FSC
FSD
FSE
FSF
FSG
FSH
FSL
FTB
FTL
FVB
FWR
FXD
FZ1
FZ2
FZ3
G00
GBB
GBZ
GH1
GH2
GH5
GH6
GM0
GM1
GM2
GM4
GM5
GM6
GM7
Plan / Benefit Description
SV 10-15/250A FIDELITY
SV 10-15/250A FIDELITY CB
SV 10-15/250A FIDELITY
SV 10-15/250A FIDELITY CB
SV 10-15/250A FIDELITY
SV 10-15/250A FIDELITY CB
FEDERAL RETIREES PLAN
RESERVED LG HMO $15/90% CB
RISK CHARGE - AGGREGATE
RESERVED LG HMO $15/90%
RISK CHARGE - SPECIFIC
TX SG HMO $15/$300 COBRA
TX SG HMO $15/$300 COBRA
TX SG HMO $15/$300 COBRA
TX SG HMO $15/$300 COBRA
TX SG HMO $25/$600 COBRA
TX SG HMO $25/$600 COBRA
TX SG HMO $25/$600 COBRA
TX SG HMO $25/$600 COBRA
TX SG HMO $15/$300
TX SG HMO $15/$300
TX SG HMO $15/$300
TX SG HMO $15/$300
TX SG HMO $25/$600
TX SG HMO $25/$600
TX SG HMO $25/$600
TX SG HMO $25/$600
SILVER SNEAKER SH/GR-WL07
SV 20-40/250D FEDS 08
SILVER SNEAKER SH/GR-WL08
SV 20-40/250D FEDS 08
CITY FT WORTH RETIREES
SV 25/240A FIDELITY 07 CB
ADVANTAGE PLAN-FAM.(COBRA)
ADVANT. PLAN FAM (COBRA 2)
ADVANT. PLAN-FAM (COBRA 3)
I/P MENTAL 100%
BELLBASIC 2002 $20/$350
BELLBASIC 2002 $20/$350 CB
SH STANDARD - GALVESTON
SH B ONLY - GALVESTON
SECURE HORIZON GP RETIREE
SH RETIREE $6 OV
GM SAL 2003 $15/100% COBRA
GM SAL 2003 $15/100%
GM SAL 2003 $15/100% COBRA
GM HOURLY - $0/100% COBRA
GM SAL 2003 $15/100%
GM SAL 2003 $15/100% COBRA
GM SAL 2003 $15/100%
490 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
GM8
GM9
GMA
GMB
GMD
GMS
GMZ
GR1
GR3
GR4
GS4
GSD
H01
H02
H03
H04
H05
H06
H07
H08
H09
H0C
H0Z
H10
H11
H12
H13
H14
H15
H16
H17
H18
H19
H1V
H1Z
H20
H21
H22
H23
H24
H25
H26
H27
H28
H29
H2C
H2X
H2Z
H30
H31
Plan / Benefit Description
GM SAL 2003 $15/100% COBRA
GM SAL 2003 $15/100%
GM RETIREE SALARIED 2003
GM RETIREE SALARIED 2003
GM HOURLY - $0/100%
GM SAL 2002 $10/100%
GM SAL 2002 $10/100% COBRA
GM RET.#601602 $5/100%
GM RET.#601602 $5/100%
GM RET.#601602 $5/100%
GM SALARIED- $5/100% COBRA
GM SALARIED - $5/100%
HRS IND.RX 5G/20BR UNLM/NF
VISION CARE BENEFIT PPO
FAMILY PLANING BENEFIT PPO
24/HOUR HEALTH INFO PPO
RESERVED FOR PPO PRODUCT
MENTAL NON-SMI PPO 90/70
RESERVED FOR PPO PRODUCT
RESERVED FOR PPO PRODUCT
MENTAL NON-SMI PPO 80/60
10/200/1000 AMERICAN A COB
SFLEX 9601 99 COBRA
STANDARD 10 PLAN
$5G/10B
HRS RET.5G/10BR UNLM/NOFRM
HRS RET 5G/20BR 1000 BR LM
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
SFLEX 10/200/1000 COBRA
STANDARD PLAN COBRA
PLAN 20
$10G/10B
RESERVED FOR PPO
$10G/20B
$5G/20B
RESERVED FOR PPO
RESERVED FOR PPO
$5G/10B
$7G/15B
RESERVED FOR PPO
ALCON 2000 COBRA
SFLEX 10/300/1200 COBRA
PLAN 20
COBRA
10G/20B/35N
RESERVED FOR PPO
491 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
H32
H33
H34
H35
H36
H37
H38
H39
H3C
H3X
H3Z
H40
H41
H42
H43
H44
H45
H46
H47
H48
H49
H4C
H4Z
H50
H51
H52
H53
H54
H55
H56
H57
H58
H59
H5C
H5Z
H60
H61
H62
H63
H64
H65
H66
H67
H68
H69
H6C
H6P
H6Z
H70
H71
Plan / Benefit Description
5G/20B/35N
7G/15B/25N
HRS RET.5G/10BR UNLM/FORM
RESERVED FOR PPO
$10G/20B
$5G/20B
380 PLAN
$5G/10B
BELL PLAN AAA 2000 COBRA
SFLEX 15/100/1000 COBRA
380 PLAN
COBRA
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
$10G/15B
RESERVED FOR PPO
$5G/5B
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
BELL NB BASIC 2000 COBRA
SFLEX 15/200/1000 COBRA
$3G/3B
RESERVED FOR PPO
$2G/2B
$5G/5B
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
CFW PLAN M 2000 COBRA
SFLEX 15/300/1200 COBRA
RESERVED FOR PPO
$5G/5B
RESERVED FOR PPO
$10G/15B
RESERVED FOR PPO
RESERVED FOR PPO
20% COPAY
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
CFW HIGH OPTION 2000 COBRA
15-25/100A GR06
SFLEX 15/400/1500 COBRA
RESERVED FOR PPO
RESERVED FOR PPO
492 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
H72
H73
H74
H75
H76
H77
H78
H79
H7C
H7Z
H80
H81
H82
H83
H84
H85
H86
H87
H88
H89
H8A
H8B
H8C
H8D
H8E
H8F
H8G
H8J
H8K
H8P
H8R
H8T
H8V
H8X
H8Z
H90
H91
H92
H93
H94
H95
H96
H97
H98
H99
H9C
H9Z
HA1
HA2
HA3
Plan / Benefit Description
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
10G/15B/30N
RESERVED FOR PPO
CFW LOW OPTION 2000 COBRA
SFLEX 20/300/1200 COBRA
$20G/$40B
RESERVED FOR PPO
RESERVED FOR PPO
$5G/20B
RESERVED FOR PPO
$5G/10B/25N
RESERVED FOR PPO
$10G/$20B/$35N POS
880 PLAN
$5G/$10B/$20N POS
0/500A 3YRS PL HA-SH08
0/1300A 3YRS DX HA-SH08
GM HOURLY 2000 COBRA
0/800A 3YRS DX HA-SH08
25/400A 3YRS HA-SH08
25/900A 3YRS PL HA-SH08
0/800A 3YRS HA-SH08
5/400A 3YRS HA-SH08
0/600A 2YRS HA-SH08
15-25/100A AARP GR08
3/20/40/40 RX-GR08
15-25/100A AARP GR08
15-25/100A AARP C GR08
SFLEX 20/400/1500 COBRA
880 PLAN
COBRA
$7G/$15B/$25N POS
$10G/$20B
$5G/$20B/$35N POS
$10G/$20B/$35N POS
$7G/$15B/$25N POS
$3G/$3B POS
RESERVED FOR PPO
RESERVED
RESERVED FOR PPO
RESERVED FOR PPO
GM SALARIED 99 COBRA
SFLEX 25/600/2000 98 COBRA
TEXAS A&M PLAN
HEARING AID - $1000 MAX
HEARING AID-UNLIMITED MAX
493 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
HA4
HA5
HAB
HAD
HAJ
HAN
HAO
HAR
HAS
HAX
HAZ
HB1
HB2
HB3
HB4
HB5
HB6
HB7
HB8
HB9
HBA
HBB
HBC
HBD
HBE
HBF
HBG
HBH
HBI
HBJ
HBK
HBL
HBM
HBN
HBO
HBP
HBQ
HBR
HBS
HBT
HBU
HBV
HBW
HBX
HBY
HBZ
HC0
HC1
HC2
HC3
Plan / Benefit Description
HEARING AID - $1,120 MAX
HEARING AID BENEFIT $5.00
HARRIS INDIV. PART B ONLY
HEARING AID DISCOUNT
HEARING AID $500 EVERY 3YR
300A/24M GR-HA07
HEARING AID BENEFIT
23RRIS SH INDIVIDUAL PLAN
SECURE GOLD SCREEN + AID
SFLEX 25/600/2000 99 COBRA
TEXAS A&M PLAN
DOMESTIC PARTNERSHIP PPO
MENTAL NON-SMI PPO 80
MENTAL NON-SMI 80/50 PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
FLEX PREF 99 COBRA
10/200/1000 AMERICAN AIR
ALCON 2000
BELL PLAN AAA 2000
BELL NB HARRIS BASIC 2000
494 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
HC4
HC5
HC6
HC7
HC8
HC9
HCA
HCB
HCC
HCD
HCE
HCF
HCG
HCH
HCI
HCJ
HCK
HCL
HCM
HCN
HCO
HCP
HCQ
HCR
HCS
HCT
HCZ
HD1
HD6
HDD
HDE
HDW
HDZ
HE1
HE2
HEZ
HF4
HF6
HFZ
HGZ
HH0
HH1
HH2
HH3
HH4
HH5
HH6
HH7
HH8
HH9
Plan / Benefit Description
CFW PLAN M 2000
CFW HIGH OPTION 2000
CFW LOW OPTION 2000
GM HOURLY 2000
GM SALARIED 99
HALLIBURTON ENERGY 99
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
KMART 1999
15/200/1200 THR CSTM 2000
LOCKHEED PLAN M P1-99
INDIV PRODUCT 20/20%/2000
LOCKHEED SALARIED 2000
LOCKHEED HOURLY 2000
MILLER 1999
TEXAS A&M 2000
THOMSON CORP 2000
RESERVED FOR PPO
INDIV PRODUCT 15/20%/2000
TEXAS UTILITIES 2000
CORNING FLEX 10/300/1200
RESERVED FOR PPO
RESERVED FOR PPO
FLEX P10 99 COBRA
HARRIS DENTAL $7 CO-PAY
5/400A 3 YRS SH-HA06
380 PLAN
300A 2YRS HA-GR08
380 PLAN COBRA
FLEX 1-10 99 COBRA
HARRIS HEARING AID UNLIM
HARRIS HEARNG AID $500 LIM
FLEX PLAN 1 99 COBRA
FEDERAL EMPLOYEE PLAN 1994
25/400A 3 YRS SH-HA06
FLEX 10/0/800 COBRA
FLEX 10/100/1000 COBRA
HEARING AID 1 EA MAX 500EA
SH STANDARD - HOUSTON
SH B-ONLY HOUSTON
HEARING AID 500 EA EAR
HEARING AID 1EA EAR NO MAX
SECURE HORIZON GP RETIREE
SH RETIREE $6 OV
HEARING AID 500 PER EAR
HEARING AID 500 EACH EAR
HEARING AID 1,000 EA EAR
495 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
HHB
HHC
HHE
HHZ
HIZ
HJZ
HKZ
HL8
HLZ
HM1
HM2
HM4
HM6
HMC
HMD
HME
HMF
HMG
HMJ
HMK
HML
HMP
HMZ
HN1
HN2
HNZ
HOA
HOE
HOI
HP1
HP2
HP3
HP4
HP5
HP6
HP7
HP8
HP9
HPE
HPZ
HQZ
HR1
HR2
HR3
HR5
HR6
HR7
HR8
HRB
HRD
Plan / Benefit Description
RESERVED FOR PPO
HEARING AID - $900 PER EAR
500A 3YRS HA-GR08
FLEX 10/200/1000 COBRA
FLEX 10/250/1000 COBRA
FLEX 10/300/1200 COBRA
FLEX 15/100A/1000 COBRA
400A 3YRS 0PREM HA-GR08
FLEX 15/100/1000 COBRA
$5G/10B
5G/10B/20N
$5G/5B
HRS RET.5G/5BR UNLIM NOFRM
FLEX 15/100/1000
FLEX 15/200/1000
FLEX 15/300/1200
FLEX 15/400/1500
FLEX 20/200/1000
FLEX 20/300/1200
FLEX 20/400/1500
FLEX 25/600/2000 IND CONV
FLEX 25/600/2000
FLEX 15/200/1000 COBRA
HOUSTON AREA-SH INDIVIDUAL
HOUSTON-SH INDV.PRT B ONLY
FLEX 15/300/1200 COBRA
RESERVED HEARING PFFS
RESERVED HEARING PFFS
RESERVED HEARING PFFS
5G/20B $1000B MAX
HRS RX RET.5G/10BR UNLM/NF
HRS RX RET.5G/20BR UNLM/FM
HRS RX RET.5G/20BR UNLM/NF
HRS RX RET.5G/10BR UNLM/FM
HRS RX RET.5G/10BR UNLM/FM
HRS RX RET.5G/10BR UNLM/NF
HRS RX RET.5G/5BR UNLM/NF
HRS RX RET.5G/20BR $1000MX
RESERVED PFFS
FLEX 15/400/1500 COBRA
FLEX 20/200/1000 COBRA
DALLAS-SH INDIVIDUAL
DALLAS-SH INDV.PRT B ONLY
EMP. RET. SYS. - HOUSTON
SH GRP RET $5/100% 2001
SH GRP RET $6/100% 2001
HRING AID $500 ALLOWANCE
HRING AID $300 ALLOWANCE
0/500A 3YRS SH-HA07
0/800A 3YRS DX SH-HA07
496 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
HRE
HRF
HRG
HRJ
HRK
HRL
HRP
HRR
HRY
HRZ
HS0
HS1
HS2
HS3
HS4
HS5
HS6
HS7
HS8
HS9
HSA
HSB
HSC
HSD
HSE
HSF
HSG
HSJ
HSL
HSM
HSN
HST
HSZ
HTC
HTZ
HUZ
HVZ
HWZ
HX6
HZ5
I01
I02
I03
I04
I05
I06
I07
I08
I09
I0A
Plan / Benefit Description
5/400A 3YRS SH-HA07
25/400A 3YRS SH-HA07
SH INDIV. HEARING
0/800A 3YRS SH-HA07
0/600A 2YRS SH-HA07
25/900A 3YRS PL SH-HA07
0/500A 3YRS PL SH-HA07
300A GR-HA07
0/1300A 3YRS DX SH-HA07
FLEX 20/300/1200 COBRA
SFLEX 9601 99
STANDARD PLAN
SFLEX 10/200/1000
SFLEX 10/300/1200
SFLEX 15/100/1000
STANDARD 5 PLAN
SFLEX 15/200/1000
SFLEX 15/300/1200
SFLEX 15/400/1500
SFLEX 20/300/1200
HARRS RET $7OV/$50ER/$25UR
HARRIS RET.5 OV/50 ER/25UR
HARRIS RET.$5OV/$25ER/$5UR
SFLEX 20/400/1500
HARRIS RETIREE IBM
SFLEX 25/600/2000 98
SFLEX 25/600/2000 99
HARRIS RET. JC PENNEY
HARRIS RET $5OV/$25ER/$5UR
HARRIS RET.MITCHELL ENERGY
HARRIS RET.SBC
HARRIS RET $0 OV/$0ER & UR
EMP. RET. SYS. COBRA
500A 2YRS HA-GR08
STANDARD 10 PLAN COBRA
FLEX 20/400/1500 COBRA
FLEX 25/600/2000 IND CV CB
FLEX 25/600/2000 COBRA
15-25/100A CORP CHRIS GR06
STANDARD 5 PLAN
INDEMNITY PLAN
INDEMNITY PLAN
INDEMNITY PLAN
INDEMNITY PLAN
INDEMNITY PLAN
HOSPITAL INDEMNITY PLAN
HOSPITAL INDEMNITY PLAN
HOSPITAL INDEMNITY PLAN
SMALL GROUP PPO
SMALL GROUP PPO
497 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
I0B
I0C
I0D
I0E
I0F
I0G
I0H
I0I
I0J
I0K
I0L
I0M
I0N
I0P
I0Q
I0R
I0S
I0T
I0U
I0V
I0W
I0Z
I11
I12
I13
I14
I16
I17
I18
I19
I1A
I1B
I1C
I1D
I1J
I1K
I1L
I1M
I1P
I1Z
I21
I22
I23
I24
I26
I27
I28
I29
I2A
I2B
Plan / Benefit Description
SMALL GROUP PPO
PREV. PRIM. CARE-INDEMNITY
PREV. PRIM. CARE-INDEMNITY
PREV. PRIM. CARE-INDEMNITY
BASIC COVERAGE/INDEMNITY
BASIC COVERAGE/INDEMNITY
BASIC COVERAGE/INDEMNITY
STD HEALTH BENEFIT/IND
STD. HEALTH BENEFIT/IND
STD. HEALTH BENEFIT/IND.
CATASTROPHIC/INDEMNITY
CATASTROPHIC/INDEMNITY
CATASTROPHIC/INDEMNITY
80/60 SMALL GRP PPO 1-99
80/60 PPO SMALL GRP 1-99
80/60 PPO SMALL GRP 1-99
DUMMY
80/60 SM GRP PPO-PHCS NTWK
80/60 SM GRP PPO-PHCS NTWK
80/60 SM GRP PPO-PHCS NTWK
80/60 SM GRP PPO-PHCS NTWK
IDY 500/80-20% 4000/8000CB
LARGE GRP PPO PLAN 1 CBRA
LARGE GRP PPO PLAN 1 CBRA
LARGE GRP PPO PLAN 1 CBRA
LARGE GROUP PPO PLAN 1 COB
PPO PLAN1 LG/CBR-PHCS NTWK
PPO PLAN1 LG/CBRA-PHCS NET
PPO PLAN1 LG/CBRA-PHCS NET
PPO PLAN1 LG/CBRA-PHCS NTW
LARGE GROUP PPO PLAN 1
LARGE GROUP PPO PLAN 1
LARGE GROUP PPO PLAN 1
LARGE GROUP PPO PLAN 1
PPO PLAN 1 LG-PHCS NETWORK
PPO PLAN 1 LG-PHCS NETWORK
PPO PLAN 1 LG-PHCS NETWORK
PPO PLAN 1 LG-PHCS NETWORK
NATIONAL PPO (SAN ANTONIO)
NATIONAL PPO/COBRA SAN ANT
LARGE GRP PPO PLAN 2 CBRA
LARGE GRP PPO PLAN 2 CBRA
LARGE GRP PPO PLAN 2 CBRA
LARGE GROUP PPO PLAN 2 COB
PPO PLAN2 LG/CBRA-PHCS NET
PPO PLAN2 LG/CBRA-PHCS NET
PI2MPLAN2 LG/CBRA-PHCS NET
PPO PLAN2 LG/CBRA-PHCS NET
LARGE GROUP PPO PLAN 2
LARGE GROUP PPO PLAN 2
498 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
I2C
I2D
I2J
I2K
I2L
I2M
I31
I32
I33
I34
I36
I37
I38
I39
I3A
I3B
I3C
I3D
I3H
I3J
I3K
I3L
I3M
I3P
I3Z
I41
I42
I43
I44
I46
I47
I48
I49
I4A
I4B
I4C
I4D
I4H
I4J
I4K
I4L
I4M
I4P
I4Z
I50
I51
I52
I53
I54
I56
Plan / Benefit Description
LARGE GROUP PPO PLAN 2
LARGE GROUP PPO PLAN 2
PPO PLAN 2 LG-PHCS NETWORK
PPO PLAN 2 LG-PHCS NETWORK
PPO PLAN 2 LG-PHCS NETWORK
PPO PLAN 2 LG-PHCS NETWORK
LARGE GRP PPO PLAN 3 CBRA
LARGE GRP PPO PLAN 3 CBRA
LARGE GRP PPO PLAN 3 CBRA
LARGE GROUP PPO PLAN 3 COB
PPO PLAN3 LG/CBRA-PHCS NET
PPO PLAN3 LG/CBRA-PHCS NET
PPO PLAN3 LG/CBRA-PHCS NET
PPO PLAN3 LG/CBRA-PHCS NET
LARGE GROUP PPO PLAN 3
LARGE GROUP PPO PLAN 3
LARGE GROUP PPO PLAN 3
LARGE GROUP PPO PLAN 3
UNIDEN IDY COBRA
PPO PLAN 3 LG-PHCS NETWORK
PPO PLAN 3 LG-PHCS NETWORK
PPO PLAN 3 LG-PHCS NETWORK
PPO PLAN 3 LG-PHCS NETWORK
NATIONAL PPO (HOUSTON)
NATIONAL PPO/COBRA HOUSTON
LARGE GRP PPO PLAN 4 CBRA
LARGE GRP PPO PLAN 4 CBRA
LARGE GRP PPO PLAN 4 CBRA
LARGE GROUP PPO PLAN 4 COB
PPO PLAN4 LG/CBRA-PHCS NET
PPO PLAN4 LG/CBRA-PHCS NET
PPO PLAN4 LG/CBRA-PHCS NET
PPO PLAN4 LG/CBRA-PHCS NET
LARGE GROUP PPO PLAN 4
LARGE GROUP PPO PLAN 4
LARGE GROUP PPO PLAN 4
LARGE GROUP PPO PLAN 4
GREENVILLE ALTER COBRA
PPO PLAN 4 LG-PHCS NETWORK
PPO PLAN 4 LG-PHCS NETWORK
PPO PLAN 4 LG-PHCS NETWORK
PPO PLAN 4 LG-PHCS NETWORK
NATIONAL PPO DALLAS
NATIONAL PPO/COBRA DALLAS
INDEMNTIY SAN ANTONIO
LARGE GRP PPO PLAN 5 CBRA
LARGE GRP PPO PLAN 5 CBRA
LARGE GRP PPO PLAN 5
LARGE GROUP PPO PLAN 5 COB
PPO PLAN5 LG/CBRA-PHCS NET
499 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
I57
I58
I59
I5A
I5B
I5C
I5D
I5H
I5J
I5K
I5L
I5M
I5P
I5X
I5Z
I60
I61
I62
I63
I64
I6A
I6B
I6C
I6D
I6H
I6P
I6X
I6Z
I70
I71
I72
I73
I74
I7A
I7B
I7C
I7D
I7H
I7P
I7X
I7Z
I81
I82
I83
I8C
I8D
I8P
I8X
IA0
IA1
Plan / Benefit Description
PPO PLAN5 LG/CBRA-PHCS NET
PPO PLAN5 LG/CBRA-PHCS NET
PPO PLAN5 LG/CBRA-PHCS NET
LARGE GROUP PPO PLAN 5
LARGE GROUP PPO PLAN 5
LARGE GROUP PPO PLAN 5
LARGE GROUP PPO PLAN 5
DELEON ISD ALTERNATE COBRA
PPO PLAN 5 LG-PHCS NETWORK
PPO PLAN 5 LG-PHCS NETWORK
PPO PLAN 5 LG-PHCS NETWORK
PPO PLAN 5 LG-PHCS NETWORK
NATIONAL PPO- PHCS NETWORK
NATIONAL PPO-PHCS NTWK COB
INDEMNITY SAN ANTONIO COB
INDEMNITY-HOUSTON
LARGE GRP IND PLAN 6 CBRA
LARGE GRP IND PLAN 6 CBRA
LARGE GRP IND PLAN 6 CBRA
LARGE GRP IND PLAN 6 COBRA
LARGE GRP INDEMNITY PLAN 6
LARGE GRP INDEMNITY PLAN 6
LARGE GRP INDEMNITY PLAN 6
LARGE GRP INDEMNITY PLAN 6
COMMERCE ISD ALT COBRA
NATIONAL PPO- PHCS NETWORK
NATIONAL PPO-PHCS NTWK COB
INDEMNITY HOUSTON COBRA
INDEMNITY DALLAS
LARGE GRP IND PLAN 7 CBRA
LARGE GRP IND PLAN 7 CBRA
LARGE GRP IND PLAN 7 CBRA
LARGE GRP IND PLAN 7 COBRA
LARGE GRP INDEMNITY PLAN 7
LARGE GRP INDEMNITY PLAN 7
LARGE GRP INDEMNITY PLAN 7
LARGE GRP INDEMNITY PLAN 7
ROYSE CITY ISD ALT COBRA
NATIONAL PPO- PHCS NETWORK
NATIONAL PPO-PHCS NTWK COB
INDEMNITY DALLAS COBRA
IND. CONVERSION PLAN 880
INDIVIDUAL CONVERSION (2)
INDIVIDUAL CONVERSION (3)
PPO PLAN 8 20 80/60 500
PPO PLAN 8 20 80/60 500
NATIONAL PPO- PHCS NETWORK
NATIONAL PPO-PHCS NTWK COB
PPO PLAN10 15 80/60 250
PPO PLAN1 15 90/70 250
500 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
IA2
IA3
IA4
IA5
IA6
IA7
IA8
IA9
IAZ
IB0
IB1
IB2
IB3
IB4
IB5
IB6
IB7
IB8
IB9
IBZ
IC0
IC1
IC2
IC3
IC4
IC5
IC6
IC7
IC8
IC9
ICA
ICB
ICZ
ID0
ID1
ID2
ID3
ID4
ID5
ID6
ID7
ID8
ID9
IDN
IDZ
IE1
IF1
IH0
IH1
IH2
Plan / Benefit Description
PPO PLAN2 20 90/70 250
PPO PLAN 3 10 90/70 250
PPO PLAN 4 20 90/70 500
PPO PLAN 5 15 80/60 500
PPO PLAN 6 20 90/70 500
PPO PLAN 7 10 80/60 500
PPO PLAN 8 20 80/60 500
PPO PLAN 9 25 80/60 500
COLSCH-1097 (IDY) COBRA
PPO PLAN10 15 80/60 250
PPO PLAN1 15 90/70 250
PPO PLAN2 20 90/70 250
PPO PLAN 3 10 90/70 250
PPO PLAN 4 20 90/70 500
PPO PLAN 5 15 80/60 500
PPO PLAN 6 20 90/70 500
PPO PLAN 7 10 80/60 500
PPO PLAN 8 20 80/60 500
PPO PLAN 9 25 80/60 500
TCU IDY 500/80-20% 98 CBRA
PPO PLAN10 15 80/60 250
PPO PLAN 1 15 90/70 250
PPO PLAN 2 20 90/70 250
PPO PLAN 3 10 90/70 250
PPO PLAN 4 20 90/70 500
PPO PLAN 5 15 80/60 500
PPO PLAN 6 20 90/70 500
PPO PLAN 7 10 80/60 500
INDIVIDUAL CONVERSION (3)
PPO PLAN 9 25 80/60 500
CUSTOM PPO
DUMMY OK TO USE
INDEMNITY INDIV CONV COBRA
PPO PLAN10 15 80/60 250
PPO PLAN 1 15 90/70 250
PPO PLAN 2 20 90/70 250
PPO PLAN 3 10 90/70 250
PPO PLAN 4 20 90/70 500
PPO PLAN 5 15 80/60 500
PPO PLAN 6 20 90/70 500
PPO PLAN 7 10 80/60 500
INDIVIDUAL CONVERSION
PPO PLAN 9 25 80/60 500
INDEMNITY NATIONAL PPO
INDEMNITY NATIONAL PPO COB
PPO PLAN11 20 80/60 250
IN VITRO FERTILIZATION
IDY 500/80-20% 4000/8000
COLSCH-1097 (IDY)
TCU IDY 500/80-20% 98
501 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
IH3
IH4
IH5
IH6
IH7
IH8
IHC
IHN
IHZ
IJ1
IK1
IK2
IK3
IK4
IK5
IK6
IK7
IK8
IL1
IM0
IM1
IM2
IM3
IM4
IM5
IM6
IM7
IM8
IM9
IMB
IMC
IMD
IME
IMF
IMG
IMH
IMJ
IMK
IML
IMM
IMN
IMO
IMQ
IMR
IMS
IMT
IMU
IMV
IMZ
IN1
Plan / Benefit Description
UNIDEN IDY
GREENVILLE ALTER
DELEON ISD ALTERNATE
COMMERCE ISD ALT
ROYSE CITY ISD ALT
INDIVIDUAL CONVERSION
INDEMNITY INDIV CONVERSION
INDEMNITY NATIONAL PPO
INDEMNITY NATIONAL PPO COB
PPO PLAN11 20 80/60 250
INDEMNITY CUSTOM
INDEMNITY CUSTOM COBRA
INDEMNITY CUSTOM
INDEMNITY CUSTOM COBRA
INDEMNITY CUSTOM
INDEMNITY CUSTOM COBRA
INDEMNITY CUSTOM
INDEMNITY CUSTOM COBRA
PPO PLAN11 20 80/60 250
IP MNTL HLTH SFLEX 110-3
IP MNTL HLTH SFLEX 119-003
IP MNTL HLTH SFLEX 103-4
IP MNTL HLTH SFLEX 99-3
IP MNTL HLTH SFLEX 107-4
IP MNTL HLTH SFLEX 98-3
IP MNTL HTLH SFLEX 102-4
IP MNTL HLTH SFLEX 101-4
IP MNTL HLTH SFLEX 114-2
IP MNTL HLTH SFLEX 114-003
IP MNTL HLTH KMART 116-003
IP MNTL HLTH 15/200 188-5
IP MNTL HLTH PLN M 009-004
IP MNTL HLTH LOCKSAL 4-011
IP MNTL HLTH LOCKHR 004-12
IP MNTL HLTH MILLER 14-004
IP MNTL HLTH TXA&M 19-006
IP MNTL HLTH THOMSON 349-1
IP MNTL HLTH TXUT 183-003
IP MNTL HLTH IND PRO 262-4
IP MNTL HLTH IND PRO 341-1
IP MNTL HLTH POSFLEX 193-4
IP MNTL HLTH POSFLEX 189-3
IP MNTL HLTH POSFLEX 108-3
IP MNTL HLTH POSFLEX 109-3
IP MNTL HLTH POSFLEX 219-3
IP MNTL HLTH POSFLEX 106-4
IP MNTL HLTH POSFLEX 100-3
IP MNTL HLTH POSFLEX 123-3
IP MNTL HLTH SFLEX 92-003
IND PLAN 1 80%/250/2000
502 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
IN2
IN3
IN4
IN5
IN6
IN7
IN8
IO9
IOP
IOQ
IOR
IOS
IR1
IS1
IS2
IS3
IS4
IS5
IS6
IS7
IS8
ISN
ISZ
IX1
IX2
IX3
IX4
IX5
IX6
IX7
IX8
IX9
IXP
IXQ
IXR
IY1
IY2
IY3
IY4
IY5
IY6
IY7
IY8
IZ1
IZ2
IZ3
IZ4
IZ5
IZ6
IZ7
Plan / Benefit Description
IND PLAN 2 80%/500/4000
IND PLAN 1 80%/250/2000
IND PLAN 2 80%/500/4000
IND PLAN 1 80%/250/2000
IND PLAN 2 80%/500/4000
IND PLAN 1 80%/250/2000
IND PLAN 2 80%/500/4000
HOSPITAL INDEMNITY PLAN
BASIC COVERAGE/INDEMNITY
STD HEALTH BENEFIT/IND
CATASTROPHIC/INDEMNITY
80/60 SMALL GRP PPO 1-99
PPO PLAN11 20 80/60 250
INDEMNITY SG 80% 300 2000
INDEMNITY SG 80% 500 4000
INDEMNITY SG 80% 300 2000
INDEMNITY SG 80% 500 4000
INDEMNITY SG 80% 300 2000
INDEMNITY SG 80% 500 4000
INDEMNITY SG 80% 300 2000
INDEMNITY SG 80% 500 4000
INDEMNITY NATIONAL PPO
INDEMNITY NATIONAL PPO COB
IND PLAN 1 80%/250/2000 CB
IND PLAN 2 80%/500/4000 CB
IND PLAN 1 80%/250/2000 CB
IND PLAN 2 80%/500/4000 CB
IND PLAN 1 80%/250/2000 CB
IND PLAN 2 80%/500/4000 CB
IND PLAN 1 80%/250/2000 CB
IND PLAN 2 80%/500/4000 CB
HOSPITAL INDEMNITY COBRA
BASIC COVERAGE/IND. COBRA
STD HEALTH BENEFIT/IND COB
CATASTROPHIC/INDEMNITY COB
IND S GRP 80% 300 2000 CBR
IND S GRP 80% 500 4000 CBR
IND S GRP 80% 300 2000 CBR
IND S GRP 80% 500 4000 CBR
IND S GRP 80% 300 2000 CBR
IND S GRP 80% 500 4000 CBR
IND S GRP 80% 300 2000 CBR
IND S GRP 80% 500 4000 CBR
INDEMNITY PLAN COBRA
INDEMNITY PLAN COBRA
ADVANTAGE PLAN-INDV(COBRA)
INDEMNITY PLAN
INDEMNITY PLAN (COBRA)
HOSPITAL INDEMNITY PLAN
HOSPITAL INDEMNITY PLAN
503 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
IZ8
IZ9
IZA
IZB
IZC
IZD
IZE
IZF
IZG
IZH
IZI
IZJ
IZK
IZL
IZM
IZN
IZP
IZQ
IZR
IZS
IZT
IZU
IZV
IZW
J1C
J1Z
JDD
JDW
JKR
JR3
JR4
JR6
KA2
KA3
KA4
KA5
KA6
KA7
KA8
KA9
KB2
KB3
KB4
KB5
KB6
KB7
KB8
KB9
KD2
KD3
Plan / Benefit Description
HOSPITAL INDEMNITY PLAN
SMALL GROUP PPO-COBRA
SMALL GROUP PPO-COBRA
SMALL GROUP PPO-COBRA
PREV. PRIM. CARE-IND.COBRA
PREV. PRIM. CARE-IND COBRA
PREV. PRIM. CARE-IND COBRA
BASIC COVERAGE/INDEM-COBRA
BASIC COVERAGE/INDEM-COBRA
BASIC COVERAGE/INDEM-COBRA
STD. HEALTH BEN./IND COBRA
STD. HEALTH BEN./IND COBRA
STD. HEALTH BEN./IND COBRA
CATASTROPHIC-INDEMNITY/COB
CATASTROPHIC/INDEMNITY-COB
CATASTROPHIC/INDEMNITY-COB
80/60 PPO SMALL GRP 1-99CB
80/60 PPO SMALL GRP 1-99CB
80/60 PPO SMALL GRP 1-99CB
80/60 SMALL GRP PPO COBRA
80/60 SM GRP PPO/CBRA-PHCS
80/60 SM GRP PPO/CBRA-PHCS
80/60 SM GRP PPO/CBRA-PHCS
80/60 SM GRP PPO/CBRA-PHCS
880 MFP PLAN
880 MFP PLAN -COBRA
880 PLAN
880 PLAN COBRA
5-25/300A JKR W/D SH05
JCPENNY GRP RET $6/100%
JCPENNY GRP RET $6/100%
JCPENNY GRP RET $6/100%
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
504 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
KD4
KD5
KD6
KD7
KD8
KD9
KE2
KE3
KE4
KE5
KE6
KE7
KE8
KE9
KF2
KF3
KF4
KF5
KF6
KF7
KF8
KF9
KG2
KG3
KG4
KG5
KG6
KG7
KG8
KG9
KH8
KH9
KJ2
KJ3
KJ4
KJ5
KJ6
KJ7
KJ8
KJ9
KL2
KL3
KL4
KL5
KL6
KL7
KL8
KL9
KM2
KM3
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
505 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
KM4
KM5
KM6
KM7
KM8
KM9
KR2
KR3
KR4
KR5
KR6
KR7
KR8
KR9
KRJ
KS2
KS3
KS4
KS5
KS6
KS7
KS8
KS9
KT2
KT3
KT4
KT5
KT6
KT7
KT8
KT9
KU2
KU3
KU4
KU5
KU6
KU7
KU8
KU9
KV2
KV3
KV4
KV5
KV6
KV7
KV8
KV9
KW2
KW3
KW4
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
5-25/300A JKR SH05
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
506 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
KW5
KW6
KW7
KW8
KW9
KX2
KX3
KX4
KX5
KX6
KX7
KX8
KX9
KY2
KY3
KY4
KY5
KY6
KY7
KY8
KY9
L01
L02
L03
L1A
L1B
L1C
L1D
L1E
L1F
L2C
L2D
L2E
L2F
L31
L32
L33
L3A
L3B
L3C
L3D
L3E
L3F
L41
L42
L43
L4A
L4B
L4C
L4D
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
LIFE COVERAGE
LIFE COVERAGE PLAN
LIFE COVERAGE
STANDARD $20 POS PLAN
STANDARD $20 POS PLAN CBRA
POS 20/90/70
POS 20/90/70 COBRA
POS 20/90/60
POS 20/90/60 COBRA
POS 20/90/70
POS 20/90/70 COBRA
POS 20/90/60
POS 20/90/60 COBRA
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
STANDARD $20 POS SMALL GRP
STANDARD $20 POS SMALL CBR
POS 20/90/70
POS 20/90/70 COBRA
POS 20/90/60
POS 20/90/60 COBRA
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
STANDARD POS $20 SMALL GRP
STANDARD $20 POS SMALL CBR
POS 20/90/70
POS 20/90/70 COBRA
507 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
L4E
L4F
L50
L51
L52
L53
L54
L55
L56
L57
L58
L59
L5A
L5B
L5C
L5D
L60
L61
L62
L63
L64
L65
L66
L67
L68
L69
L6A
L6B
L6C
L6D
L70
L71
L72
L73
L74
L75
L76
L77
L78
L79
L7A
L7B
L7C
L7D
L8A
L8B
L8C
L8D
L9A
L9B
Plan / Benefit Description
POS 20/90/60
POS 20/90/60 COBRA
LIFE W/O SEAT LRG SAN ANT
LIFE W/O SEAT LRG SAN ANT
LIFE W/O SEAT LRG SAN ANT
LIFE W/O SEAT LRG SAN ANT
LIFE W/SEAT LRG SAN ANT
LIFE W/SEAT LRG SAN ANT
LIFE W/SEAT LRG SAN ANT
LIFE W/SEAT LRG SAN ANT
LIFE W/O SEAT SMALL SAN AN
LIFE W/SEAT SMALL SAN ANT
$20 POS
$20 POS COBRA
POS 20/80/60
POS 20/80/60 COBRA
LIFE W/O SEAT LRG HOUSTON
LIFE W/O SEAT LRG HOUSTON
LIFE W/O SEAT LRG SAN ANT
LIFE W/O SEAT LRG SAN ANT
LIFE W/SEAT LRG HOUSTON
LIFE W/SEAT LRG HOUSTON
LIFE W/SEAT LRG HOUSTON
LIFE W/SEAT LRG HOUSTON
LIFE W/O SEAT SMALL HOUST
LIFE W/SEAT SMALL HOUSTON
$20 POS
$20 POS COBRA
POS 20/80/60
POS 20/80/60 COBRA
LIFE W/O SEAT LRG DALLAS
LIFE W/O SEAT LRG DALLAS
LIFE W/O SEAT LRG DALLAS
LIFE W/O SEAT LRG DALLAS
LIFE W/SEAT LRG DALLAS
LIFE W/SEAT LRG DALLAS
LIFE W/SEAT LRG DALLAS
LIFE W/SEAT LRG DALLAS
LIFE W/O SEAT SMALL DALLAS
LIFE W/SEAT SMALL DALLAS
$20 POS
$20 POS COBRA
POS 20/80/60
POS 20/80/60 COBRA
$20 POS
$20 POS COBRA
POS 20/80/60
POS 20/80/60 COBRA
STANDARD $20 POS PLAN
STANDARD $20 POS PLAN COB
508 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
LA4
LAD
LBC
LBH
LC1
LC2
LC3
LC4
LC5
LC6
LC7
LC8
LC9
LCA
LCB
LCC
LDC
LDF
LEB
LEC
LF1
LF3
LF4
LFC
LFD
LFG
LG6
LH1
LH2
LH3
LH4
LH5
LH6
LH7
LH8
LH9
LHA
LHB
LHC
LHD
LHE
LHF
LHG
LHH
LHI
LHZ
LID
LIE
LIR
LJC
Plan / Benefit Description
20-30/250A LOKHEED GR06
20-30/250A LOKHEED GR06
SV 15-20/75A LHMRTN 08
SV 15/100A LOCKHEED 07 CB
LIFE W/SEAT MID/LG SAN ANT
LIFE W/SEAT MID/LG SAN ANT
LIFE W/SEAT MID/LG SAN ANT
LIFE W/SEAT MID/LG HOUSTON
LIFE W/SEAT MID/LG HOUSTON
LIFE W/SEAT MID/LG HOUSTON
LIFE W/SEAT MID/LG DALLAS
LIFE W/SEAT MID/LG DALLAS
LIFE W/SEAT MID/LG DALLAS
LIFE W/SEAT MID/LG AUSTIN
LIFE W/SEAT MID/LG AUSTIN
LIFE W/SEAT MID/LARGE AUST
SV 15-20/75A LHMRTN 08 CB
SV 15/100A LOCKHEED 07
SV 20-40/250A LHMRTN 08
SV 20-40/250A LHMRTN 08
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
SV 15/100A LOCKHEED 07
SV 15/100A LOCKHEED 07
SV 15/100A LOCKHEED 07 CB
20-30/250A LOKHEED CC GR06
LIFE
LOCKHEED $20/100%
LOCKHEED $20/100% COBRA
LOCKHEED $20/100%
LOCKHEED $20/100% COBRA
LOCKHEED $20/100%
LOCKHEED $20/100% COBRA
LOCKHEED $20/100%
LOCKHEED $20/100% COBRA
LOCKHEED HOURLY 2001
SV $10/100% LOCKHEED L
SV $10/100% LOCKHEED L CB
SV $10/100% LOCKHEED L
SV $10/100% LOCKHEED L CB
SV $10/100% LOCKHEED L
SV $10/100% LOCKHEED L CB
SV $10/100% LOCKHEED L
SV $10/100% LOCKHEED L CB
LOCKHEED HOURLY 2001 COBRA
DENTAL - SECURE GOLD
LOW INCOME EDUCATION
LOW INCOME EDUCATION 05
SV 20-40/250A LHMRTN 08 CB
509 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
LK1
LK2
LK3
LK4
LK5
LK6
LK7
LK8
LKC
LL3
LLA
LLB
LLC
LLD
LLE
LLF
LLG
LLH
LM1
LM2
LM3
LM4
LMB
LMC
LMD
LME
LMH
LMJ
LMS
LMX
LMZ
LOC
LOG
LOK
LOL
LON
LOP
LPW
LQB
LQC
LQS
LQW
LR1
LR3
LR4
LRS
LRW
LS1
LS2
LS3
Plan / Benefit Description
SV 20/100% LOCKHEED
SV 20/100% LOCKHEED CB
SV 20/100% LOCKHEED
SV 20/100% LOCKHEED CB
SV 20/100% LOCKHEED
SV 20/100% LOCKHEED CB
SV 20/100% LOCKHEED
SV 20/100% LOCKHEED CB
SV 20-40/250A LHMRTN 08
LIFELINK
SV 10/100% LOCKHEED
SV 10/100% LOCKHEED CB
SV 10/100% LOCKHEED
SV 10/100% LOCKHEED CB
SV 10/100% LOCKHEED
SV 10/100% LOCKHEED CB
SV 10/100% LOCKHEED
SV 10/100% LOCKHEED CB
LIFE W/SEAT MID/LG SAN ANT
LIFE W/SEAT MID/LG HOUSTON
LIFE W/SEAT MID/LG DALLAS
LIFE W/SEAT MID/LG AUSTIN
SV 20-40/250A LHMRTN 08 CB
SV 20-30/100A 06
SV 20-30/100A 06 CB
SV 20-30/100A 06
SV 20-30/100A 06 CB
SV 20-30/100A 06
SV 20-30/100A 06 CB
SV 20-30/100A 06
SV 20-30/100A 06 CB
20-30/250A LOKHEED CC GR07
20-30/250A LOKHEED GR07
20-30/250A LOKHEED GR07
20-30 LOKHEED NON-AARP GR8
20-30 LOKHEED NON-AARP GR8
20-30 LOKHEED NON-AARP GR8
SV 20-30/100A LKHEED 07
SV 20-40/250A LHMRTN 08
SV 20-40/250A LHMRTN 08 CB
SV 15-20/75A LHMRTN 08
SV 20-30/100A LKHEED 07 CB
LOCKHEED RET600018 $5/100%
LOCKHEED RET600018 $5/100%
LOCKHEED RET600018 $5/100%
SV 15-20/75A LHMRTN 08 CB
SV 20-30/100A LKHEED 07
LIFE W/SEAT SMALL SAN ANT
LIFE W/SEAT SMALL HOUSTON
LIFE W/SEAT SMALL DALLAS
510 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
LS4
LSS
LSW
LT1
LT3
LT4
LTC
LTD
LTG
LTM
LTS
LTW
LUB
LUC
LUE
LUW
LV1
LV3
LV4
LVW
LWB
LWW
M00
M0A
M1S
M1W
M1Y
M70
M80
M90
MA2
MA4
MAB
MAC
MAD
MDD
MDW
MH0
MH1
MH2
MH3
MH4
MH5
MH6
MH7
MH8
MH9
MHA
MHB
MHD
Plan / Benefit Description
LIFE W/SEAT SMALL AUSTIN
SV 15-20/75A LHMRTN 08
SV 20-30/100A LKHEED 07 CB
LOCKHEED RET#18021$5/100%
LOCKHEED RET#18021$5/100%
LOCKHEED RET#18021$5/100%
SV 15-20/75A LHMRTN 08
RESERVED FOR PPO LIFE
SV 15/100A LOCKHEED 07 CB
RESERVED FOR LIFETIME MAX
SV 15-20/75A LHMRTN 08 CB
SV 20-30/100A LKHEED 07
SV 15/100A LOCKHEED 07
SV 15-20/75A LHMRTN 08 CB
SV 15/100A LOCKHEED 07 CB
SV 20-30/100A LKHEED 07 CB
LOCKHEED RET#18057$5/100%
LOCKHEED RET#18057$5/100%
LOCKHEED RET#18057$5/100%
SV 20-30/100A LKHEED 07
SV 20-40/250A LHMRTN 08 CB
SV 20-30/100A LKHEED 07 CB
INPATIENT MENTAL (100%)
IP MH $500 ADMIT MERCER
2070 PLAN (OPT)
2070 PLAN (OPT)
2070 PLAN (OPT)
INPATIENT MENTAL (70%)
INPATIENT MENTAL (80%)
INPATIENT MENTAL (90%)
MOTOROLA $5/100% COBRA
MOTOROLA $5/100% COBRA
MOTOROLA $5/100%
IP MENTAL HEALTH 100%
MOTOROLA $5/100%
PLAN 20
PLAN 20 COBRA
MENTAL HEALTH $250
MENTAL HEALTH O/P $5 OV
MENTAL HEALTH O/P $10 OV
MENTAL HEALTH O/P $15 OV
MENTAL HEALTH $200
MENTAL HEALTH $300
MENTAL HEALTH $400
IP MNTL HLTH FLEX 97-003
MENTAL HEALTH $600
IP MNTL HLTH FLEX 118-003
MENTAL HEALTH $150
I/P MNTL HLTH - CUSTOM GM
IP MNTL HLTH FLEX 172-004
511 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
MHE
MHF
MHG
MHH
MHI
MHJ
MHK
MHL
MHM
MHQ
MHR
MHT
MHU
MHV
MHW
MHX
MHY
MI0
MI1
MI4
MI5
MI6
MI7
MI8
MI9
MIB
MIC
MID
MIE
MIF
MIG
MIH
MIJ
MIK
MIL
MS0
MS2
MS6
MS7
MS9
MSB
MSE
MSF
MSG
MSI
MSJ
MSK
MSN
MSP
MSQ
Plan / Benefit Description
IP MNTL HLTH FLEX 225-003
IP MNTL HLTH FLEX 193-004
IP MNTL HLTH FLEX 321-002
IP MNTL HLTH FLEX 111-004
IP MNTL HLTH FLEX 335-002
IP MNTLH HLTH FLEX 189-003
IP MNTL HLTH FLEX 104-003
IP MNTL HLTH FLEX 218-003
IP MNTL HLTH FLEX 112-003
IP MNTL HLTH FLEX 108-003
IP MNTL HLTH FLEX 109-003
IP MNTL HLTH FLEX 219-003
IP MNTL HLTH FLEX 106-004
IP MNTL HLTH FLEX 100-003
IP MNTL HLTH FLEX 308-001
IP MNTL HLTH FLEX 123-003
IP MNTL HLTH AAIR 339-001
SMI $10OV/200IP AAIR 339-1
SMI $20OV/300IP ALCN 345-2
SMI $0OV/0IP CWF-M 120-3
SMI $5OV/0IP CWF-HI 121-3
SMI $10OV/20%IP CWFL 122-3
SMI $0OV/0IP GM-HOUR 320-2
SMI $0OV/0IP GM-SALA 342-1
SMI $10OV/250IP HLBN 187-3
SMI $10OV/400IP KMRT 116-3
SMI $15OV/200IP CUST 188-5
SMI $0OV/0IP LM-PLAN M 9-4
SMI $10OV/0IP LM SAL 4-11
SMI $10OV/0IP LM-HOUR 4-12
SMI $5OV/0IP MILLER 14-4
SMI $10OV/20%IP TX AM 19-6
SMI $0OV/0IP THOMSON 349-1
INDEPENDENT $25 PLAN
SMI $15OV/20%IP TXUT 183-3
SMI $15OV/20%IP FLEX 97-3
SMI $10OV/20%IP FLEX 118-3
SMI $10OV/0IP FLEX 172-4
SMI $3OV/0IP FLEX 225-3
SMI $10OV/0IP FLEX 193-4
SMI $10OV/100IP FLEX 321-2
SMI $10OV/200IP FLEX 111-4
SMI $10OV/250IP FLEX 335-2
SMI $10OV/300IP FLEX 189-3
SMI $15OV/100IP FLEX 104-3
SMI $15OV/100IP FLEX 218-3
SMI $15OV/200IP FLEX 112-3
SMI $15OV/300IP FLEX 108-3
SMI $15OV/400IP FLEX 109-3
SMI $20OV/200IP FLEX 219-3
512 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
MSR
MSS
MST
MSU
MT0
MT3
MT4
MT5
MT6
MT7
MT8
MTK
MTM
N01
N02
N03
N04
N05
N06
N07
N08
N09
N0F
N0R
N10
N11
N12
N13
N14
N15
N16
N17
N18
N19
N1A
N1B
N1C
N1D
N1E
N1F
N1G
N1R
N20
N21
N22
N23
N24
N25
N26
N27
Plan / Benefit Description
SMI $20OV/300IP FLEX 106-4
SMI $20OV/400IP FLEX 100-3
SMI $25OV/600IP FLEX 308-1
SMI $25OV/600IP FLEX 123-3
IP MNTL HLTH ALCON 345-002
IP MNTL HLTH CFW 120-003
IP MNTL HLTH CFWHG121-003
IP MNTL HLTH CFWLO 122-003
IP MNTL HLTH GMHR 320-002
IP MNTL HLTH GMSAL 342-001
IP MNTL HLTH HALLIB 187-3
10/5V 1YR MSG THRPY SH07
10/5V 1YR MSG THRPY SH08
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
SV 15-30/250A NAT'L CB
NAT'L $20/$40/$400 DAY CBR
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
NAT'L PLN 1 $5 GRP RET
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 3 $15 GRP RET
NAT'L PLN 2A $10 GRP RET
NAT'L PLN 2B $10 GRP RET
NAT'L PLN 3A $15 GRP RET
NAT'L PLN 3B $15 GRP RET
NAT'L $10/$20/$100 COBRA
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
513 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
N28
N29
N2F
N2R
N30
N3A
N3B
N3C
N3D
N3E
N3F
N3G
N3R
N4A
N4B
N4C
N4D
N4E
N4F
N4G
N4R
N5F
N5R
N6F
N6R
N7F
N7R
N8F
N8R
N9F
N9R
NA1
NA2
NA3
NA4
NA5
NA6
NA8
NAA
NAB
NAC
NAD
NAE
NAF
NAG
NAH
NAI
NAK
NAL
NAN
Plan / Benefit Description
INDEMNITY PLANS
INDEMNITY PLANS
SV 20-40/400D NAT'L CB
NAT'L $15/$30/$250 COBRA
INDEMNITY PLANS
NAT'L PLN 1 $5 GRP RET
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 3 $15 GRP RET
NAT'L PLN 2A $10 GRP RET
NAT'L PLN 2B $10 GRP RET
NAT'L PLN 3A $15 GRP RET
NAT'L PLN 3B $15 GRP RET
NAT'L $15/$30/$400 COBRA
NAT'L PLN 1 $5 GRP RET
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 3 $15 GRP RET
NAT'L PLN 2A $10 GRP RET
NAT'L PLN 2B $10 GRP RET
NAT'L PLN 3A $15 GRP RET
NAT'L PLAN 3B $15 GRP RET
NAT'L $20/$40/$250 DAY CBR
SV 15-30/250A NAT'L CB
NAT'L $20/$40/$400 DAY CBR
SV 15-30/400A NAT'L CB
NAT'L $10/$20/$100 COBRA
SV 20-40/250D NAT'L CB
NAT'L $15/$30/$250 COBRA
SV 20-40/400D NAT'L CB
NAT'L $15/$30/$400 COBRA
SV 10-20/100A NAT'L CB
NAT'L $20/$40/$250 DAY CBR
PHS NATL $5/100% CBRA
PHS NATL $10/100% CBRA
PHS NATL $10/$100 COBRA
PHS NATL $10/$250 COBRA
PHS NATL $15/$250 COBRA
PHS NATL $15/100% COBRA
PHS NATL $15/$100 COBRA
PHS NATL $5/100%
PHS NATL $10/100%
PHS NATL $10/$100
PHS NATL $10/$250
PHS NATL $15/$250
PHS NATL $15/100%
NATL POS $10/100%/70%
NATL POS $10/90%/70%
PHS NATL $15/$100
NATL POS $15/80%/60%
NATL POS $15/$150/70%
NATL POS $10/100%/70%
514 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
NAO
NAQ
NAR
NC1
NC2
NC3
NCA
NCB
NCC
ND1
ND2
ND3
ND4
ND5
ND6
ND8
NDA
NDB
NDC
NDD
NDE
NDF
NDG
NE1
NE2
NE3
NE4
NE5
NE6
NE7
NEA
NEB
NEC
NED
NEE
NEF
NEG
NF0
NF1
NF2
NF3
NF4
NF5
NF6
NF7
NF8
NF9
NFA
NFB
NFC
Plan / Benefit Description
NATL POS $10/90%/70%
NATL POS $15/80%/60%
NATL POS $15/$150/70%
$10/$0 MERCER PLAN 1 COBRA
$10/$0 MERCER PLAN 2 COBRA
$15/$500 MERCER PLAN3 CBRA
$10/$0 MERCER PLAN 1
$15/$0 MERCER PLAN 2
$15/$500 MERCER PLAN3
PHS NATL $5/100% COBRA
PHS NATL $10/100% COBRA
PHS NATL $10/$100 COBRA
PHS NATL $10/$250 COBRA
PHS NATL $15/$250 COBRA
PHS NATL $15/100% COBRA
PHS NATL $15/$100 COBRA
PHS NATL $5/100%
PHS NATL $10/100%
PHS NATL $10/$100
PHS NATL $10/$250
PHS NATL $15/$250
PHS NATL $15/100%
PHS NATL $15/$100
SV 5/100% NATL CB
SV 10/100% NATL CB
SV 15/100% NATL CB
SV 10/100A NATL CB
SV 10/250A NATL CB
SV 15/250A NATL CB
SV 15/100A NATL CB
SV 5/100% NATL
SV 10/100% NATL
SV 15/100% NATL
SV 10/100A NATL
SV 10/250A NATL
SV 15/250A NATL
SV 15/100A NATL
SV 15-30/250A NAT'L CB
$10/$0 MERCER PLAN 1 COBRA
$15/$0 MERCER PLAN 2 COBRA
$15/$500 MERCER PLAN 3 COB
SV 10-20/100A NAT'L CB
SV 15-30/250A NAT'L CB
SV 15-30/400A NAT'L CB
SV 20-40/250D NAT'L CB
SV 20-40/400D NAT'L CB
SV 10-20/100A NAT'L CB
$10/$0 MERCER PLAN 1
$15/$0 MERCER PLAN 2
$15/$500 MERCER PLAN 3
515 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
NFD
NFE
NFF
NFG
NFH
NFI
NFJ
NFK
NFL
NFM
NFN
NFO
NFP
NFQ
NFR
NFS
NFT
NFU
NFV
NFW
NFY
NFZ
NGA
NGB
NGC
NGD
NGX
NGZ
NHX
NHZ
NJ1
NJ2
NJ3
NJ4
NJ5
NJ6
NJ7
NJA
NJB
NJC
NJD
NJE
NJF
NJG
NK1
NK2
NK3
NK4
NK5
NK6
Plan / Benefit Description
SV 10-20/100A NAT'L
SV 15-30/250A NAT'L
SV 15-30/400A NAT'L
SV 20-40/250D NAT'L
SV 20-40/400D NAT'L
SV 10-20/100A NAT'L
SV 15-30/250A NAT'L
SV 15-30/400A NAT'L
SV 20-40/250D NAT'L
SV 20-40/400D NAT'L
SV 10-20/100A NAT'L
SV 15-30/250A NAT'L
SV 15-30/400A NAT'L
SV 20-40/250D NAT'L
SV 20-40/400D NAT'L
SV 10-20/100A NAT'L
SV 15-30/250A NAT'L
SV 15-30/400A NAT'L
SV 20-40/250D NAT'L
SV 20-40/400D NAT'L
SV 15-30/400A NAT'L CB
SV 10-20/100A NAT'L CB
NAT'L PLN 2C $20 GRP RET
NAT'L PLN 2C $20 GRP RET
NAT'L PLN 2D $20 GRP RET
NAT'L PLN 2D $20 GRP RET
NATL POS $10/100%/70% CBRA
NATL POS $10/100%/70% CBRA
NATL POS $10/90%/70% COBRA
NATL POS $10/90%/70% COBRA
SV 5/100% NATL CB
SV 10/100% NATL CB
SV 15/100% NATL CB
SV 10/100A NATL CB
SV 10/250A NATL CB
SV 15/250A NATL CB
SV 15/100A NATL CB
SV 5/100% NATL
SV 10/100% NATL
SV 15/100% NATL
SV 10/100A NATL
SV 10/250A NATL
SV 15/250A NATL
SV 15/100A NATL
SV 5/100% NATL CB
SV 10/100% NATL CB
SV 15/100% NATL CB
SV 10/100A NATL CB
SV 10/250A NATL CB
SV 15/250A NATL CB
516 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
NK7
NKA
NKB
NKC
NKD
NKE
NKF
NKG
NKX
NKZ
NL8
NLF
NLG
NLX
NLZ
NN1
NN2
NN3
NN4
NN5
NN6
NN7
NNA
NNB
NNC
NND
NNE
NNF
NNG
NNX
NNZ
NOX
NOZ
NPG
NPH
NPK
NPL
NPN
NPO
NPQ
NPR
NQX
NQZ
NR0
NR1
NR2
NR3
NR4
NR5
NR6
Plan / Benefit Description
SV 15/100A NATL CB
SV 5/100% NATL
SV 10/100% NATL
SV 15/100% NATL
SV 10/100A NATL
SV 10/250A NATL
SV 15/250A NATL
SV 15/100A NATL
NATL POS $15/80%/60% COBRA
NATL POS $15/80%/60% COBRA
24HR NURSLINE WL-SH/GR08
SV 20-40/250D NAT'L CB
24HOUR NURSE LINE SH07
NATL POS $15/$150/70% CBRA
NATL POS $15/$150/70% CBRA
SV 5/100% NATL CB
SV 10/100% NATL CB
SV 15/100% NATL CB
SV 10/100A NATL CB
SV 10/250A NATL CB
SV 15/250A NATL CB
SV 15/100A NATL CB
SV 5/100% NATL
SV 10/100% NATL
SV 15/100% NATL
SV 10/100A NATL
SV 10/250A NATL
SV 15/250A NATL
SV 15/100A NATL
NATL POS $10/100%/70% CBRA
NATL POS $10/100%/70% CBRA
23TL POS $10/90%/70% COBRA
NATL POS $10/90%/70% COBRA
NATL POS $10/100%/70%
NATL POS $10/90%/70%
NATL POS $15/80%/60%
NATL POS $15/$150/70%
NATL POS $10/100%/70%
NATL POS $10/90%/70%
NATL POS $15/80%/60%
NATL POS $15/$150/70%
NATL POS $15/80%/60% COBRA
NATL POS $15/80%/60% COBRA
NAT'L $20/$40/$400 DAY CBR
NAT'L $10/$20/$100 COBRA
NAT'L $15/$30/$250 COBRA
NAT'L $15/$30/$400 COBRA
NAT'L $20/$40/$250 DAY CBR
NAT'L $20/$40/$400 DAY CBR
NAT'L $10/$20/$100 COBRA
517 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
NR7
NR8
NR9
NRA
NRB
NRC
NRD
NRE
NRF
NRG
NRH
NRI
NRJ
NRK
NRL
NRM
NRN
NRO
NRP
NRQ
NRR
NRS
NRT
NRX
NRZ
NS1
NSH
NSI
NSL
NSX
NSZ
NTB
NTC
NTF
NTL
NTQ
NTS
NTU
NUF
NV1
NV2
NV3
NVA
NVB
NVC
NVF
NW1
NW2
NW3
NWA
Plan / Benefit Description
NAT'L $15/$30/$250 COBRA
NAT'L $15/$30/$400 COBRA
NAT'L $20/$40/$250 DAY CBR
NAT'L $10/$20/$100
NAT'L $15/$30/$250
NAT'L $15/$30/$400
NAT'L $20/$40/$250 PER DAY
NAT'L $20/$40/$400 PER DAY
NAT'L $10/$20/$100
NAT'L $15/$30/$250
NAT'L $15/$30/$400
NAT'L $20/$40/$250 PER DAY
NAT'L $20/$40/$400 PER DAY
NAT'L $10/$20/$100
NAT'L $15/$30/$250
NAT'L $15/$30/$400
NAT'L $20/$40/$250 PER DAY
NAT'L $20/$40/$400 PER DAY
NAT'L $10/$20/$100
NAT'L $15/$30/$250
NAT'L $15/$30/$400
NAT'L $20/$40/$250 PER DAY
NAT'L $20/$40/$400 PER DAY
NATL POS $15/$150/70% CBRA
NATL POS $15/$150/70% CBRA
NORTHSIDE IND.HOSP.COBRA
NORTHSIDE ISD HIGH OPTION
NORTHSIDE HOSP.INDEMNITY
NORTHSIDE ISD LOW OPTION
NORTHSIDE ISD LOW OPT COBR
NORTHSIDE ISD HIGH OPT CBR
0/24-1W NON-ER TRANS SH07
0/24-1W NON-ER TRANS SH07
0/12-1W NON-ER TRANS SH07
0/24-1W NON-ER TRANS SH08
0/24-1W NON-ER TRANS SH08
0/12-1W NON-ER TRANS SH08
0/20-1W NON-ER TRANS SH08
SV 15-30/400A NAT'L CB
$10/$0 MERCER PLAN 1 COBRA
$15/$0 MERCER PLAN 2 COBRA
$15/$500 MERCER PLAN3 CBRA
$10/$0 MERCER PLAN 1
$15/$0 MERCER PLAN 2
$15/$500 MERCER PLAN3
SV 20-40/250D NAT'L CB
$10/$0 MERCER PLAN 1 COBRA
$15/$0 MERCER PLAN 2 COBRA
$15/$500 MERCER PLAN3 CBRA
$10/$0 MERCER PLAN 1
518 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
NWB
NWC
NWF
NX1
NX2
NX3
NX4
NX5
NX6
NX8
NXA
NXB
NXC
NXD
NXE
NXF
NXG
NY1
NY2
NY3
NY4
NY5
NY6
NY8
NYA
NYB
NYC
NYD
NYE
NYF
NYG
O11
O1A
O1B
O1D
O1F
O1G
O1J
O1L
O1Q
O1R
O1U
O1V
O1W
O1X
O1Y
O2J
O2L
O2Q
O2R
Plan / Benefit Description
$15/$0 MERCER PLAN 2
$15/$500 MERCER PLAN3
SV 20-40/400D NAT'L CB
PHS NATL $5/100% CBRA
PHS NATL $10/100% CBRA
PHS NATL $10/$100 COBRA
PHS NATL $10/$250 COBRA
PHS NATL $15/$250 COBRA
PHS NATL $15/100% COBRA
PHS NATL $15/$100 COBRA
PHS NATL $5/100%
PHS NATL $10/100%
PHS NATL $10/$100
PHS NATL $10/$250
PHS NATL $15/$250
PHS NATL $15/100%
PHS NATL $15/$100
PHS NATL $5/100% CBRA
PHS NATL $10/100% CBRA
PHS NATL $10/$100 COBRA
PHS NATL $10/$250 COBRA
PHS NATL $15/$250 COBRA
PHS NATL $15/100% COBRA
PHS NATL $15/$100 COBRA
PHS NATL $5/100%
PHS NATL $10/100%
PHS NATL $10/$100
PHS NATL $10/$250
PHS NATL $15/$250
PHS NATL $15/100%
PHS NTL $15/$100
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 1 $5 GRP RET
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 2A $10 GRP RET
NAT'L PLN 3A $15 GRP RET
NAT'L PLN 3B $15 GRP RET
10-15/50A T1A CC GR07
10-20/750A T2A CC GR07
10-20/750A T2A GR07
15-25/200D T3A GR07
15-25/200D T3A GR07
10-20/750A T2A GR07
10-15/50A T1A GR07
10-15/50A T1A GR07
15-25/200D T3A CC GR07
10-15/50A T1A CC GR07
10-20/750A T2A CC GR07
10-20/750A T2A GR07
15-25/200D T3A GR07
519 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
O2U
O2V
O2W
O2X
O2Y
O3J
O3L
O3Q
O3R
O3U
O3V
O3W
O3X
O3Y
O44
O4A
O4B
O4D
O4F
O4G
O4J
O4L
O4Q
O4R
O4U
O4V
O4W
O4X
O4Y
O5J
O5L
O5Q
O5R
O5U
O5V
O5W
O5X
O5Y
O6J
O6L
O6Q
O6R
O6U
O6V
O6W
O6X
O6Y
O7J
O7L
O7Q
Plan / Benefit Description
15-25/200D T3A GR07
10-20/750A T2A GR07
10-15/50A T1A GR07
10-15/50A T1A GR07
15-25/200D T3A CC GR07
10-15/50A T1A CC GR07
10-20/750A T2A CC GR07
10-20/750A T2A GR07
15-25/200D T3A GR07
15-25/200D T3A GR07
10-20/750A T2A GR07
10-15/50A T1A GR07
10-15/50A T1A GR07
15-25/200D T3A CC GR07
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 1 $5 GRP RET
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 2A $10 GRP RET
NAT'L PLN 3A $15 GRP RET
NAT'L PLAN 3B $15 GRP RET
5-20/100A T1B CC GR07
15-25/130D T2B CC GR07
15-25/130D T2B GR07
15-30/220D T3B GR07
15-30/220D T3B GR07
15-25/130D T2B GR07
5-20/100A T1B GR07
5-20/100A T1B GR07
15-30/220D T3B CC GR07
5-20/100A T1B CC GR07
15-25/130D T2B CC GR07
15-25/130D T2B GR07
15-30/220D T3B GR07
15-30/220D T3B GR07
15-25/130D T2B GR07
5-20/100A T1B GR07
5-20/100A T1B GR07
15-30/220D T3B CC GR07
5-20/100A T1B CC GR07
15-25/130D T2B CC GR07
15-25/130D T2B GR07
15-30/220D T3B GR07
15-30/220D T3B GR07
15-25/130D T2B GR07
5-20/100A T1B GR07
5-20/100A T1B GR07
15-30/220D T3B CC GR07
10-20/200A T1C CC GR07
10-25/150D T2C CC GR07
10-25/150D T2C GR07
520 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
O7R
O7U
O7V
O7W
O7X
O7Y
O8J
O8L
O8Q
O8R
O8U
O8V
O8W
O8X
O8Y
O9J
O9L
O9Q
O9R
O9U
O9V
O9W
O9X
O9Y
OA1
OA4
OAN
OB1
OB2
OB4
OCM
OD1
OD2
OD4
ODB
ODG
ODM
ODS
ODU
OE1
OE2
OE4
OEM
OES
OF1
OF2
OF3
OF4
OF5
OF6
Plan / Benefit Description
20-35/250D T3C GR07
20-35/250D T3C GR07
10-25/150D T2C GR07
10-20/200A T1C GR07
10-20/200A T1C GR07
20-35/250D T3C CC GR07
10-20/200A T1C CC GR07
10-25/150D T2C CC GR07
10-25/150D T2C GR07
20-35/250D T3C GR07
20-35/250D T3C GR07
10-25/150D T2C GR07
10-20/200A T1C GR07
10-20/200A T1C GR07
20-35/250D T3C CC GR07
10-20/200A T1C CC GR07
10-25/150D T2C CC GR07
10-25/150D T2C GR07
20-35/250D T3C GR07
20-35/250D T3C GR07
10-25/150D T2C GR07
10-20/200A T1C GR07
10-20/200A T1C GR07
20-35/250D T3C CC GR07
NAT'L PLN 1 $5 GRP RET
NAT'L PLN 1 $5 GRP RET
NAT'L ACCT EXTENDED OOA
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 2 $10 GR 06
NAT'L PLN 2 $10 GRP RET
15-25/500A AARP GR08
NAT'L PLN 2A $10 GR 06
NAT'L PLN 2A $10 GR 06
NAT'L PLN 2A $10 GR 06
5/100% AARP GR08
DO NOT USE
15-25/500A AARP GR08
10/100% NON-AARP GR08
5/100% AARP GR08
NAT'L PLN 2B $10 GR 06
NAT'L PLN 2B $10 GR 06
NAT'L PLN 2B $10 GR 06
15-25/500A AARP GR08
10/100% NON-AARP GR08
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
521 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
OF7
OF8
OF9
OFA
OFB
OFC
OFD
OFE
OFS
OFV
OG1
OG2
OG4
OGD
OGP
OGV
OH2
OH4
OHB
OHV
OI2
OJ1
OJ2
OJ4
OJB
OJJ
OJX
OK1
OK2
OK4
OKJ
OL1
OL2
OL4
OLJ
OLP
OM1
OM2
OM4
ON1
ON2
ON4
ONP
OOB
OOK
OON
OOR
OOS
OOT
OP1
Plan / Benefit Description
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
10/100% NON-AARP GR08
5/100% NON-AARP GR08
NAT'L PLN 3B $15 GR 06
NAT'L PLN 3B $15 GR 06
NAT'L PLN 3B $15 GR 06
NAT'L PLN 2D $20 GRP RET
20-40/250A NON-AARP GR08
5/100% NON-AARP GR08
NAT'L PLN 1 $5 GR 06
NAT'L PLN 1 $5 GR 06
5/100% AARP GR08
5/100% NON-AARP GR08
NAT'L PLN 2 $10 GR 06
NAT'L PLN 2A $10 GR 06
NAT'L PLN 2A $10 GR 06
NAT'L PLN 2A $10 GR 06
5/100% AARP GR08
15/250A AARP GR08
5/100% AARP GR08
NAT'L PLN 2B $10 GR 06
NAT'L PLN 2B $10 GR 06
NAT'L PLN 2B $10 GR 06
15/250A AARP GR08
NAT'L PLN 3A $15 GR 06
NAT'L PLN 3A $15 GR 06
NAT'L PLN 3A $15 GR 06
15/250A AARP GR08
20-40/250A NON-AARP GR08
NAT'L PLAN 3B $15 GR 06
NAT'L PLAN 3B $15 GR 06
NAT'L PLAN 3B $15 GR 06
NAT'L PLN 2C $20 GR 06
NAT'L PLN 2C $20 GR 06
NAT'L PLN 2C $20 GR 06
20-40/250A NON-AARP C GR08
5/100% AARP GR08
15/250A NON-AARP GR08
POS - OUT OF AREA
POS OUT OF AREA (AUSTIN)
POS OUT OF AREA (HOUSTON)
POS OUT OF AREA (DALLAS)
NAT'L PLN 2C $20 GR 06
522 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
OP2
OP4
OPK
OPX
OQ2
OQ4
OQK
OR2
OR3
OR4
ORF
ORX
OS2
OS4
OT1
OT2
OT4
OTF
OUX
OVR
OVT
OWF
OWR
OWT
OXK
OXR
OXT
OYK
OZK
P00
P0Z
P2P
P3P
P4P
P4Z
P5P
P5Z
P6H
P6P
P6Z
P70
P7P
P7Z
P80
P8P
P8Z
P9P
P9Z
PA2
PA3
Plan / Benefit Description
NAT'L PLN 2C $20 GR 06
NAT'L PLN 2C $20 GR 06
15/250A NON-AARP GR08
5/100% AARP GR08
NAT'L PLN 2D $20 GR 06
NAT'L PLN 2D $20 GR 06
15/250A NON-AARP GR08
NAT'L PLN 2D $20 GR 06
NAT'L PLN 2D $20 GR 06
NAT'L PLN 2D $20 GR 06
10-20/250A NON-AARP GR08
OTHR RX NOT THRU RX SOL
NAT'L PLN 1 $5 GR 06
NAT'L PLN 1 $5 GR 06
NAT'L PLN 3A $15 GR 06
NAT'L PLN 3A $15 GR 06
NAT'L PLN 3A $15 GR 06
10-20/250A NON-AARP GR08
5/100% AARP GR08
10/100% AARP GR08
10-20/250A AARP GR08
10-20/250A NON-AARP GR08
10/100% AARP GR08
10-20/250A AARP GR08
20-40/250A AARP GR08
10/100% AARP GR08
10-20/250A AARP GR08
20-40/250A AARP GR08
20-40/250A AARP GR08
INPATIENT PSYCHIATRIC 100%
POS FLEX 10/0/800 99 COBRA
RESERVED PPO
RESERVED PPO
RESERVED PPO
POS FLEX 20/200/1000 99 CB
RESERVED PPO
POS FLEX 20/300/1200 99 CB
15-25/100A GR06
RESERVED PPO
POS FLEX 20/400/1500 99 CB
INPATIENT MENTAL HEALTH
RESERVED PPO
POS FLEX 25/600/2000 99 CB
INPATIENT PSYCHIATRIC 80%
RESERVED PPO
BELL AAA POS IN-NET COBRA
RESERVED PPO
BELL POS 123 IN NET COBRA
RESERVED PPO
RESERVED PPO
523 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
PA4
PA5
PA6
PA7
PA8
PA9
PAA
PAB
PAC
PAD
PAE
PAF
PAG
PAH
PAK
PB1
PB2
PB3
PB4
PB5
PB6
PB7
PB8
PBA
PBB
PBF
PBG
PCE
PCF
PCG
PCH
PCI
PCW
PD2
PD3
PD4
PD5
PD6
PD7
PDH
PDL
PDN
PDS
PDW
PEH
PEK
PEY
PF0
PF2
PF3
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
PPO - PFFS
RESERVED PFFS
PPO ADMINISTRATIVE CHARGE
PPO - PFFS
PPO - PFFS
RESERVED PFFS
RESERVED PFFS
RESERVED PFFS
RESERVED PFFS
PPO CUSTOM
PPO CUSTOM COBRA
PPO CUSTOM
PPO CUSTOM COBRA
PPO CUSTOM
PPO CUSTOM COBRA
PPO CUSTOM
PPO CUSTOM COBRA
PPO - PFFS
RESERVED PFFS
RESERVED PFFS
RESERVED PFFS
PPO - PFFS
SV 15-30/100A PC
SV 15-30/100A PC
SV 15-30/100A PC
SV 15-30/100A PC
$45/Q PHB CREDIT SH08
PDV CUSTOM DENTAL ONLY
PDV VISION ONLY
PDV CUSTOM VISION ONLY
PDV DENTAL & VISION
PDV CUSTOM DENTAL & VISION
PDV DENTAL ONLY
O/4V 1YR POD SH07
O/4V 1YR+SHOE POD SH07
O/6V 1YR POD SH07
O/3V 1YR POD SH08
O/6V 1YR POD SH08
RESERVED PFFS
RESERVED PFFS
$20/Q PHB CREDIT SH08
I/P PSYCHIATRIC CARE(FEDS)
RESERVED PPO
RESERVED PPO
524 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
PF4
PF5
PF6
PF7
PF8
PF9
PFA
PFB
PFC
PFD
PFJ
PFL
PFM
PFZ
PG1
PG2
PG3
PG4
PG5
PG6
PG7
PG8
PGD
PH0
PH1
PH2
PH3
PH4
PH5
PH6
PH7
PH8
PH9
PHA
PHB
PHC
PHD
PHE
PHF
PHG
PHH
PHV
PHZ
PIE
PIF
PIG
PIH
PII
PIK
PIL
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 20-40/200A PHS 06
SV 20-40/200A PHS 06 CB
SV 20-40/200A PHS 06
SV 20-40/200A PHS 06 CB
SV 20-40/200A PHS 06
SV 20-40/200A PHS 06 CB
SV 20-40/200A PHS 06
SV 20-40/200A PHS 06 CB
PBG $20/$200
PBG $20/$200 COBRA
PBG $20/$200
PBG $20/$200 COBRA
PBG $20/$200
PBG $20/$200 COBRA
PGB $20/$200
PBG $20/$200 COBRA
PPO - PFFS
POS FLEX 10/0/800 99
POS FLEX 10/300/1200 99
POS FLEX 15/300/1200 99
POS FLEX 15/400/1500 99
POS FLEX 20/200/1000 99
POS FLEX 20/300/1200 99
POS FLEX 20/400/1500 99
POS FLEX 25/600/2000 99
BELL AAA POS IN-NET BARG
BELL POS 123 IN-NET
PPO CUSTOM - HIGH OPTION
PPO CUSTOM - HI-OPT COBRA
PPO CUSTOM - HIGH OPTION
PPO CUSTOM - HI-OPT COBRA
PPO CUSTOM - HIGH OPTION
PPO CUSTOM - HI-OPT COBRA
CUSTOM PPO - HIGH OPTION
PPO CUSTOM - HI-OPT COBRA
$45/Q PHB CREDIT SH07
POS FLEX 10/300/1200 99 CB
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
525 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
PIN
PIO
PL2
PL3
PL4
PLA
PLB
PLC
PLD
PLE
PLF
PLG
PLH
PLP
PMZ
PPA
PPB
PPC
PPD
PPE
PPF
PPG
PPH
PPJ
PPK
PPL
PPM
PPN
PPQ
PPR
PPS
PPT
PPU
PPV
PPW
PPX
PPY
PPZ
PR1
PR2
PR3
PT1
PT2
PT3
PT4
PT5
PTZ
PYI
PZ1
PZ2
Plan / Benefit Description
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED PPO
RESERVED PPO
RESERVED PPO
PPO CUSTOM - LOW OPTION
PPO CUSTOM - LOW-OPT COBRA
PPO CUSTOM - LOW OPTION
PPO CUSTOM - LOW-OPT COBRA
PPO CUSTOM - LOW OPTION
PPO CUSTOM - LOW-OPT COBRA
PPO CUSTOM - LOW OPTION
PPO CUSTOM - LOW-OPT COBRA
PAYMENT LAG PREMIUM ALLOC
POS FLEX 15/400/1500 99 CB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
PREFERRED PLAN
PREFERRED PLAN (2)
PREFERRED PLAN
$5G/$15BR $1500 BRND MAX
$5G/$25BR $1000 CMBND MAX
$5G/$20BR $1200 CMBND MAX
UFCW $3G/$6BR UNLIMITED
$5G/$15BR $1200 BRND MAX
POS FLEX 15/300/1200 99 CB
RESERVED PFFS
PREFERRED PLAN (COBRA)
PREFERRED PLAN (COBRA) (2)
526 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
PZ3
PZF
PZG
PZH
PZI
QAC
QAZ
QBC
QBI
QBZ
QCC
QCZ
QDC
QDG
QDZ
QIK
R01
R02
R03
R04
R05
R06
R07
R08
R10
R12
R2B
R34
R3B
R4B
R4C
R4Z
R5B
R5C
R5Z
R6B
R6C
R6Z
R7C
R7Z
R8C
R8Z
R9C
R9Z
RA3
RA4
RA5
RA6
RA8
RAC
Plan / Benefit Description
PREFERRED PLAN (COBRA) (3)
SV 15-30/100A PC CB
SV 15-30/100A PC CB
SV 15-30/100A PC CB
SV 15-30/100A PC CB
$20 PLAN
$20 PLAN COBRA
$20 PLAN
QUALITY BUSINESS INCENTIVE
$20 PLAN COBRA
$20 PLAN
$20 PLAN COBRA
$20 PLAN
*OK TO USE*LOADED IN ERROR
$20 PLAN COBRA
INDEPENDENT $20 PLAN
REGION LG $20-$40/$250 DAY
REGION $20-$40/$250 DAY CB
REGION LG $20-$40/$250 DAY
REGION $20-$40/$250 DAY CB
REGION LG $20-$40/$250 DAY
REGION $20-$40/$250 DAY CB
REGION LG $20-$40/$250 DAY
REGION $20-$40/$250 DAY CB
$10
$12G/$25B
$7G/$14B
$5
$10G/$20B
$10G/$25B
$10/$250 NAT'L ACCT PLAN
$10/$250 NAT'L ACCT COBRA
$10G/$20B/$40NF
$10/$250 NAT'L ACCT PLAN
$10/$250 NAT'L ACCT COBRA
$15G/$25B/$40NF
$10/$250 NAT'L ACCT PLAN
$10/$250 NAT'L ACCT COBRA
$10/$250 NATIONAL FOLEYS
$10/$250 NATL FOLEYS COBRA
$10/$250 NATIONAL FOLEYS
$10/$250 NATL FOLEYS COBRA
$10/$250 NATIONAL FOLEYS
$10/$250 NATL FOLEYS COBRA
$7G/$14B
$10G/$20B
$10G/$25B
$10G/$20B/$40NF
$15G/$25B/$40NF
$10/$250 NATIONAL FOLEYS
527 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
RAZ
RB4
RB6
RB7
RB8
RB9
RD5
RE1
RE2
RE3
RE4
RE5
RE6
RE7
RE8
REA
REB
REC
RED
REE
REF
REG
REH
RF5
RGM
RH1
RH2
RH3
RH4
RH5
RJD
RJW
RP5
RPE
RPX
RS0
RS1
RS2
RS4
RS5
RS6
RS7
RS8
RSA
RSB
RSI
RST
RT5
RX0
RX1
Plan / Benefit Description
$10/$250 NAT'L FOLEYS COB
$7G/$14B
$10G/$20B
$10G/$25B
$10G/$20B/$40NF
$15G/$25B/$40NF
$5G/$15B 1800 ANN MAX RX
REED ELSE $10-$20/$250
REED ELSE $10-$20/$250 CBR
REED ELSE $10-$20/$250
REED ELSE $10-$20/$250 CBR
REED ELSE $10-$20/$250
REED ELSE $10-$20/$250 CBR
REED ELSE $10-$20/$250
REED ELSE $10-$20/$250 CBR
SWR 10-40/100D 5M
SWR 10-40/100D 5M COBRA
SWR 10-40/100D 5M
SWR 10-40/100D 5M COBRA
SWR 10-40/100D 5M
SWR 10-40/100D 5M COBRA
SWR 10-40/100D 5M
SWR 10-40/100D 5M COBRA
$5
$7G/$15B/$15NF
FMR HRRS RT$5OV/$25ER/$5UR
FMR HRRS RT $0 OV/$0 ER&UR
FMR HRRS RT $7OV/50ER/25UR
FMR HRRS RT $5OV/25ER/5UR
FMR HRRS RT $5OV/50ER/25UR
J.C. PENNY 10/200
J.C. PENNEY 10/200 COBRA
$5
RESPITE/PERS CARE SH07
RESPITE/PERS CARE WL-SH08
$15G
$10
$10G/$30B
$10G
$5G/$25B 1200 ANN.MAX.
$6G/$20B
$10G/$30B/100%NF
$10G/$30B
$6G/$20B
$6G/$20B
INDEMNITY PHARMACY BENEFIT
$5G/$25B 1800 ANN.MAX.
$5G/10B
$0
$1
528 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
RX2
RX3
RX4
RX5
RX6
RX7
RX8
RX9
RXA
RXB
RXC
RXD
S00
S10
S12
S13
S1C
S1Z
S70
S80
SA1
SA2
SER
SF9
SFC
SFD
SH0
SH1
SH2
SH4
SH5
SH6
SH7
SH8
SH9
SHB
SHC
SHD
SHE
SHF
SHG
SHH
SHJ
SHK
SHL
SHM
SHN
SHO
SHP
SHR
Plan / Benefit Description
X2
$3
$4
$5
$6
$7
$8
$9
$5G/$10B
$5G/$10B
$5G/$10B
PHARMACY DISCOUNT
SERIOUS MENTAL ILL. (100%)
STANDARD 10 PLAN
STANDARD 10 PLAN (2)
STANDARD 10 PLAN (3)
DUMMY CODE
DUMMY CODE
SERIOUS MENTAL ILL. (70%)
SERIOUS MENTAL ILL. (80%)
SAN ANTONIO AREA-SH INDIV.
SA AREA-SH INDV.PRT B ONLY
SUPP ELIGIBILITY RIDER
SECURE HORIZ. B ONLY PLAN
SPLIT FAMILY COVERAGE
$10/$30/$60 SF
SPEECH & HEARING
SECURE HORIZONS STANDARD
SECURE HORIZONS B-ONLY
SA SH STANDARD PLAN
SECURE HORIZON GP RETIREE
SH RETIREE $6 OV
SA SH STANDARD PLAN PRT B
HOUSTON SH STANDARD PLAN
HOUSTON SH STANDARD PRT B
DALLAS SH STANDARD PRT B
SA SH STANDARD PLAN $10
FHP SENIOR PLAN/SILVER DNT
TX SH STANDARD PLAN
SECURE HORIZ. B ONLY PLAN
FHP SENIOR PLAN
FHP SENIOR PLAN PART B
TX SH STANDARD PLAN
TX SH STANDARD PLAN PART B
TX SH STANDARD PLAN PART B
TX SH STANDARD PLAN
TX SH PART B
DALLAS SH STANDARD PLAN
FHP SENIOR PLAN PLUS
RETIREE GOLD SENIOR FHPS
529 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
SHS
SHT
SHU
SM1
SM7
SM8
SMA
SMB
SMC
SMD
SME
SMF
SMG
SMH
SMJ
SMK
SML
SMM
SMN
SMO
SMP
SMQ
SMR
SMS
SMT
SMU
SMV
SMW
SMY
SMZ
SP1
SR5
SR6
SS2
SS4
SS6
SS7
SS9
SSB
SSE
SSG
SSH
SSI
SSJ
SSK
SSM
SSP
SSR
SST
ST1
Plan / Benefit Description
SECURE HORIZONS PLAN
TX SH STANDARD PLAN
TX SH PART B
SERIOUS MENTAL ILL. 100%
SERIOUS MENTAL ILL. 70%
SERIOUS MENTAL ILL. 80%
SERIOUS MENTAL ILL. (70%)
SERIOUS MENTAL ILL (80%)
SERIOUS MENTAL ILL. (100%)
SERIOUS MENTAL ILL. (90%)
SERIOUS MENTAL ILL $0 I/P
SERIOUS MENTAL ILL $100 IP
SERIOUS MENTAL ILL $250 IP
SMI IP&OP OP$15/60V MERCER
SMI $10OV/0IP FLEX 193-4
SMI $10OV/300IP FLEX 189-3
SMI $15OV/300IP FLEX 108-3
SERIOUS MENTAL ILL. $400
SMI $15OV/400IP FLEX 109-3
SERIOUS MENTAL ILL. $600
SMI $20OV/200IP FLEX 219-3
SMI $20OV/300IP FLEX 106-4
SMI $20OV/400IP FLEX 100-3
SERIOUS MENTAL ILL. $150
SMI $25OV/600IP FLEX 123-3
SERIOUS MENTAL ILL (100%)
SMI - CUSTOM GENERAL MOTOR
SERIOUS MENTAL ILL $250 IP
SERIOUS MNTL ILL 100% FEDS
SERIOUS MENTAL ILL - SG
SUPPLEMENTAL LIFE BENE
SH GRP RET $5/100% 2001
SH GRP RET $6/100% 2001
SMI $15OV/200IP SFLEX 99-3
SMI $15OV/100IP SFLX 103-4
SMI $10OV/200IP SFLX 110-3
SMI $15OV/20%IP SFLEX 92-3
SECURE HORIZONS STANDARD
SECURE HORIZONS B-ONLY
SMI $15OV/300IP SFLX 107-4
SMI $20OV/400IP SFLX 101-4
SMI $15OV/400IP SFLEX 98-3
SMI $25OV/600IP SFLX 114-2
SMI $20OV/300IP SFLX 102-4
SMI $10OV/300IP SFLX 119-3
SMI $25OV/600IP SFLX 114-3
SH SILVER SNEAKERS
SLV SNEAK/FITNESS BEN GR06
SECURE HORIZONS STANDARD
STANDARD PLAN
530 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
ST2
ST3
ST5
STD
SWK
SWV
SZ0
SZ1
SZ2
SZ3
SZ5
SZE
T0Z
T1S
T1X
T2A
T2S
T2Z
T3A
T3P
T3Z
T4A
T4P
T4Z
T5A
T5Z
T6A
T6Z
T7Z
T8Z
T9Z
TA1
TA6
TAK
TAW
TAX
TBZ
TC1
TC2
TC3
TC4
TCA
TCB
TCC
TCD
TCZ
TDA
TDB
TDC
TDD
Plan / Benefit Description
STANDARD PLAN
STANDARD PLAN
STANDARD 5 PLAN
RESERVED FOR PPO LIFE
WALLA WALLA POS PLAN
WALLA WALLA POS PLAN-COBRA
STANDARD 10 PLAN (COBRA)
STANDARD PLAN (COBRA)
STANDARD PLAN (COBRA) (2)
STANDARD PLAN (COBRA) (3)
STANDARD 5 PLAN
EMP. RET. SYS. STATE COBRA
PPO 0/10/200 98 IN NET CBR
TX SG HMO $20/$40/$250D CB
PPO 0/10/300 98 IN NET CBR
TX SH STANDARD PLAN
TX SG HMO $20/$40/$250D CB
PPO 0/15/200 98 IN-NET CBR
TX SH STANDARD PLAN PART B
15-20/100A GR06
PPO 0/15/300 IN-NET CBR
TX SH STANDARD PLAN 05
5-10/100% GR06
PPO O/14/400 98 IN-NET CBR
TX SH STD PLAN PART B 05
PPO 0/20/300 98 IN-NET CBR
TX SH STANDARD PLAN W/D
PPO 0/20/300A 98 IN-NETCBR
PPO 0/20/400 98 IN-NET CBR
PPO 0/25/600 98 IN-NET CBR
PPO 100/15/90% 98 IN-NETCB
TEXAS A&M PLAN
0/24T NON-ER TRANS SH-06
5-15/75D ATAS/KEN SH05
TEXAS A&M PLAN - COBRA
TAX PCTX PREMIUM TAX
PPO 250/10/90% 98 IN-NETCB
LOCKHEED $0/100% COBRA
LOCKHEED $0/100% COBRA
LOCKHEED $0/100% COBRA
LOCKHEED $0/100% COBRA
LOCKHEED $0/100%
LOCKHEED $0/100%
LOCKHEED $0/100%
LOCKHEED $0/100%
PPO 250/20/80% 98 IN-NETCB
TX SH STANDARD PLAN
TX SH STANDARD PLAN PART B
TX SH STANDARD-D/C
TX SH STANDARD PLAN 05
531 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
TDE
TDF
TDZ
TEZ
TF1
TF2
TF3
TF4
TF5
TFZ
TGA
TGZ
TH0
TH1
TH2
TH3
TH4
TH5
TH6
TH7
TH8
TH9
THA
THB
THC
THD
THE
THF
THG
THH
THJ
THZ
TI1
TI2
TI3
TI4
TI5
TI6
TI7
TI8
TIA
TIB
TIC
TID
TIT
TJZ
TKA
TKZ
TL1
TL2
Plan / Benefit Description
TX SH STD PLAN PART B 05
TX SH STANDARD PLAN W/D
PPO 250/20/90% 98 IN-NETCB
PPO 300/20/80% 98 IN-NETCB
TEXAS PLAN I LIMITED FEE
TEXAS PLAN II LIMITE FEE
TEXAS PLAN III LIMITED FEE
TEXAS PLAN IV LIMITED FEE
TEXAS PLAN V LIMITED FEE
PPO 500/15/80% 98 IN-NETCB
0/50A SECURE GOLD SH05
PPO 500/25/80% 98 IN-NETCB
PPO 0/10/200 98 IN NET
PPO 0/10/300 98 IN NET
PPO 0/15/200 98 IN-NET
PPO 0/15/300 IN-NET
PPO O/15/400 98 IN-NET
PPO 0/20/300 98 IN-NET
PPO 0/20/300A 98 IN-NET
PPO 0/20/400 98 IN-NET
PPO 0/25/600 98 IN-NET
PPO 100/15/90% 98 IN-NET
PPO 250/15/80%C 98 IN-NET
PPO 250/10/90% 98 IN-NET
PPO 250/20/80% 98 IN-NET
PPO 250/20/90% 98 IN-NET
PPO 300/20/80% 98 IN-NET
PPO 500/15/80% 98 IN-NET
PPO 500/25/80% 98 IN-NET
CFW PPO 200/15/80% 98 IN
PPO JCPENNY IN-NET
CFW PPO 200/15/80% 98 INCB
REGIONAL LG $20/80%
REGIONAL LG $20/80% COBRA
REGIONAL LG $20/80%
REGIONAL LG $20/80% COBRA
REGIONAL LG $20/80%
REGIONAL LG $20/80% COBRA
REGIONAL LG $20/80%
REGIONAL LG $20/80% COBRA
TX-SA SECURE GOLD
TX-D SECURE GOLD
TX-SA SECURE GOLD 05
TX-D SECURE GOLD 05
TRANSPORTATION S GOLD
PPO JC PENNY IN NET COBRA
5-15/75D ATAS/KEN W/D SH05
PPO 250/15/80%C 98 IN CBRA
TX LG HMO $20/100% COBRA
TX LG HMO $20/100% COBRA
532 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
TL3
TL4
TL5
TL6
TL7
TL8
TLA
TLB
TLC
TLD
TLE
TLF
TLG
TLH
TLI
TLJ
TLK
TLL
TLW
TLX
TLY
TLZ
TN1
TN2
TN3
TN4
TN5
TN6
TN7
TNS
TP3
TP4
TPH
TPL
TS0
TS1
TS2
TS3
TS4
TS5
TS6
TS7
TS8
TS9
TSA
TSB
TSC
TSD
TSE
TSF
Plan / Benefit Description
TX LG HMO $20/100% COBRA
TX LG HMO $20/100% COBRA
TX LG HMO $20/$400 COBRA
TX LG HMO $20/$400 COBRA
TX LG HMO $20/$400 COBRA
TX LG HMO $20/$400 COBRA
TX LG HMO $20/100%
TX LG HMO $20/100%
TX LG HMO $20/100%
TX LG HMO $20/100%
TX LG HMO $20/$400
TX LG HMO $20/$400
TX LG HMO $20/$400
TX LG HMO $20/$400
TX LG HMO $20/80%
TX LG HMO $20/80%
TX LG HMO $20/80%
TX LG HMO $20/80%
TX LG HMO $20/80% COBRA
TX LG HMO $20/80% COBRA
TX LG HMO $20/80% COBRA
TX LG HMO $20/80% COBRA
$15G/$25B
$15G/$35B
$10G/$35B
$10G/$20B/$30NF
$10G/$25B/$50NF
$10G/$25B/$40NF
$15G/$25B/$40NF
5-15/75D N-SP W/D SH05
TOWERS PERRIN $15 PLAN
TOWERS PERRIN $15 PLAN
5-10/100% GR06
15-20/100A GR06
TX SG HMO $20/$40/$250D CB
TX SG HMO $10/$200 COBRA
TX SG HMO $10/$200 COBRA
TX SG HMO $10/$200 COBRA
TX SG HMO $10/$200 COBRA
TX SG HMO $20/$400 COBRA
TX SG HMO $20/$400 COBRA
TX SG HMO $20/$400 COBRA
TX SG HMO $20/$400 COBRA
TX SG HMO $20/$40/$250D CB
TX SG HMO $10/$200
TX SG HMO $10/$200
TX SG HMO $10/$200
TX SG HMO $10/$200
TX SG HMO $20/$400
TX SG HMO $20/$400
533 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
TSG
TSH
TSI
TSJ
TSK
TSL
TSN
TU1
TU2
TU3
TU4
TU5
TU6
TZ2
TZ3
U01
U02
U03
U04
U05
U06
U07
U08
U09
U10
U11
U12
U13
U14
U15
U16
U17
U18
U19
U20
U21
U22
U23
U24
U25
U26
U27
U28
U29
U30
U31
U32
U33
U34
U35
Plan / Benefit Description
TX SG HMO $20/$400
TX SG HMO $20/$400
TX SG HMO $20/$40/$250D
TX SG HMO $20/$40/$250D
TX SG HMO $20/$40/$250D
TX SG HMO $20/$40/$250D
5-15/75D N-SP SH05
TEXAS SM GRP PLAN I UC
TEXAS SM GRP PLAN II UC
TEXAS SM GRP PLAN III UC
TEXAS SM GRP PLAN IV UC
TEXAS SM GRP PLAN V UC
TEXAS SM GRP INDEMNITY UC
STANDARD 10 PLAN (COBRA 2)
STANDARD 10 PLAN (COBRA 3)
USUSAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUSAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUSAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PP9O
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
534 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
U36
U37
U38
U39
U40
U41
U42
U43
U44
U45
U46
U47
U48
U49
U50
U51
U52
U53
U54
U55
U56
U57
U58
U59
U60
UHC
UTC
UTS
UZS
V07
V12
V15
V17
V1A
V1B
V1C
V1D
V20
V22
V23
V25
V27
V28
V2C
V2D
V2F
V30
V32
V3A
V3B
Plan / Benefit Description
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
DUAL-OPTION - UHC 06
TAKING CHARGE OF YOU
UNIVERSITY OF TEXAS
UNIVERS. OF TEXAS (COBRA)
VISION CARE $7 (VSP)
VISION CARE $12 (VSP)
VISION CARE $15 (VSP)
FISION CARE $5REF/$12MAT
STANDARD $15 POS PLAN
STANDARD $15 POS PLAN CBRA
POS 15/90/70
POS 15/90/70 COBRA
VISION CARE $8REF/$12MAT
VISION CARE $10REF/$12MAT
VISION CARE $23 (VSP)
VISION CARE $5REF/$20MAT
SC 20 ELIGIBILITY ONLY
VISION CARE $8REF/$20MAT
POS 15/90/70
POS 15/90/70 COBRA
25/70A TOWERS GR-VN06 VSP
VISION CARE $10REF/$20MAT
VISION CARE $20REF/$12MAT
STANDARD $15 POS SMALL GRP
STANDARD 15 POS SMALL CBRA
535 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
V3C
V3D
V3S
V40
V4A
V4B
V4C
V4D
V4S
V5A
V5B
V5C
V5D
V5S
V6A
V6B
V6C
V6D
V6S
V7A
V7B
V7C
V7D
V8A
V8B
V8C
V8D
V8P
V8Q
V8R
V8S
V8T
V8U
V8V
V8W
V8X
V9A
V9B
VA6
VAA
VAB
VAC
VAD
VAE
VAF
VAG
VAH
VAI
VAJ
VAK
Plan / Benefit Description
POS 15/90/70
POS 15/90/70 COBRA
SH $15/$150 ALLOWANCE
VISION CARE $20REF/$20MAT
STANDARD $15 POS SMALL GRP
STANDARD $15 POS SMALL CBR
POS 15/90/70
POS 15/90/70 COBRA
SH $20/$150 ALLOWANCE
$15 POS
$15 POS COBRA
POS 15/80/60
POS 15/80/60 COBRA
$5/$100 ALLOW S GOLD
$15 POS
$15 POS COBRA
POS 15/80/60
POS 15/80/60 COBRA
SH 25/150 ALLOWANCE (COLE)
$15 POS
$15 POS COBRA
POS 15/80/60
POS 15/80/60 COBRA
$15 POS
$15 POS COBRA
POS 15/80/60
POS 15/80/60 COBRA
0 REFRAC 1/V YR VN-GR08
5 REFRAC 1/V YR VN-GR08
10 REFRAC 1/V YR VN-GR08
15 REFRAC 1/V YR VN-GR08
20 REFRAC 1/V YR VN-GR08
25 REFRAC 1/V YR VN-GR08
30 REFRAC 1/V YR VN-GR08
35 REFRAC 1/V YR VN-GR08
40 REFRAC 1/V YR VN-GR08
STANDARD $15 POS PLAN
STANDARD $15 POS PLAN COB
5/100A 2 YRS SH-VN06
VISION $3 REF/$65 ALLOW.
VISION $5 REF/$65 ALLOW.
VISION $8 REF/$65 ALLOW.
VISION $10 REF/$65 ALLOW.
VISION $20 REF/$65 ALLOW
VISION $3 REF/$100 ALLOW.
VISION $5 REF/$100 ALLOW.
VISION $8 REF/$100 ALLOW.
VISION $10 REF/$100 ALLOW.
VISION $20 REF/$100 ALLOW
VISION $3 REF/$125 ALLOW.
536 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
VAL
VAM
VAN
VAO
VAP
VAQ
VAR
VAS
VAT
VB6
VDA
VFP
VFQ
VG6
VGP
VGQ
VH1
VH2
VH4
VH5
VH6
VJQ
VKP
VMQ
VN1
VN2
VN5
VNQ
VP6
VPE
VPP
VQC
VQD
VQF
VQG
VQJ
VQK
VQL
VQP
VQR
VQT
VQX
VRR
VS1
VS2
VS3
VSE
VSF
VSG
VSK
Plan / Benefit Description
VISION $5 REF/$125 ALLOW.
VISION $8 REF/$125 ALLOW.
VISION $10 REF/$125 ALLOW.
VISION $20 REF/$125 ALLOW.
VISION $5 REF/$100 ALLOW.
VISION $10 REF/$100 ALLOW.
VISION $15 REF/$100 ALLOW.
VISION $20 REF/$100 ALLOW.
VISION $25 REF/$100 ALLOW.
25/150A 2 YRS SH-VN06
15/70A GR-VN07
0/75A 2YRS VN-GR08
0/125A 2YRS VN-GR08
25/75A VN-GR06
5/75A 2YRS VN-GR08
5/125A 2YRS VN-GR08
SENIOR VISION 7 OV/100 ALW
VISION SUPP $10 COPAY
VISION SUPP $5 COPAY
VISION SUPP $15 COPAY
VISION PPO SUPPLEMENT
10/75 2YRS VN-GR08
10/125A 2YRS VN-GR08
15/125A 2YRS VN-GR08
GRP RET $5OV/$125 ALLOWNCE
GRP RET $10OV/$75 ALLOWNCE
GRP RET $20V/$75 ALLOWANCE
20/75A 2YRS VN-GR08
ADVANCE WELLNESS SH-WL06
RESERVED PFFS
20/125A 2YRS VN-GR08
15/130A 1YR DLX VN-SH08
30/70A 2YRS VN-SH08
0/130A 2YRS VN-SH08
25/150A 2YRS VN-SH08
5/100A 2YRS VN-SH08
0/75A 2YRS VN-SH08
0/300A 2 YRS+GLS VN-SH08
25/70A 2YRS VN-GR08
0/70A 2YRS VN-SH08
0/100A 2YRS VN-SH08
0 1YR/100A 2YRS VN-SH08
10/75A GR-VN07
SENIOR VISION 7 OV/100 ALW
SENIOR VISION 5 OV/100 ALW
SENIOR VISION 0 OV/100 ALW
0/75A 2YRS SH-VN07
0/130A 2YRS SH-VN07
0/300A 2 YRS+GLS SH-VN07
5/100A 2YRS SH-VN07
537 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
VSM
VSQ
VSX
VV1
VV2
VV3
VV4
VV5
VV6
VV7
VVP
VVQ
VWP
VWQ
WAP
WB6
WEL
WIK
WJR
WJS
WJT
WLQ
WLR
WLT
WPR
WPS
WPT
WQR
WQS
WQT
WRR
WRS
WRT
WUR
WUS
WUT
WVR
WVS
WVT
WXR
WXS
WXT
WYR
WYS
WYT
X10
X5M
XA5
XAA
XAB
Plan / Benefit Description
25/150A 2YRS SH-VN07
30/70A 2YRS SH-VN07
15/130A 1YR DLX SH-VN07
VISION STANDARD $0 COPAY
VISION STANDARD $5 COPAY
VISION STANDARD $10 COPAY
VISION STANDARD $15 COPAY
VISION STANDARD $20 COPAY
VISION STANDARD $25 COPAY
VISION STANDARD $30 CO-PAY
15/75A 2YRS VN-GR08
25/75A 2YRS VN-GR08
25/125A 2YRS VN-GR08
0/70A 2YRS VN-GR08
RESERVED WT ALT PROGRAM
HLTH EDUC SH-WL06
SUPPLEMENTAL WELLNESS
INDEPENDENT $15 PLAN
10-15/50A T1A CC GR07
5-20/100A T1B CC GR07
10-20/200A T1C CC GR07
10-20/750A T2A CC GR07
15-25/130D T2B CC GR07
10-25/150D T2C CC GR07
10-15/50A T1A GR07
5-20/100A T1B GR07
10-20/200A T1C GR07
10-20/750A T2A GR07
15-25/130D T2B GR07
10-25/150D T2C GR07
15-25/200D T3A GR07
15-30/220D T3B GR07
20-35/250D T3C GR07
15-25/200D T3A GR07
15-30/220D T3B GR07
20-35/250D T3C GR07
10-20/750A T2A GR07
15-25/130D T2B GR07
10-25/150D T2C GR07
10-15/50A T1A GR07
5-20/100A T1B GR07
10-20/200A T1C GR07
15-25/200D T3A CC GR07
15-30/220D T3B CC GR07
20-35/250D T3C CC GR07
$10G/$15B
$5G/ $5B
$5
$5G/$15B
$5G/$20B
538 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
XAC
XAD
XAE
XAF
XAG
XAH
XAT
XGM
XGS
XM0
XM1
XM2
XM3
XM4
XM5
XM6
XM7
XM8
XM9
XMA
XMB
XMC
XMD
XME
XMF
XMG
XMH
XMI
XMJ
XMK
XML
XMM
XMN
XMO
XMP
XMQ
XMR
XMT
XMU
XMW
XNN
XP5
XPA
XPB
XPC
XPD
XTU
XXX
YXA
YXJ
Plan / Benefit Description
$5G/$25B
$10G/$20B
$10G/25B
$10
$10G/$30B
$5G/$10B
$10G/$30B
$2G/$2B OPEN FORMULARY
$5G/$5B OPEN FORMULARY
$0
$1
$2
$3
$4
$5
$6
$7
$8
$9
$10
$5G/$10B
$5G/$15B
$5G/$20B
$5G/$25B
$10G/$20B
$10G/$25B
$10G/$30B
$8G/$12B
$10G/$15B
$10
$5GF/$10BF
$5GF/$15BF
$10GF/$15BF
$10GF/$25BF
$5/$10/$25
$5GF/$10BF
$5/$10/$25
$5GF/$10BF
$5G/$10BR CUSTOM
$5G/$5B OPEN FORMULARY
DO NOT USE
$5
$10
$5/$15/70%
$10/$25/60%
$10/$25/70%
$5G/$5B OPEN FORMULARY
PREMIUM ALLOCATION
SV 35/240A W/BH9 06
SV 35/240A W/BH9 06 CB
539 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
YYA
YYB
YYJ
YYX
YZC
YZZ
Z2J
Z2M
Z2P
Z2R
Z2T
Z2U
Z2V
Z2X
Z2Y
Z5M
Z5R
Z5V
Z8J
Z8P
Z8X
ZA2
ZA3
ZA4
ZA5
ZA6
ZA7
ZA8
ZA9
ZB2
ZB3
ZB4
ZB5
ZB6
ZB7
ZB8
ZB9
ZC2
ZC3
ZC4
ZC5
ZC6
ZC7
ZC8
ZC9
ZD2
ZD3
ZD4
ZD5
ZD6
Plan / Benefit Description
SV 35/240A W/BH9 06
SV 35/240A W/BH9 06 CB
SV 35/240A W/BH9 06
SV 35/240A W/BH9 06 CB
SV 35/240A W/BH9 06
SV 35/240A W/BH9 06 CB
10-15/50A T1A NON-AARP GR8
10-20/750A T2A NO-AARP GR8
10-15/50A T1A NON-AARP GR8
10-20/750A T2A NO-AARP GR8
15-25/200D T3A NO-AARP GR8
15-25/200D T3A NO-AARP GR8
10-20/750A T2A NO-AARP GR8
10-15/50A T1A NON-AARP GR8
15-25/200D T3A NO-AARP GR8
15-25/130D T2B NO-AARP GR8
15-25/130D T2B NO-AARP GR8
15-25/130D T2B NO-AARP GR8
10-20/200A T1C NO-AARP GR8
10-20/200A T1C NO-AARP GR8
10-20/200A T1C NO-AARP GR8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
540 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
ZD7
ZD8
ZD9
ZE2
ZE3
ZE4
ZE5
ZE6
ZE7
ZE8
ZE9
ZF2
ZF3
ZF4
ZF5
ZF6
ZF7
ZF8
ZF9
ZG2
ZG3
ZG4
ZG5
ZG6
ZG7
ZG8
ZG9
ZH2
ZH3
ZH4
ZH5
ZH6
ZH7
ZH8
ZH9
ZJ2
ZJ3
ZJ4
ZJ5
ZJ6
ZJ7
ZJ8
ZJ9
ZK2
ZK3
ZK4
ZK5
ZK6
ZK7
ZK8
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
541 of 640
Plan Benefit - TX
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Plan / Benefit
ZK9
ZM2
ZM3
ZM4
ZM5
ZM6
ZM7
ZM8
ZM9
ZN2
ZN3
ZN4
ZN5
ZN6
ZN7
ZN8
ZN9
ZP2
ZP3
ZP4
ZP5
ZP6
ZP7
ZP8
ZP9
ZR2
ZR3
ZR4
ZR5
ZR6
ZR7
ZR8
ZR9
ZZZ
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
HISTORICAL PLAN
542 of 640
Plan Benefit - WA
Cap/Eligibility CP7810
Assigned Plan Benefit Codes & Descriptions
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
11C
1C1
1LL
1MS
1U7
1WS
1ZL
213
21C
21U
22U
23C
23U
24C
24U
25U
26U
27U
28U
29U
2AL
2AN
2AT
2AY
2BL
2BU
2C4
2CA
2CJ
2CK
2EU
2FH
2FL
2GH
2HH
2JH
2KH
2KU
2LU
2MH
2MU
2NH
Plan / Benefit Description
$0
$7/$7
INDIVIDUAL CONV-COMPREHNSV
15 SH-RX05
UNAVIAL DO NOT USE IN WA
$9G SH
INDIVIDUAL CONV-MAJOR
RESERVED FOR PREMIER PASS
$5G/$10B
$5G/$10B
$5G/$15B
$9G/$15B
$5G/$20B
$7.50G/$15B
$5G/$25B
$10G/$20B
$10G/$25B
$10G/$35B
$15G/$25B
$15G/$35B
INDIVIDUAL CONV-BASIC
4/20/40 LO GR-RX07
5/15 RX 06
4/25/50 HI GR-RX07
10/25/50 RX-GR08
$5G/$15B
$5G/$15B AT&T
$5G/$15B
$5G/$15B
$10G/$20B
$10G/$20B
4/15/30 RX-GR08
5/20/45 RX-GR08
4/20/40 RX-GR08
4/15/30 RX-GR08
4/20/40 RX-GR08
4/25/50 RX-GR08
$5/10 W/INF
$5/15 W/INF
4/25/45 RX-GR08
$10/20 W/INF
4/28/55 RX-GR08
543 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
2NU
2ON
2OU
2P2
2PH
2PU
2QH
2QU
2S1
2S2
2S3
2S4
2S5
2S6
2S7
2SA
2SB
2SC
2SD
2SE
2SF
2SH
2U1
2U2
2U3
2U4
2U5
2U6
2U7
2UA
2UB
2UC
2UD
2UE
2UF
2UH
2VH
2WH
2XH
2YH
2ZA
2ZB
2ZC
2ZD
2ZE
2ZF
3
31C
31S
32C
Plan / Benefit Description
$10/25 W/INF
POS-OUT OF NETWORK
$10/35 W/INF
RESERVED 2003 SH CODE
4/28/58 RX-GR08
$15/25 W/INF
4/25/50 RX-GR08
$15/35 W/INF
$5G/$10B
$5G/$15B
$5G/$20B
$5G/$25B
$10G/$20B
$10G/$25B
$10G/$35B
$15G/$40B
$5G/$15B
$10/20
$10/25
$10G/$20B
$10/35
$15/40
$5G/$10B
$5G/$15B
$5G/$20B
$5G/$25B
$10G/$20B
$10G/$25B
$10G/$35B
DO NOT USE IN WA
OR RX CODE DONT USE IN WA
DO NOT USE IN WA
RX CODE DO NOT USE IN WA
OR RX CODE DONT USE IN WA
OR RX CODE DONT USE IN WA
10/25/50 RX-GR08
10/25/50 RX-GR08
5/20/45 RX-GR08
5/20/45 RX-GR08
4/10/20 RX-GR08
0/0 GR-RX07
2/40 GR-RX07
5/25 GR-RX07
5/65 GR-RX07
5/10 GR-RX07
10/20 GR-RX07
CODE INCOMPLETE
$5/$10/$15
$10/$20/50%
$10/$20/$30
544 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
32S
33C
33S
33U
34C
35C
35U
36C
36U
37C
37U
38C
38U
39C
39U
3AC
3AL
3AU
3B6
3BC
3BD
3BE
3BU
3C1
3C2
3C4
3C5
3C6
3C7
3C8
3C9
3CA
3CU
3CW
3CY
3D1
3D2
3D3
3D4
3D5
3D6
3D7
3D8
3DE
3EA
3FC
3FD
3GA
3GB
3GF
Plan / Benefit Description
$10/15/30
$10/$20/$30
$15/25/40
$10/$15/$30
$0/$0/$0
$5/$10/$25
$5/$10/$25
$8G/$13B/$28NF
$10G/$20B/$30NF
$5G/$10B/$10NF
$10G/$25B/$40NF
$10G/$25B/$40NF
$10G/$25B/$50NF
$10G/$20B/$40NF
$15G/$25B/$40NF
$10G/$20B/$30NF
5/10/25 WSD RX05
$10/20/45 W/INF E
15/30/50/100D RX06
$10/20/35 W/O INF
10/20/35 UNDER LAB
5/10/25 RX 06
$10/30/50 W/INF E
$10/$15/$30
$10/$20/$30
$0/$0/$0
$10G/$15B/$25NF
$10G/$25B/$50NF
$10G/$20B/$35NF
$10G/$25B/$40NF
$10G/$20B/$40NF
5/10/25 RX 06
$15/25/50 W/INF E
$10G/$25B/$50NF WF
10G/20B/35NF I VBA
$15G/$25B/$40NF $100 DED
$15G/$25B/$40NF $200 DED
$15/30/50/100D E
$15/35/60/200D E
$15/25/40/$100D
$15/25/40/$200D
$15/30/50/$100D E
$15/35/60/$200D E
15/30/50 RX 08
RESERVED FIDELITY RX 06
10/30/50 RX05
15/30/60 RX06 SF
$15G/$25B/$40NF
15G/25B/40NF W/INJ
20/30/45 RX 07
545 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
3HA
3HC
3HP
3JC
3JU
3KU
3LU
3MU
3NU
3OU
3PC
3PD
3PH
3PU
3QU
3S1
3S2
3S3
3S4
3S5
3S6
3SC
3SD
3SE
3SH
3SJ
3SK
3TU
3U1
3U2
3U3
3U4
3U5
3U6
3U7
3U8
3U9
3UA
3UB
3UC
3UD
3UE
3UF
3UG
3UH
3UI
3UJ
3UK
3UN
3W3
Plan / Benefit Description
10/30/45 RX 06
10G/25B/40NF I HP
5/30/45 GR-RX07
0/0/0 RX 07
$5/10/25 W/INF
$10/15/30 W/INF
$10/20/30 W/INF
$10/25/40 W/INF
$10/25/50 W/INF
$15/25/40 W/INF
10G/30B/40NF E W/I
10/20/40 RX06
10/30/50 RX06
$10/20/45 W/INF E
$10/30/50 W/INF E
$3/$8/$23
$8/$13/$28
$15/$25/$40
$7/$12/$27
$5G/$10B/$25NF
$10G/$15B/$30NF
$10G/$20B/$45NF E
$10G/$30B/$50NF E
$15G/$25B/$50NF E
$10/20/45 E
$10/30/50 E
$15/25/50 E
$15/25/50 W/INF E
DO NOT USE IN WA
DO NOT USE IN WA
$10/$15/$30
DO NOT USE IN WA
$5/$10/$25
DO NOT USE IN WA
DO NOT USE IN WA
DO NOT USE IN WA
DO NOT USE IN WA
OR RX CODE DONT USE IN WA
OR RX COD DONT USE IN WA
OR RX CODE DONT USE IN WA
OR RX CODE DONT USE IN WA
$10/20/45 W/INFRTL
OR RX CODE DONT USE IN WA
OR RX CODE DONT USE IN WA
OR RX CODE DONT USE IN WA
OR RX CODE DONT USE IN WA
OR RX CODE DONT USE IN WA
OR RX CODE DONT USE IN WA
10/20/35 RX 06
$15/30/50/100D I E
546 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
3W4
3W5
3W6
3ZE
3ZF
3ZG
3ZH
3ZJ
3ZK
3ZL
3ZM
40A
40B
40C
40D
40E
40F
40G
40H
40I
40J
40K
40L
40M
40N
40O
40P
40Q
40R
40S
40T
40U
40V
40W
40X
40Y
40Z
41A
41B
41C
41D
41E
41F
41G
41H
41I
41J
41K
41L
41M
Plan / Benefit Description
$15/35/60/200D I E
$15/30/50/$100D I E
$15/35/60/$200D I E
5/10/20 GR-RX07
10/20/35 GR-RX07
10/20/35 GR-RX07
10/25/55 GR-RX07
10/40/75 GR-RX07
7/20/50% GR-RX07
2/30/60 GR-RX07
10/25/50 GR-RX07
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
547 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
41N
41O
41P
41Q
41R
41S
41T
41U
41V
41W
41X
41Y
41Z
42I
43I
440
44I
45I
46I
47I
48A
48I
49I
4A0
4A1
4AI
4AO
4B0
4B1
4BI
4BO
4C0
4C1
4CI
4CO
4D0
4D1
4E0
4E1
4EI
4EO
4F0
4F1
4FI
4FO
4G0
4G1
4GI
4H0
4H1
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
MCC 3 CENTRAL GR08
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
548 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
4HI
4HO
4I0
4I1
4IA
4IB
4IC
4ID
4IE
4IF
4IG
4IH
4II
4IJ
4IK
4IL
4IN
4IO
4IP
4IQ
4IR
4IS
4IT
4IU
4IV
4IW
4IX
4IY
4IZ
4J0
4J1
4JI
4JO
4K0
4K1
4KI
4KO
4L0
4L1
4LI
4M0
4M1
4MI
4MO
4N0
4N1
4NI
4NO
4O0
4O1
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
549 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
4OA
4OB
4OC
4OD
4OF
4OH
4OI
4OJ
4OK
4OL
4OM
4OO
4OP
4OQ
4OS
4OT
4OU
4OV
4OW
4OX
4OY
4OZ
4P0
4P1
4PI
4PO
4Q0
4Q1
4QI
4QO
4R0
4R1
4RO
4S0
4S1
4T0
4T1
4TI
4U0
4U1
4UI
4UO
4V0
4V1
4VI
4VO
4W0
4W1
4WI
4WO
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
550 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
4X0
4X1
4XI
4XO
4Y0
4Y1
4YI
4YO
4Z0
4Z1
4ZI
4ZO
500
501
502
503
504
505
506
507
508
509
50A
50B
50C
50D
50E
50F
50G
50H
50I
50J
50K
50L
50M
50N
50O
50P
50Q
50R
50S
50T
50U
50V
50W
50X
50Y
50Z
510
511
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
MANDATED OFFER RIDERS PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
551 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
512
513
514
515
516
517
518
519
51A
51B
51C
51D
51E
51F
51G
51H
51I
51J
51K
51L
51M
51N
51O
51P
51Q
51R
51S
51T
51U
51V
51W
51X
51Y
51Z
520
521
522
523
524
525
526
527
528
529
52I
530
535
536
537
538
Plan / Benefit Description
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
MANDATED OFFER RIDER PPO
RESERVED BENEFIT PPO
MANDATED OFFER RIDER PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
552 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
539
53I
540
541
542
543
544
545
546
547
548
549
54I
550
551
552
553
554
555
556
557
558
559
55I
560
561
562
563
564
565
566
567
568
569
56I
570
571
572
573
574
575
576
577
578
579
57I
580
581
582
583
Plan / Benefit Description
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
553 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
584
585
586
587
588
589
58I
590
591
592
593
594
59I
5A0
5A1
5AI
5AO
5B0
5BI
5BO
5C0
5C1
5CI
5CO
5D0
5D1
5E0
5E1
5EI
5F0
5F1
5FI
5FO
5G0
5G1
5GI
5H0
5H1
5HI
5HO
5I0
5I1
5IA
5IB
5IC
5ID
5IE
5IF
5IG
5IH
Plan / Benefit Description
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
554 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
5II
5IJ
5IK
5IL
5IN
5IO
5IP
5IQ
5IR
5IS
5IU
5IV
5IW
5IX
5IY
5IZ
5J0
5J1
5JI
5JO
5K0
5K1
5KI
5KO
5L0
5L1
5LI
5M0
5M1
5MI
5N0
5N1
5NI
5NO
5O0
5O1
5O2
5O3
5O4
5O5
5O6
5O7
5O8
5O9
5OA
5OB
5OD
5OF
5OH
5OI
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
555 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
5OJ
5OK
5OL
5OM
5ON
5OO
5OQ
5OS
5OT
5OU
5OV
5OW
5OX
5OY
5OZ
5P0
5P1
5PI
5PO
5Q0
5Q1
5QI
5QO
5R0
5RO
5S0
5T0
5T1
5TI
5U0
5U1
5UI
5UO
5V0
5V1
5VI
5VO
5W0
5W1
5WI
5WO
5X0
5X1
5XI
5XO
5Y0
5Y1
5YI
5YO
5Z0
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
556 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
5Z1
5Z2
5ZI
5ZO
635
636
637
638
639
640
641
642
643
644
645
646
647
648
649
650
651
652
653
654
655
656
657
658
659
660
661
662
663
664
665
666
667
668
669
670
671
672
673
674
675
676
677
678
679
680
Plan / Benefit Description
RESERVED BENEFIT PPO
STANDARD 5 PLAN (COBRA)
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
557 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
681
682
683
684
685
686
687
688
689
690
691
692
693
694
6AH
6AL
6BH
6BL
6CD
6DH
6DL
6EH
6EL
6FH
6FL
6GP
6HH
6HL
6HR
6JH
6JL
6JP
6KH
6KL
6KP
6LH
6LL
6MA
6MH
6ML
6NH
6NL
6NM
6PH
6PL
6PM
6QH
6QL
6RH
6RL
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
0/0 HI GR-RX07
0/0 LO GR-RX07
2/30/60 HI GR-RX07
2/30/60 LO GR-RX07
7/14 GR-RX06
2/40 HI GR-RX07
2/40 LO GR-RX07
5/25 HI GR-RX07
5/25 LO GR-RX07
5/65 HI GR-RX07
5/65 LO GR-RX07
8.50/26.45/50% SH6
5/10 HI GR-RX07
5/10 LO GR-RX07
10/20 GR-RX06
5/10/20 HI GR-RX07
5/10/20 LO GR-RX07
8.50/26.70/50% SH6
7/14 HI GR-RX07
7/14 LO GR-RX07
8.50/26.70/50% SH6
7/20/50% HI GR-RX7
7/20/50% LO GR-RX7
10/25%/40% RX-GR06
10/20 HI GR-RX07
10/20 LO GR-RX07
10/20/40 HI GR-RX7
10/20/40 LO GR-RX7
5/15/30 GR-RX06
10/20 HI GR-RX07
10/20 LO GR-RX07
5/15/30 GR-RX06
10/20/35 HI GR-RX7
10/20/35 LO GR-RX7
10/20/35 HI GR-RX7
10/20/35 LO GR-RX7
558 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
6SH
6SL
6SR
6TH
6TL
6TP
6UH
6UL
6VM
6WH
6XR
70C
70S
710
711
712
713
714
715
716
717
718
719
71A
71B
71C
71D
71E
71F
71G
71H
71I
71J
71K
71L
71M
71N
71O
71P
71Q
71R
71S
71T
71U
71V
71W
71X
71Y
71Z
720
Plan / Benefit Description
10/25/55 HI GR-RX7
10/25/55 LO GR-RX7
10/20/40 GR-RX06
10/40/75 HI GR-RX7
10/40/75 LO GR-RX7
4.50/14.50/50% SH6
15/25/40 HI GR-RX7
15/25/40 LO GR-RX7
5/5 GR-RX06
10/25/50 HI GR-RX7
15/25/40 GR-RX06
VALUE $25/70% SMALL GROUP
VALUE $25/70% SG
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
559 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
721
722
723
724
725
726
727
728
729
72A
72B
72C
72D
72E
72F
72G
72H
72I
72J
72K
72L
72M
72N
72O
72P
72Q
72R
72S
72T
72U
72V
72W
72X
730
731
732
733
734
735
736
737
738
739
73A
73B
73C
73D
73E
73F
73G
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
560 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
73H
73I
73J
73K
73L
73M
73N
73O
73P
73Q
73R
73S
73T
73U
73V
73W
73X
73Y
73Z
740
741
742
743
744
745
746
747
748
749
74A
74B
74C
74D
74E
74F
74G
74H
74I
74J
74K
74L
74M
74N
74O
74P
74Q
74R
74S
74T
74U
Plan / Benefit Description
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
561 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
74V
74W
74X
74Y
74Z
750
751
752
753
754
755
756
757
758
759
75A
75B
75C
75D
75E
75F
75G
75H
75I
75J
75K
75L
75M
75N
75O
75P
75Q
75R
75S
75T
75U
75V
75W
75X
75Y
75Z
760
761
762
763
764
765
766
767
768
Plan / Benefit Description
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
562 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
769
76A
76B
76C
76D
76E
76F
76G
76H
76I
76J
76K
76L
76M
76N
76O
76P
76Q
76R
76S
76T
76U
76V
7AQ
7AR
7BD
7BH
7BI
7BL
7BR
7C1
7C2
7CD
7CI
7CM
7CP
7CZ
7DD
7DH
7DL
7DM
7DR
7ED
7EH
7EL
7EM
7ER
7FD
7FH
7FL
Plan / Benefit Description
RESERVED RX PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
RESERVED PLAN PPO
7/20 GR-RX07
0/0 GR-RX07
7/14 GR-RX07
4/10/20 T1A H GRX7
7/14 I GR-RX07
4/10/20 T1A L GRX7
0/0 FLAT GR-RX07
$25/70% SG
$25/70% SG
COBRA
7/14 GR-RX07
7/14 I GR-RX07
15/25/40 GR-RX07
5/29/60 N/G SH-RX7
VALUE $25/70% SG COBRA
7/20/30 GR-RX07
4/15/30 T1B H GRX7
4/15/30 T1B L GRX7
15/25/40 GR-RX07
10/10 FLAT GR-RX07
7/7 GR-RX07
4/20/40 T1C H GRX7
4/20/40 T1C L GRX7
3/3 FLAT GR-RX07
10/20 GR-RX07
7/7 C GR-RX07
4/25/50 T1D H GRX7
4/25/50 T1D L GRX7
563 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
7FM
7FR
7GD
7GM
7GR
7HH
7HI
7HL
7HR
7JH
7JL
7JM
7JR
7KH
7KI
7KL
7KM
7KR
7LH
7LL
7LM
7LR
7MA
7MH
7MI
7ML
7MR
7NH
7NL
7NM
7O1
7O2
7PH
7PI
7PL
7PM
7PR
7QH
7QI
7QL
7QM
7QR
7RA
7RB
7RC
7RD
7RH
7RL
7RM
7RR
Plan / Benefit Description
3/3/3 GR-RX07
10/20 GR-RX07
10/20/30 GR-RX07
5/10 GR-RX07
10/20 GR-RX07
4/15/30 T2A H GRX7
10/20 I GR-RX07
4/15/30 T2A L GRX7
10/20 GR-RX07
4/28/58 T3C H GRX7
4/28/58 T3C L GRX7
5/10 GR-RX07
10/10 GR-RX07
4/28/55 T3B H GRX7
10/20/35 I GR-RX07
4/28/55 T3B L GRX7
5/10/20 GR-RX07
10/20/35 GR-RX07
4/25/45 T3A H GRX7
4/25/45 T3A L GRX7
5/15 GR-RX07
15/25/40 GR-RX07
10/25%/40% GR-RX07
4/20/40 T2B H GRX7
10/20/40 I GR-RX07
4/20/40 T2B L GRX7
10/20/40 GR-RX07
4/25/50 T2C H GRX7
4/25/50 T2C L GRX7
5/15/30 GR-RX07
ALREADY USED
ALREADY USED
4/25/50 T2C H GRX7
10/20/40 I GR-RX07
4/25/50 T2C L GRX7
5/15/30 GR-RX07
10/20/40 GR-RX07
4/20/40 T2B H GRX7
10/20/40 I GR-RX07
4/20/40 T2B L GRX7
5/15/30 GR-RX07
10/20/40 GR-RX07
10/20/35 RDS GRX7
10/20 RDS GR-RX07
10/20/35 RDS GRX7
10/20 RDS GR-RX07
4/15/30 T2A H GRX7
4/15/30 T2A L GRX7
5/15/30 GR-RX07
15/35/50/50 GR-X07
564 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
7S1
7S2
7SB
7SI
7SR
7SZ
7TH
7TL
7TM
7TR
7UH
7UL
7UM
7UR
7VH
7VL
7VM
7WH
7WI
7WL
7WM
7WR
7XA
7XB
7XC
7XD
7XE
7XF
7XG
7XH
7XJ
7XL
7XM
7XP
7YH
7YI
7YL
7YM
7YR
7ZH
7ZL
7ZM
7ZR
80C
80S
810
811
812
813
814
Plan / Benefit Description
$25/70% SG
$25/70% SG
COBRA
10/25%/40% GR-RX07
10/20/40 I GR-RX07
10/20/40 GR-RX07
VALUE $25/70% SG COBRA
4/28/55 T3B H GRX7
4/28/55 T3B L GRX7
5/5 GR-RX07
10/25/40 GR-RX07
4/28/58 T3C H GRX7
4/28/58 T3C L GRX7
5/5 GR-RX07
15/25/40 GR-RX07
4/25/50 T1D H GRX7
4/25/50 T1D L GRX7
5/5 GR-RX07
4/20/40 T1C H GRX7
15/25/40 I GR-RX07
4/20/40 T1C L GRX7
5/7.50 GR-RX07
15/25/40 GR-RX07
4/10/20 RDS GR-RX7
4/15/30 RDS GR-RX7
4/20/40 RDS GR-RX7
4/25/50 RDS GR-RX7
4/10/20 RDS GR-RX7
4/15/30 RDS GR-RX7
4/20/40 RDS GR-RX7
4/15/30 T1B H GRX7
4/25/50 RDS GR-RX7
4/15/30 T1B L GRX7
7/14 GR-RX07
5/29/60 N/G SH-RX7
4/10/20 T1A H GRX7
15/25/40 I GR-RX07
4/10/20 T1A L GRX7
7/14 GR-RX07
15/25/40 GR-RX07
4/25/45 T3A H GRX7
4/25/45 T3A L GRX7
7/14 GR-RX07
15/25/40 GR-RX07
VALUE $20/80% SG
VALUE $20/80% SG
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
565 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
815
816
817
818
819
820
821
822
823
824
825
826
827
828
829
82A
82B
82C
82D
82E
82F
82G
82H
82J
82K
82L
82M
82N
82P
82Q
82R
82S
82T
82U
82V
82W
82X
82Y
82Z
830
831
832
833
834
835
836
837
838
839
83A
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
15-25/200D T3A AARP GR08
566 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
83B
83C
83D
83E
83F
83G
83H
83J
83K
83L
83M
840
841
842
843
844
845
846
847
848
849
84A
84B
84C
84D
84E
84F
84G
84H
84J
84K
84L
84M
84N
84P
84Q
84R
84S
84T
84U
84V
84W
84X
84Y
84Z
850
851
852
853
854
Plan / Benefit Description
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
10-15/50A T1A AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
5-20/100A T1B AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/200A T1C AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
10-20/750A T2A AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
15-25/130D T2B AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
10-25/150D T2C AARP GR08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
567 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
855
856
857
858
859
85A
85B
85C
85D
85E
85F
85G
85H
85J
85K
85L
85M
860
861
862
863
864
865
866
867
868
869
881
882
8A8
8AH
8AR
8B8
8BH
8C1
8C2
8CH
8CZ
8DD
8DH
8DR
8ED
8EH
8EM
8ER
8FD
8FH
8GH
8GM
8HD
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-25/200D T3A AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
15-30/220D T3B AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
20-35/250D T3C AARP GR08
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED RX PPO
880 PLAN
880 PLAN
5/29/60NG RX-SH08
0/0 HI C GR-RX07
0/0 C GR-RX07
5/29/60NG RX-SH08
DO NOT USE
$20/80% SG
$20/80% SG
COBRA
2/30/60 HI C GRX07
VALUE $20/80% SG COBRA
7/20/30 C GR-RX07
2/40 HI C GR-RX07
10/10 FLAT C GRX07
7/7 C GR-RX07
5/25 HI C GR-RX07
3/3 FLAT C GR-RX07
10/20 C GR-RX07
7/7 C GR-RX07
5/65 HI C GR-RX07
510 HI C GR-RX07
5/10 C GR-RX07
10/20/30 C GR-RX07
568 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
8HH
8KM
8LH
8LM
8MA
8N8
8NM
8O1
8O2
8PH
8PM
8RH
8RM
8S1
8S2
8SH
8SZ
8TH
8TM
8TR
8UM
8UR
8VM
8WH
8Z1
90C
90S
910
911
912
913
914
915
916
917
918
919
91H
920
921
922
923
924
925
926
927
928
929
92H
930
Plan / Benefit Description
DO NOT USE
5/10/20 C GR-RX07
7/20/50% HI C GRX7
5/15 C GR-RX07
10/25%/40% C GRX07
5/29/60G RX-SH08
5/15/30 C GR-RX07
ALREADY USED
ALREADY USED
10/20 HI C GR-RX07
5/15/30 C GR-RX07
10/20/35 HI C GRX7
5/15/30 C GR-RX07
$20/80% SG
$20/80% SG
COBRA
10/25/55 HI C GRX7
VALUE $20/80% SG COBRA
10/40/75 HI C GRX7
5/5 C GR-RX07
10/25/40 C GR-RX07
5/5 C GR-RX07
15/25/40 C GR-RX07
5/7.50 C GR-RX07
10/25/50 HI C GRX7
880 PLAN (COBRA)
VALUE $15/90% SG
VALUE $15/90% SG
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
15/25/40 HI RX-GR8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/25/50 HI RX-GR8
RESERVED PPO
569 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
931
932
933
934
935
936
937
938
939
93H
940
941
942
943
944
945
946
947
948
949
94H
950
951
952
953
954
955
956
957
958
959
95H
960
961
962
963
964
965
966
967
968
969
970
971
972
973
974
975
976
977
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/20/40 HI RX-GR8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/20 HI RX-GR08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10/40/75 HI C XGR8
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
570 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
979
980
981
982
983
984
985
986
987
988
989
990
991
992
993
994
9AN
9AQ
9AR
9AY
9BE
9BH
9BL
9C1
9C2
9CM
9CZ
9DH
9DR
9EH
9EL
9ER
9FD
9FH
9FL
9GE
9GM
9HD
9HH
9HK
9HL
9HN
9HP
9JH
9JL
9KH
9KL
9KS
9LH
9LL
Plan / Benefit Description
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
RESERVED BENEFIT PPO
4/20/40 LO RX-GR08
7/20 RX-GR08
0/0 RX-GR08
4/25/50 HI RX-GR08
7/14 RX-GR08
4/10/20 T1A H XGR8
4/10/20 T1A L XGR8
$15/90% SG
$15/90% SG
COBRA
15/25/40 RX-GR08
VALUE $15/90% SG COBRA
4/15/30 T1B H XGR8
10/10 FLAT C XGR08
4/20/40 T1C H XGR8
4/20/40 T1C L XGR8
10/20 RX-GR08
7/7 C RX-GR08
4/25/50 T1D H XGR8
4/25/50 T1D L XGR8
10/20/30 RX-GR08
5/10 RX-GR08
10/20/30 C RX-GR08
4/15/30 T2A H XGR8
4/10/20 RX-GR08
4/15/30 T2A L XGR8
4/15/30 RX-GR08
5/30/45 RX-GR08
4/28/58 T3C H XGR8
4/28/58 T3C L XGR8
4/28/55 T3B H XGR8
4/28/55 T3B L XGR8
10/20/35 RX-GR08
4/25/45 T3A H XGR8
4/25/45 T3A L XGR8
571 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
9LM
9LP
9LV
9MA
9MH
9MI
9ML
9MR
9NH
9NL
9NM
9O1
9O2
9PH
9PL
9PZ
9QH
9QL
9RH
9RL
9RP
9RS
9RX
9S1
9S2
9SZ
9TH
9TL
9UH
9UL
9VH
9VL
9VM
9WH
9WI
9WL
9WM
9XH
9XL
9YH
9YL
9ZH
9ZL
A1C
A1H
A1K
A1L
A1V
A1Z
A2C
Plan / Benefit Description
5/15 C RX-GR08
5/15 RX-GR08
10/20/35 RX-GR08
10/25%/40% RX-GR08
4/20/40 T2B H XGR8
10/20/40 I RX-GR08
4/20/40 T2B L XGR8
10/20/40 RX-GR08
4/25/50 T2C H XGR8
4/25/50 T2C L XGR8
5/15/30 RX-GR08
ALREADY USED
ALREADY USED
4/25/50 T2C H XGR8
4/25/50 T2C L XGR8
5/29/60 P RX-GR08
4/20/40 T2B H XGR8
4/20/40 T2B L XGR8
4/15/30 T2A H XGR8
4/15/30 T2A L XGR8
5/15/30 RX-GR08
15/35/50/50 X-GR08
NO RX
$15/90% SG
$15/90% SG
COBRA
VALUE $15/90% SG COBRA
4/28/55 T3B H XGR8
4/28/55 T3B L XGR8
4/28/58 T3C H XGR8
4/28/58 T3C L XGR8
4/25/50 T1D H XGR8
4/25/50 T1D L XGR8
5/5 RX-GR08
4/20/40 T1C H XGR8
15/25/40 I RX-GR08
4/20/40 T1C L XGR8
5/7.50 RX-GR08
4/15/30 T1B H XGR8
4/15/30 T1B L XGR8
4/10/20 T1A H XGR8
4/10/20 T1A L XGR8
4/25/45 T3A H XGR8
4/25/45 T3A L XGR8
94-AA-480
PLAN A
SNOHOMISH-UNIFORMED (ASO)
PLAN A
SNOHOMISH-UNIF/COBRA (ASO)
94-AA-480 COBRA
BASIC HLT PLN PLUS
572 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
A2L
A3C
A3H
A3L
A3Z
A4H
A4L
AA9
AAB
AAC
AAF
AB3
AB5
AB6
AB7
AB8
AB9
AC1
AC2
AC3
AC4
AC5
AC6
AC7
AC8
ACC
ACF
ACR
ACZ
AD2
AD7
ADA
AE6
AE8
AEF
AFA
AFS
AGB
AIC
AIZ
AJ1
AJ2
AJ3
AJ4
AK1
AK2
AKH
AKK
AKL
AKV
Plan / Benefit Description
INDIVIDUAL CONV BASIC
AA-480 PREFERRED
A PLAN COBRA
A PLAN
AA-480 PREFERRED COBRA
PLAN A COBRA
PLAN A
5/UNL ACU/CHIRO/NAT/MASS
SV 10/100% AMGEN 06
SV 10/80% 06
SV 10/80% 06 CB
10/UNL ACU/CHIRO/NAT/MASS
15/UNL ACU/CHIRO/NAT/MASS
20/UNL ACU/CHIRO/NAT/MASS
25/UNL ACU/CHIRO/NAT/MASS
5/UNL CAM KING COUNTY
NOT USED--SEE OLD CODE AP5
$5 CHIRO/ACU/NATUR/MASSAGE
$10 CHIRO/ACU/NATUR/MASSAG
$15 CHIRO/ACU/NATUR/MASSAG
$20 CHIRO/ACU/NATUR/MASSAG
$25 CHIRO/ACU/NATUR/MASSAG
$3 CHIRO/ACU/NATUR/MASSAG
$0 CHIRO/ACU/NATUR/MASSAG
$35 CAM
AA-480 PREFERRED
ADMIN/CONSULTANTS FEE
ADMIN. CONTRACT REFUND
AA-480 PREFERRED COBRA
ADVANTAGE PLAN
3/UNL ACU/CHIRO/NAT/MASS
SV 10/100% AMGEN 06 CB
35/UNL ACU/CHIRO/NAT/MASS
0/UNL ACU/CHIRO/NAT/MASS
EXECU-FIT
SV 10/100% AMGEN 06
ADMINISTRATIVE SERVICE FEE
SV 10/100% AMGEN 06 CB
DO NOT USE
DO NOT USE
SV 10/100%
SV 10/100% CB
SV 10/100%
SV 10/100% CB
$5/$10 CAM KING COUNTY HMO
$10/$20 CAM KNG COUNTY POS
KING COUNTY-DUAL-COBRA
KING COUNTY POS-DUAL COV
KING COUNTY DUAL COVERAGE
KG COUNTY POS-DUAL/COBRA
573 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
ALF
ALH
ALL
AM0
AM2
AM3
AM4
AM5
AMC
AMD
AMF
AMG
AMH
AML
AMR
AMS
AMX
AMZ
AN1
AN2
AN3
AN5
ANH
ANL
ANS
ANZ
AP5
APB
APD
APF
APK
APN
APV
AQK
AQV
ART
AS0
ASA
ASH
ASL
AT1
AT2
AT3
AT4
AT7
ATA
ATB
ATC
ATD
ATF
Plan / Benefit Description
ALREADY USED
KNG CNTY B10 DUAL CV COBRA
KNG CNTY B10 DUAL COVERAGE
SV $10/100% AMGEN CB
AMGEN $10/100
AMGEN $10/100 COBRA
AMGEN $10/100
AMGEN $10/100 COBRA
AMER MED RESPONSE
AMMD RSP $20/$300 ADMT
SV $10/100% AMGEN
SV $10/100% AMGEN
KING CNTY POLICE DUAL COBR
KING CNTY POLICE DUAL COV
AMER MED RESPONSE
AMMD RSP $20/$300 ADMT
AMMD RSP $20/$300 ADMT CBR
AMMD RSP $20/$300 ADMT CBR
$5 CHIRO/ACU/NATUR/MASSAGE
$10 CHIRO/ACU/NATUR/MASSAG
$15 CHIRO/ACU/NATUR/MASSAG
RESERVED PEBB ACU/CH/MT
PEBB 10/100 DUAL COVER CBR
PEBB 10/100 DUAL COVERGE
SV 25/80% NSHORE 05
SV 25/80% NSHORE 05 CB
PEBB 2005 $10 CAM
ALREADY USED
ALREADY USED
10/12V 1YR ACU SH07
PEBB POS DUAL COVERAGE
10/12V 1YR ACU SH08
PEBB POS DUAL COV/COBRA
KNG CNTY 10/100 POS DUAL
KNG CNTY 10/100 POS DUALCB
RESERVED ART CODE
ALLERGY SERUM 100%
ADMINISTRATIVE FEE (ASO)
CITY OF SEATTLE (COBRA)
CITY OF SEATTLE
SV $10-$15/$100A AT&T
SV $10-$15/$100A AT&T CB
SV $10-$15/$100A AT&T
SV $10-$15/$100A AT&T CB
ATW-STD SH-WL07
SV 10-15/100A AT&T 06
SV 10-15/100A AT&T 06
AT & T CORP
SV 10-15/100A AT&T 06 CB
SV 15/100% VERIZON 06
574 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
ATH
ATJ
ATK
ATL
ATM
ATP
ATQ
ATT
ATU
ATV
ATX
ATZ
AW5
AW6
AW7
AW8
AWC
AWF
AZ2
AZC
AZG
AZM
AZT
B2A
B2B
B2C
B2D
B2E
B2F
B2G
B2H
B2J
B2P
B2R
B3A
B3B
B3C
B3D
B3E
B3F
B3G
B3H
B3J
B3P
B3R
B4A
B4B
B4C
B4D
B4E
Plan / Benefit Description
CITY OF SEATTLE-DUAL-COBRA
SV 15/100% VERIZON 06 CB
SV 10-15/100A AT&T 06 CB
CITY OF SEATTLE-DUAL
SV 15/100% VERIZON 06
ATW-PLUS SH-WL07
ATW ENHANCED SH08
AT& T CORP
ATW-PLUS WL-SH08
ATW-STD WL-SH08
SV 15/100% VERIZON 06 CB
AT & T CORP COBRA
SV 10/100% 06
SV 10/100% 06 CB
SV 10/100% 06
SV 10/100% 06 CB
WASH BASIC HLTH-MEDICAID19
ALREADY USED
STANDARD 10 PLAN (COBRA)
AMER MED RESPONSE COBRA
SV $10/100% AMGEN CB
AMER MED RESPONSE COBRA
AT& T CORP COBRA
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPOR
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
575 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
B4F
B4G
B4H
B4J
B4P
B4R
B5A
B5B
B5C
B5D
B5E
B5F
B5G
B5H
B5J
B5P
B5R
B6A
B6B
B6C
B6D
B6E
B6F
B6G
B6H
B6J
B6R
B7A
B7B
B7C
B7D
B7E
B7F
B7G
B7H
B7J
B7P
B7R
B8A
B8B
B8C
B8D
B8E
B8F
B8G
B8H
B8J
B8P
B8R
B9A
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED PPO
576 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
B9B
B9C
B9D
B9E
B9F
B9G
B9H
B9J
B9P
B9R
BA1
BA2
BAA
BAC
BC8
BFF
BJ1
BJ2
BJ3
BJ4
BJ5
BJ6
BJ7
BJ8
BK5
BK6
BOE
BOF
BOG
BOH
BP2
BP3
BP4
BP5
BP6
BP7
BP8
BP9
BPA
BPC
BPD
BPE
BPF
BPG
BPH
BPJ
BPK
BPL
BPM
BPN
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
BASIC PLAN
BASIC PLAN
SV 10/250A 06
SV 10/250A 06 CB
SMI/MH/CD 25/100%/45V VEBA
SV 15-25/250A BOEING 08
SV $10/80%
SV $10/80% CB
SV $10/80%
SV $10/80% CB
SV 10/80% SG
SV 10/80% SG CB
SV 10/80% SG
SV 10/80% SG CB
ALREADY USED
ALREADY USED
SV $15-$25/$250A VEBA
SV $15-$25/$250A VEBA CB
SV $15-$25/$250A VEBA
SV $15-$25/$250A VEBA CB
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
577 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
BPP
BPQ
BPR
BPS
BPU
BPV
BPW
BPX
BPY
BPZ
BR2
BR3
BR4
BR5
BR6
BR7
BR8
BR9
BRC
BRD
BRE
BRF
BRJ
BRR
BRW
BRZ
BTB
BTE
BTF
BU1
BU2
BU3
BU4
BU5
BU6
BU7
BU8
BU9
BUC
BUD
BUE
BUF
BUG
BUH
BUI
BUJ
BUK
BUL
BUM
BUN
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
SV 20/250A BRE PROPERTS
SV 20/250A BRE PROPERTS CB
SV 20/250A BRE PROPERTS
SV 20/250A BRE PROPERTS CB
SV 20/250A BRE PROP 06
SV 20/250A BRE PROP 06 CB
SV 20/250A BRE PROP 06
SV 20/250A BRE PROP 06 CB
SV 15-25/250A BOEING 08
SV 15-25/250A BOEING 08 CB
SV 15-25/250A BOEING 08 CB
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
578 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
BVA
BVB
BVC
BVD
BVE
BVK
BVL
BVN
BW5
BW6
BW7
BW8
BX2
BX3
BX4
BX5
BX6
BX7
BX8
BX9
BXA
BXB
BXC
BXD
BXE
BXF
BXG
BXH
BXJ
BXK
BXL
BXM
BXN
BXP
BXR
BXS
BXT
BXU
BXV
BXW
BXX
BXY
BXZ
BYA
BYB
BYC
BYD
BYE
BYF
BYG
Plan / Benefit Description
SV 15-25/250A BOEING 06
SV 15-25/250A BOEING 06 CB
SV 15-25/250A BOEING 06
SV 15-25/250A BOEING 06 CB
15/100A BOEING VEBA GR07
15/100A BOEING VEBA GR07
15 BO VEBA NON-AARP GR08
15 BO VEBA NON-AARP GR08
SV 10/80% 06
SV 10/80% 06 CB
SV 10/80% 06
SV 10/80% 06 CB
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
579 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
BYH
BYJ
BYK
BYL
BYM
BYN
BYP
BYR
BYS
BZ1
BZ2
BZ3
BZ4
BZ5
BZ6
BZ7
BZ8
BZ9
BZA
BZB
BZC
BZD
BZE
BZG
BZH
BZJ
BZK
BZL
BZM
BZN
BZP
BZR
BZS
BZT
BZV
BZW
BZX
BZY
BZZ
C0C
C0Z
C1C
C1H
C1L
C1Z
C27
C2C
C2H
C2L
C2Z
Plan / Benefit Description
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
BASIC PLAN (COBRA)
BASIC PLAN (2) COBRA
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
RESERVED RX PPO
CC SCHOOL DIST $0/100%
CC SCHOOL DIST $0/$100 CBR
94-BA-480
PLAN B/3 COBRA
PLAN B/3
94-BA-480 COBRA
SC 90 ELIGIBILITY ONLY
BA-480 STANDARD
B/3 PLAN COBRA
B/3 PLAN
BA-480 STANDARD COBRA
580 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
C3C
C3H
C3L
C3Z
C6A
C6X
C6Z
C70
C71
C72
C7A
C7D
C7E
C7F
C7G
C7H
C7J
C7K
C7L
C7M
C7P
C7R
C7S
C7U
C7W
C7Y
C7Z
C80
C81
C82
C8Z
C90
C91
C92
C9Z
CA5
CAB
CAD
CBC
CBE
CBG
CBZ
CCA
CCD
CCH
CD2
CD5
CDN
CF1
CF2
Plan / Benefit Description
CC SCHOOL DIST $3/100%
PLAN B/3 COBRA
PLAN B/3
CC SCHOOL DIST $3/100$ CBR
SV 20-40/400D CKE 06
SV 20-40/400D CKE 06 AB
SV 20-40/400D CKE 06 CB
VALUE $25/70%
$25/70%
$25/70%
COBRA
5/12V 1YR GR-CH07
50%/$250MAX 1YR GR-CH07
10/12V 1YR GR-CH07
10/20V 1YR GR-CH07
10/30V 1YR GR-CH07
15/12V 1YR GR-CH07
15/20V 1YR GR-CH07
0/20V 1YR GR-CH07
15/30V 1YR GR-CH07
20/12V 1YR GR-CH07
5/10V 1YR GR-CH07
10/1500MAX GR-CH07
30/12V 1YR GR-CH07
5/20V 1YR GR-CH07
5/30V 1YR GR-CH07
5/40 1YR GR-CH07
VALUE $25/70% COBRA
VALUE $20/80%
$20/80%
$20/80%
COBRA
VALUE $20/80% COBRA
VALUE $15/90% CLARK
$15/90%
$15/90%
COBRA
VALUE $15/90% CLARK COBRA
$5G/$10B
SV 15/200D 06
SV 15/200D 06 CB
BA-480 STANDARD
SP 25/80% COM MEN HL 06
SP 25/80% COM MEN HL 06 CB
BA-480 STANDARD COBRA
SP 25/80% COM MEN HL 06
SP 25/80% COM MEN HL 06 CB
CORE CHIRO
CHEMICAL DEPEND. - RIDER 2
CHEM. DEP. RIDER 2
CHEMICAL DEPENDENCY CUSTOM
RESERVED FOR RX PPO
RESERVED FOR RX PPO
581 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
CF3
CFA
CFD
CFE
CFF
CFQ
CGG
CGI
CGL
CGO
CGP
CGS
CGV
CGX
CH0
CH1
CH2
CH3
CH4
CH5
CH6
CH7
CH8
CHA
CHB
CHC
CHD
CHE
CHF
CHG
CHH
CHJ
CHK
CHN
CHQ
CHT
CHU
CHW
CJ1
CJ2
CJ3
CJ4
CJ5
CJ6
CJ7
CJ8
CJ9
CMO
CP5
CPA
Plan / Benefit Description
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
SV 15-25/100A COMCST 07
CAREGIVER-SH GOLD
CAREGIVER-SH INDIV
CAREGIVER LITE SH06
CHIRO RET $10/$1500 MAX
CAREGIVER PROGRAM
CAREGIVER PROGRAM
CAREGIVER CG-GR08
CAREGIVER ENHANCED
CHIROPRACTIC CARE
PEBB - CHIROCARE
CHIROPRACTIC C/3
CHIROPRACTIC C/5
CHIROPRACTIC C/10
CHIROPRACTIC C/15
CHIROPRACTIC C/20
CHIRO B POS
PEBB DUAL COVERAGE $0 CHIR
CHIROPRACTIC A (CORE)
CHIROPRACTIC B
CHIROPRACTIC C/0
CHIROCARE $10
CHIRO - FEDS
CHIRO A (FEDS)
$10/40 VISITS CAL YR USWST
$15 $1500 ANNUAL MAX
FEDS CHIRO $10/30 VISITS
ALREADY USED
CHIROPRACTIC - CUSTOM
15/UNLMTD CH06
15/30V FEDS CH06
10/12V 1YR SH-CH07
10/12V 1YR SH-CH08
SV 15/80%
SV 15/80% CB
SV 15/80%
SV 15/80% CB
ALREADY USED
ALREADY USED
FEDS 15/UNL ACU/CH/NAT/MAS
OOA ACU/CHIRO/NAT/MASS 07
30/UNL ACU/CHIRO/NAT/MASS
CAM OUT-OF-AREA
$5G/$15BR RETIREE
RESERVED PFFS
582 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
CPO
CPS
CR3
CR4
CR5
CR6
CRG
CRX
CRY
CS9
CSE
CT6
CTM
CW5
CW6
CW7
CW8
D00
D1C
D1H
D1K
D1L
D1V
D1Z
D2C
D2H
D2K
D2L
D2V
D2Z
D3H
D3K
D3L
D3V
D6L
D6M
D6Q
D6R
D6T
D6U
D6V
D7P
D7Y
D8A
D8E
D8F
DAM
DAP
DBA
DBC
Plan / Benefit Description
PEBB CH RET 50%/$250MAX1YR
$30 CHIRO/ACU/NATUR/MASSAG
GRP RET CHIRO $5/12VISITS
GRP RET CHIRO $10/12VISITS
GRP RET CHIRO $15/12VISITS
GRP RET CHIRO $20/12VISITS
CUSTOM PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
ALREADY USED
ALREADY USED
30/12V GR-CH07
SH-CLARK TR-MET RET GRP $5
SV 15/80% 06
SV 15/80% 06 CB
SV 15/80% 06
SV 15/80% 06 CB
DURABLE MED EQUIP $0
94-CA-480
PLAN B/5 COBRA
100/5 PLAN POS
PLAN B/5
100/5 PLAN POS (COBRA)
94-CA-480 COBRA
CA-480
B/5 PLAN COBRA
100/5 POS PLAN
B/5 PLAN
100/5 POS PLAN COBRA
14-480 COBRA
PLAN B/5 COBRA
POS PLAN 100/5
PLAN B/5
POS PLAN 100/5 COBRA
DUAL COVERAGE STD 06
DUAL COVERAGE STD 06 CB
DUAL COVERAGE MC STD 06
DUAL COV MC STD 06 COBRA
DUAL COVERAGE MC STD 06
DUAL COV MC STD 06 COBRA
DENTAL - VISION GR06
CA-480 POS(IN-NETWK1&2)
CA-480 POS(IN-NETWK1&2)CBR
DELUXE OPTION DN-SH08
$20 469 DN-SH08
$0 466 DN-SH08
DUAL COVERAGE MC STANDARD
DUAL COVERAGE POS STANDARD
100%/70% DISCOUNT GR-DN07
CA-480
583 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
DBO
DBZ
DC1
DC2
DC3
DC4
DCE
DCH
DCL
DCN
DD6
DDG
DDK
DDP
DDR
DDS
DDV
DEH
DEL
DIR
DJ1
DJ2
DJ3
DJ4
DK1
DK2
DK3
DK4
DKH
DKK
DKL
DLH
DLL
DM2
DM4
DMA
DMH
DMK
DML
DMV
DMZ
DN1
DN2
DN3
DNK
DNP
DNT
DNV
DNY
DP1
Plan / Benefit Description
DNTL DISCNT PRGRM - WSHNGT
CA-480 COBRA
PREMIER $5/100%
PREMIER $5/100% COBRA
PREMIER $5/100%
PREMIER $5/100% COBRA
SV 15/90% 06
B/5 CITY OF SEATTLE COBRA
B/5 PLAN-CITY OF SEATTLE
SV 15/90% 06 CB
$0 466 SH-DN06
DENTAL DISCOUNT RETIREES
DOMINICAN NETWORK POS
DENTAL DISCOUNT PROGRAM
DENTAL DISCOUNT RETIREES
DENTAL DISCOUNT PROGRAM
DOMINICAN NETWORK POS COBR
B/5 SEATTLE SPMA COBRA
B/5 CITY OF SEATTLE SPMA
DUMMY-USED FOR VRU CODING
SV 10/250A
SV 10/250A CB
SV 10/250A
SV 10/250A CB
PREMIER $5/100%
PREMIER $5/100% COBRA
PREMIER $5/100%
PREMIER $5/100% COBRA
KING COUNTY POLICE COBRA
DUMMY
KING COUNTY POLICE
SEATTLE LIBRARY COBRA
CITY OF SEATTLE LIBRARY
ALREADY USED
RESERVED
DUAL COVERAGE MC STANDARD
KNG CNTY POLICE B5 COBRA
100/5 CUSTOM POS PLAN
KNG CNTY POLICE CUSTOM B5
100/5CUSTOM POS PLAN COBRA
DUAL COVERAGE MC STD COBRA
DENTAL PLAN (PACIFIC MED)
RESERVED PPO GRP RET DEN
RESERVED PPO GRP RET DEN
NORTHWEST HOSP POS (100/5)
INDEMNITY DENTAL
DENTAL PLAN
NORTHWEST HOSP POS-COBRA
DELUXE OPTION SH-DN07
DEPENDENT LIFE BENE
584 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
DP2
DP3
DP4
DP5
DPA
DPC
DPH
DPK
DPL
DPM
DPN
DPO
DPP
DPV
DPY
DPZ
DQ6
DQP
DQY
DRH
DRL
DSH
DSL
DTC
DW5
DW6
DW7
DW8
DZ2
DZM
DZP
EA3
EA5
EAA
EAD
EAP
ECE
ECN
ECP
EV1
EV2
EV3
EV4
EW5
EW6
EW7
EW8
F01
F02
F03
Plan / Benefit Description
WA PEBB PENDING PLAN
CLARK PEBB PENDING PLAN
SV 10/150D PEBB 2005
SV 10/150D PEBB 2005
DUAL COVERAGE POS STANDARD
DOMESTIC PARTNER COVERAGE
SEATTLE POLICE COBRA
PEBB SH PEND
CITY OF SEATTLE POLICE
PEBB SH PEND
PEBB SH PENDING EFF 1-99
PEBB SH PENDING 1-99
POS-CA-480
PEBB SH PEND COBRA
POS-CA-480 COBRA
DUL COVERAGE POS STD COBRA
$20 469 SH-DN06
CA-480 POS (IN-NETWK1&2)
CA-480 POS(IN-NETWK1&2)CBR
RED LIONS HOTEL (B5) COBRA
RED LIONS HOTEL (B5)
CITY OF SEATTLE (COBRA)
CITY OF SEATTLE
INACTIVE PLAN CODE
SV 10/250A 06
SV 10/250A 06 CB
SV 10/250A 06
SV 10/250A 06 CB
ADVANTAGE PLAN
COBRA
DUAL COVERGAE MC STANDARD
DUAL COVERAGE POS STD CBRA
EAP-3 VISITS (PBHI)
EAP-5 VISITS (PBHI)
SV 15/80% 06
SV 15/80% 06 CB
PBHI - EAP BENEFIT
ALREADY USED
ALREADY USED
ALREADY USED
SV $15/80% EVERETT SD
SV $15/80% EVERETT SD CB
SV 15/80% EVERETT SD 06
SV 15/80% EVERETT SD 06 CB
SV 15/200D 06
SV 15/200D 06 CB
SV 15/200D 06
SV 15/200D 06 CB
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
585 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
F04
F05
F06
F07
F08
F09
F10
F11
F12
F13
F14
F15
F16
F17
F18
F19
F1C
F1H
F1K
F1L
F1P
F1V
F1Y
F1Z
F20
F21
F22
F23
F24
F25
F26
F27
F28
F29
F2C
F2H
F2K
F2L
F2V
F2Z
F30
F31
F32
F33
F34
F35
F36
F37
F38
F39
Plan / Benefit Description
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
$10G/$10B
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
94-DA-480
PLAN B/10 COBRA
100/10 PLAN POS
PLAN B/10
94-DA-480 (OPTION)
100/10 PLAN POS (COBRA)
94-DA-480 (OPTION) COBRA
94-DA-480 COBRA
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
DA-480 STANDARD 10 PLAN
B/10 PLAN COBRA
100/10 POS PLAN
B/10 PLAN
100/10 POS PLAN COBRA
DA-480 STND 10 PLAN COBRA
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
586 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
F3H
F3K
F3L
F3S
F3V
F3X
F40
F41
F42
F43
F44
F45
F46
F47
F48
F49
F4H
F4L
F50
F51
F52
F53
F54
F55
F56
F57
F58
F59
F5H
F5L
F5M
F5N
F60
F6H
F6L
F7P
F7Y
F9C
F9S
F9X
F9Z
FAA
FAB
FAC
FAD
FAE
FAF
FAH
FAK
FAL
Plan / Benefit Description
PLAN B10 COBRA
POS PLAN 100/10
PLAN B10
PLAN B10 SG PRE-EX
POS PLAN 100/10 COBRA
PLAN B10 SG PRE-EX CBRA
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
BOEING CUSTOM 1-00 COBRA
BOEING CUSTOM 1-00
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
LIMITED FEE SCHEDULE PPO
SEATTLE SCHOOL CSTM 1-00CB
SEATTLE SCHOOL CUSTOM 1-00
SEATTLE SCHOOL DIST
SEATTLE SCHOOL DIST
LIMITED FEE SCHEDULE PPO
B/10 PLAN VENATOR COBRA
B/10 PLAN VENATOR
DA-480 POS(IN-NETWK3&4)
DA-480 POS(IN-NETWL3&4)CBR
DA-480 SMALL GROUP
DA-480 SG PRE-EX
DA-480 SG PRE-EX CBRA
DA-480 SMALL GROUP COBRA
SV 15-30/250A 06
SV 25/90/200A SSDST 05
SV 15-30/250A 06 CB
SV 10-15/250A FIDLTY 06
ALREADY USED
SV 25/90/200A SSDST 05 CB
ALREADY USED
SV 10-15/250A FIDLTY 06 CB
SV 25/240A FIDLTY 07
587 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
FAM
FAR
FAS
FB6
FBB
FBC
FBR
FBZ
FC1
FC2
FC3
FC4
FC5
FC6
FC7
FC8
FC9
FCA
FCB
FCE
FCF
FCI
FCJ
FCL
FCM
FCN
FD5
FD6
FD7
FDA
FDD
FDE
FDF
FDG
FF1
FF2
FF3
FF4
FFA
FFC
FFF
FFG
FFK
FFL
FFN
FFP
FFS
FFV
FH6
FHG
Plan / Benefit Description
ALREADY USED
FARMERS INS
SV 25/240A FIDLTY 07 CB
SV 15-30/200D FEDS 06
FITNESS BENEFIT SH06
DA-480 STANDARD 10 PLAN
FARMERS $15/$30/$250A
DA-480 STANDARD 10 PLAN CB
PREMIER $10/100%
PREMIER $10/100% COBRA
PREMIER $10/100%
PREMIER $10/100% COBRA
PREMIER $10/100 SG
PREMIER $10/100 SG COBRA
PREMIER $10/100 SG
PREMIER $10/100 SG COBRA
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
RESERVED FOR PPO RX
SV $15-$45/$250D FEDS
ALREADY USED
ALREADY USED
SV $15-$45/$250D FEDS
SV 35/240A FID IN SV 06
SV 35/240A FID IN SV 06
SV 35/240A FID IN SV 06 CB
SV 35/240A FID IN SV 06 CB
FIREMAN FUND
FIREMAN FUND COBRA
FIREMAN FUND
FIREMAN FUND COBRA
SV 10-15/250A FIDLTY 06
SV 25/240A FIDLTY 07
ADMINISTRATIVE RETENTION
ALREADY USED
SV 10-15/250A FIDLTY 06 CB
FEHB-FED EMPLOYEES
SV 25/240A FIDLTY 07 CB
POS-DA-480
FITNESS SH/GR-WL07
FITNESS SH/GR-WL08
SV 15-30/200D FEDS 06
ALREADY USED
588 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
FHH
FHK
FHL
FHM
FHV
FI1
FI2
FI3
FI4
FID
FIM
FIZ
FJB
FJM
FJN
FK1
FK2
FK3
FK4
FK5
FK6
FK7
FK8
FKB
FKH
FKK
FKL
FKV
FLH
FLK
FLL
FM6
FMC
FMH
FML
FMM
FMN
FMZ
FN1
FN2
FN3
FN4
FNA
FNB
FND
FNE
FNZ
FP1
FP2
FP3
Plan / Benefit Description
HARSCH INVEST. B/10 COBRA
CUSTOM PCW POS PLAN
HARSCH INVESTMENTS B/10
FEDERAL EMPLOYEES HEALTH
CUSTOM PCWA POS PLAN COBRA
SV 15/200D
SV 15/200D CB
SV 15/200D
SV 15/200D CB
FEDS INDEMNITY DENTAL 2001
FEDERAL EMPLOYEES PLAN1-99
DB-1000 20% SMALL GRP COBR
SV 15-30/200D FEDS 08
FEDS 2001
FEDS 2003
PREMIER $10/100%
PREMIER $10/100% COBRA
PREMIER $10/100%
PREMIER $10/100% COBRA
PREMIER $10/100% SG
PREMIER $10/100% SG COBRA
PREMIER $10/100% SG
PREMIER $10/100% SG COBRA
SV 15-30/200D FEDS 08
PLAN B10 KING COUNTY COBRA
100/10 KING COUNTY POS
PLAN B10-KING COUNTY
100/10 KING CTY POS COBRA
KING COUNTY 10/100 POS CBR
KING COUNTY 10/100 POS
DUMMY
ALREADY USED
ALREADY USED
KNG CNTY CUSTOM B10 COBRA
KNG CNTY CUSTOM B10
SV $15-30/250A FARMERS
SV $15-30/250A FARMERS
SV $15-30/250A FARMERS CB
FIDELITY NATL FINANCIAL
FIDELITY NAT FINANCE COBRA
FIDELITY NATL FINANCIAL
FIDELITY NATL FINANCE COBR
SV 10-15/250A FIDELITY
SV 10-15/250A FIDELITY CB
SV 10-15/250A FIDELITY
SV 10-15/250A FIDELITY CB
SV $15-30/250A FARMERS CB
POS $10/100%/75%
POS $10/100%/75% COBRA
POS $10/100%/75%
589 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
FP4
FPA
FPB
FPC
FPD
FPK
FPP
FPV
FPY
FQP
FQY
FRA
FRS
FRZ
FSK
FSV
FW5
FW6
FW7
FW8
FZR
G1C
G1P
G1Y
G1Z
G2C
G2R
G2Z
GAA
GAB
GBC
GBZ
GCE
GCN
GCP
GFI
GFQ
GFU
GFV
GFW
GFY
GG6
GG7
GG9
GGE
GGN
GGP
GHI
GHQ
GHU
Plan / Benefit Description
POS $10/100%/75% COBRA
POS $10/100%/75%
POS $10/100%/75% COBRA
POS $10/100%/75%
POS $10/100%/75% COBRA
PACIFICARE EMP POS(100/10)
POS-DA-480
PCC EMP POS (100/10) COBRA
POS-DA-480 COBRA
DA-480 POS(IN-NETWK3&4)
DA-480 POS(IN-NETWK3&4)CBR
RISK CHARGE - AGGREGATE
RISK CHARGE - SPECIFIC
FARMERS $15/$30/$250A CBRA
STEVENS HIGH (ASO)
STEVENS HIGH (ASO) COBRA
SV 20/300D 06
SV 20/300D 06 CB
SV 20/300D 06
SV 20/300D 06 CB
FARMERS INS COBRA
94-EA-480
94-EA-480 (OPTION)
94-EA-480 (OPTION) COBRA
94-EA-480 COBRA
EA-480
DUMMY
EA-480
COBRA
SP 20/80% 06
SP 20/80% 06 CB
EA-480
EA-480 COBRA
15-30 CENTRAL C SH06 EPO
15-30 CENTRAL C SH06
15-30 CENTRAL C SH06 ODP
ARP MCC 1 CE EP-PL SH08
ARP MCC 1 CE PP-PL SH08
ARP MCC 1 CE PP SH08
ARP MCC 1 CE PLUS SH08
ARP MCC 1 CE SH08
ARP MCC 1 CE EP SH08
MCC 1 CE PP-PL SH07
MCC 1 CE EP-PL SH07
MCC 1 CE PLUS SH07
MCC 1 CE EP SH07
MC COMP 1 CE SH07
MCC 1 CE PP SH07
ARP MCC ES CE EP-PL SH08
ARP MCC ES CE PP-PL SH08
ARP MCC ES CE PP SH08
590 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
GHV
GHW
GHY
GJ1
GJ2
GJ6
GJ7
GJ9
GJE
GJI
GJN
GJP
GJQ
GJU
GJV
GJW
GJY
GME
GMN
GMP
GN6
GN7
GN9
GNE
GNN
GNP
GRI
GRQ
GRU
GRV
GRW
GRY
GSC
GSZ
GVE
GVN
GVP
GW5
GW6
GW7
GW8
H01
H02
H03
H04
H05
H06
H07
H08
H09
Plan / Benefit Description
ARP MCC ES CE PLUS SH08
ARP MCC ES CE SH08
ARP MCC ES CE EP SH08
ALREADY USED
ALREADY USED
MCC ESS CE PP-PL SH07
MCC ESS CE EP-PL SH07
MCC ESS CE PLUS SH07
MCC ESS CE EP SH07
ARP MCC 3 CE EP-PL SH08
MC COMP ESS CE SH07
MCC ESS CE PP SH07
ARP MCC 3 CE PP-PL SH08
ARP MCC 3 CE PP SH08
ARP MCC 3 CE PLUS SH08
ARP MCC 3 CE SH08
ARP MCC 3 CE EP SH08
10-20 CENTRAL M SH06 EPO
10-20 CENTRAL M SH06
10-20 CENTRAL M SH06 ODP
MCC 3 CE PP-PL SH07
MCC 3 CE EP-PL SH07
MCC 3 CE PLUS SH07
MCC 3 CE EP SH07
MC COMP 3 CE SH07
MCC 3 CE PP SH07
ARP MCC 3 CE EP-PL SH08
ARP MCC 3 CE PP-PL SH08
ARP MCC 3 CE PP SH08
ARP MCC 3 CE PLUS SH08
ARP MCC 3 SO SH08
ARP MCC 3 CE EP SH08
94-EA-480 (SWMC)
94-EA-480 (SWMC)
5-15 CENTRAL V SH06 EPO
5-15 CENTRAL V SH06
5-15 CENTRAL V SH06 ODP
SV 20/500D 06
SV 20/500D 06 CB
SV 20/500D 06
SV 20/500D 06 CB
DOMESTIC PARTNERSHIP PPO
VISION CARE BENEFIT PPO
FAMILY PLANING BENEFIT PPO
24/HOUR HEALTH INFO PPO
HEARING AID BENEFIT PPO
MENTAL NON-SMI PPO 90/70
RESERVED FOR PPO PRODUCT
MENTAL NON-SMI PPO 90/50
MENTAL NON-SMI PPO 80/60
591 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
H10
H11
H12
H13
H14
H15
H16
H17
H18
H19
H1Z
H20
H21
H22
H23
H24
H25
H26
H27
H28
H29
H2Z
H30
H31
H32
H33
H34
H35
H36
H37
H38
H39
H3Z
H40
H41
H42
H43
H44
H45
H46
H47
H48
H49
H50
H51
H52
H53
H54
H55
H56
Plan / Benefit Description
MENTAL NON-SMI PPO 80/50
MENTAL NONSMI INDEMNITY 80
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
PREF $10/$20/$100 COBRA
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
PREF $15/$30/$250 COBRA
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
VESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
$20/$40/$400A COBRA
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
592 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
H57
H58
H59
H60
H61
H62
H63
H64
H65
H66
H67
H68
H69
H6P
H70
H71
H72
H73
H74
H75
H76
H77
H78
H79
H80
H81
H82
H83
H84
H85
H86
H87
H88
H89
H8A
H8B
H8D
H8O
H90
H91
H92
H93
H94
H95
H96
H97
H98
H99
HA1
HA2
Plan / Benefit Description
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
15-25/100A GR06
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
0/500A 3YRS PL HA-SH08
0/1300A 3YRS DX HA-SH08
0/800A 3YRS DX HA-SH08
0/500A 3YRS HA-GR08
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
RESERVED FOR PPO
PEBB - HEARING AIDS
HEARING AIDE $300
593 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
HA3
HA4
HA5
HAJ
HAN
HAO
HAZ
HB1
HB2
HB3
HBA
HBC
HBZ
HCE
HCN
HCP
HCZ
HDE
HEP
HEQ
HER
HES
HFQ
HFR
HG1
HG2
HG3
HG4
HGO
HHE
HJ1
HJ2
HJ3
HJ4
HK1
HK2
HK3
HK4
HM1
HM2
HM3
HMA
HMB
HMC
HME
HMN
HMP
HOA
HOE
HOI
Plan / Benefit Description
HEARING AID $250 ALLOW.
HEARING AID $500 EVERY 36M
HEARING $500 PER EAR/24MO
HEARING AID $500 EVERY 3YR
300A/24M GR-VN07
HEARING AID BENEFIT
PREF $10/$20/$100 COBRA
RESERVED FOR PPO PRODUCT
RESERVED FOR PPO PRODUCT
RESERVED FOR PPO PRODUCT
SV 20/300D 06
SV 20/300D 06 CB
PREF $15/$30/$250 COBRA
ALREADY USED
ALREADY USED
ALREADY USED
$20/$40/$400A COBRA
300A 2YRS HA-GR08
SV 20-40/500A HP 07
SV 20-40/500A HP 07 CB
SV 20-40/500A HP 07
SV 20-40/500A HP 07 CB
ALREADY USED
ALREADY USED
SV 10-20/100A
SV 10-20/100A CB
SV 10-20/100A
SV 10-20/100A CB
HRING AID RET $1000MAX/3YR
500A 3YRS HA-GR08
SV 15-30/250A
SV 15-30/250A CB
SV 15-30/250A
SV 15-30/250A CB
SV 20-40/400A
SV 20-40/400A CB
SV 20-40/400A
SV 20-40/400A CB
PREF $10/$20/$100
PREF $15/$30/$250
$20/$40/$400A
PREF $10/$20/$100
PREF $15/$30/$250
$20/$40/$400A
ALREADY USED
ALREADY USED
ALREADY USED
RESERVED HEARING PFFS
RESERVED HEARING PFFS
RESERVED HEARING PFFS
594 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
HP1
HP2
HP3
HP4
HP5
HPA
HPB
HPC
HPD
HPE
HPF
HPG
HPH
HPJ
HPN
HPO
HPP
HPS
HPZ
HQC
HR2
HR3
HRB
HRD
HRF
HRG
HRP
HRY
HTC
HW5
HW6
HW7
HW8
HZ2
I01
I02
I03
I06
I07
I1C
I1Z
I2C
I2Z
I40
I50
I60
I81
I82
IBC
IBZ
Plan / Benefit Description
HP $15/$300A
550 PLAN
HP $15/$300A COBRA
HP $15/$300A
HP $15/$300A COBRA
SV $15-$30/$500A HP
SV $15-$30/$500A HP CB
SV $15-$30/$500A HP
SV $15-$30/$500A HP CB
RESERVED PFFS
SV 15-30/500A HP 06
20-40/500A HP GR07
20-40/500A HP GR07
SV 15-30/500A HP 06
20-40/500A HP NO-AARP GR08
PEBB HRING AID $300MAX3YRS
20-40/500A HP NO-AARP GR08
SV 15-30/500A HP 06 CB
SV 15-30/500A HP 06 CB
$300 MAX 3YRS PEBB HA-GR08
HRING AID $500 ALLOWANCE
HRING AID $300 ALLOWANCE
0/500A 3YRS SH-HA07
0/800A 3YRS DX SH-HA07
ALREADY USED
SH INDIV. HEARING
0/500A 3YRS PL SH-HA07
0/1300A 3YRS DX SH-HA07
500A 2YRS HA-GR08
SV 20/250A 06
SV 20/250A 06 CB
SV 20/250A 06
SV 20/250A 06 CB
550 PLAN
COBRA
INDEMNITY COVERAGE PLAN
INDEMNITY PLAN
HIGHLINE INDEMNITY ASO
OOA SUBSCRIBER PLAN I
OOA SUBSCRIBER PLAN II
94-CB-800
94-CB-800 COBRA
CB-800
CB-800
COBRA
SIGNATUREVALUE 40C
SIGNATUREVALUE 50C
SIGNATUREVALUE 60C
IND. CONV. PLAN - 880
IND. CONV. PLAN - 880
CB-800
CB-800 COBRA
595 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
IC2
ICI
ICP
ID4
ID5
ID6
IGJ
IGL
IOA
IOB
IOC
IOD
IOE
IPI
IPZ
IS1
IUH
IWH
IZ1
IZ2
IZ3
IZ6
IZ7
IZA
IZB
IZC
IZD
IZL
J1K
J1V
J2K
J2V
JAA
JAJ
JJ1
JJ2
JJB
JJF
JJN
JW5
JW6
JW7
JW8
K1C
K1H
K1K
K1L
K1V
K1Y
K1Z
Plan / Benefit Description
INDIVIDUAL CONVERSION 7/90
SV 15-30/100% ICI PNTS
SV 15-30/100% ICI PNTS CB
SIGNATUREVALUE 40C
SIGNATUREVALUE 50C
SIGNATUREVALUE 60C
SV 25-35/450A INTRPUB07
SV 25-35/450A INTRPUB07 CB
INDEMNITY- OUT OF AREA
INDEMNITY OUT-OF-AREA
INDEMNITY SG OOA
INDEMNITY SG OOA
POS - OUT OF AREA
SV 15-30/100% ICI PNTS
SV 15-30/100% ICI PNTS CB
IND. CONV. - SHARE
SV 25-35/450A INTRPUB07
SV 25-35/450A INTRPUB07 CB
INDEMNITY COVERAGE COBRA
INDEMNITY-COBRA
HIGHLINE INDEMNITY ASO
OOA SUBSCRIBER PLAN I COBR
OOA SUBSCRIBER PLAN II CBR
INDEMNITY-OUT OF AREA COBR
INDEMNITY OUT-OF-AREA CBRA
INDEMNITY SG OOA COBRA
INDEMNITY SG OOA COBRA
ERRONEOUS ENTRY
HIGHLINE COMM. HOSP. (ASO)
HIGHLINE HOSP. (ASO) COBRA
SNOHOMISH-NONUNIF. ASO
SNOHOMISH-NONUNI/COB (ASO)
SV 20/250A 06
SV 20/250A 06 CB
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
SV 10-20/100A 06
SV 10-20/100A 06 CB
SV 10-20/100A 06
SV 10-20/100A 06 CB
94-DB-1000
PREFERRED $10 (COBRA)
80/10 POS PLAN
PREFERRED $10
80/10 POS PLAN COBRA
ALREADY USED
94-DB-1000 COBRA
596 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
K2C
K2H
K2K
K2L
K2P
K2V
K2Y
K2Z
K3H
K3K
K3L
K3V
K4C
K4H
K4K
K4L
K4S
K4V
K4X
K4Z
K5C
K5Z
K7P
K7Y
K8P
K8Y
K9C
K9P
K9S
K9X
K9Y
K9Z
KA2
KA3
KA4
KA5
KA6
KA7
KA8
KA9
KAA
KAB
KAC
KAP
KAS
KAX
KAY
KAZ
KB2
KB3
Plan / Benefit Description
DB-1000 IPGB
PLAN D (COBRA)
90/10 POS PLAN
PLAN D
94-DB-1000-OPTION
90/10 POS PLAN COBRA
94-DB-1000-OPTION
DB-1000 IPGB COBRA
D PLAN COBRA
POS PLAN 90/10
D PLAN
POS PLAN 90/10 COBRA
DB-1000 SHARE PLAN
PLAN D COBRA
POS PLAN 80/10
PLAN D
PLAN D SG PRE-EX
POS PLAN 80/10 COBRA
PLAN D SG PRE-EX CBRA
DB-1000 SHARE PLAN COBRA
00-DB-1000
00-DB-1000 COBRA
DB-1000 POS (IN-NETWK5)
DB-1000 POS(IN-NETWK5) CBR
00-DB 1000 POS(IN-NETWK5)
00-DB1000POS(IN-NETWK5)CBR
DB-1000 20% SMALL GRP
DB-1000 POS SMALL GRP
DB-1000 20% SG PRE-EX
DB-1000 20% SG PRE-EX CBRA
DB-1000 POS SMALL GROUP CB
DB-1000 20% PLAN SMALL CBR
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SP 10/80% 06
SP 10/80% 06 CB
00-DB 1000 SMALL GROUP
00-DB 1000 POS SMALL GROUP
00-DB 1000 SG PRE-EX
00-DB 1000 SG PRE-EX CBRA
00-DB 1000 POS SMALL COBRA
00-DB 1000 SMALL GRP COBRA
RESERVED PPO
RESERVED PPO
597 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
KB4
KB5
KB6
KB7
KB8
KB9
KBA
KBP
KBY
KC1
KC2
KC3
KC4
KC5
KC6
KC7
KC8
KCC
KCH
KD2
KD3
KD4
KD5
KD6
KD7
KD8
KD9
KDC
KDZ
KE2
KE3
KE4
KE5
KE6
KE7
KE8
KE9
KEC
KEH
KEL
KEZ
KF2
KF3
KF4
KF5
KF6
KF7
KF8
KF9
KFA
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
OK TO USE ENTERED IN ERROR
00-DB 1000 POS SG PRE-EX
00-DB 1000 POS SG PRE-EX C
PREMIER $10/80%
PREMIER $10/80% COBRA
PREMIER $10/80%
PREMIER $10/80% COBRA
PREMIER $10/80% SG
PREMIER $10/80% SG COBRA
PREMIER $10/80% SG
PREMIER $10/80% SG COBRA
SV 5/100% KCS 06
SV 5/100% KCS 06 CB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
DB-1000 SHARE PLAN
DB-1000 SHARE PLAN COBRA
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
00-DB-1000
EVERETT MUTUAL SAVING COBR
EVERETT MUTUAL SAVINGS
00-DB-1000 COBRA
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
ALREADY USED
598 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
KFB
KFC
KFD
KG2
KG3
KG4
KG5
KG6
KG7
KG8
KG9
KH8
KH9
KHA
KHJ
KJ2
KJ3
KJ4
KJ5
KJ6
KJ7
KJ8
KJ9
KK1
KK2
KK3
KK4
KK5
KK6
KK7
KK8
KKA
KKJ
KL2
KL3
KL4
KL5
KL6
KL7
KL8
KL9
KM2
KM3
KM4
KM5
KM6
KM7
KM8
KM9
KP1
Plan / Benefit Description
ALREADY USED
ALREADY USED
ALREADY USED
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SV 5/100% KCSHERIFFS 06
SV 5/100% KCSHERIFFS 06 CB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
PREMIER $10/80%
PREMIER $10/80% COBRA
PREMIER $10/80%
PREMIER $10/80% COBRA
PREMIER $10/80% SG
PREMIER $10/80% SG COBRA
PREMIER $10/80% SG
PREMIER $10/80% SG COBRA
KING CNTY POLICE DU COV 06
KING CNTY POLICE DUAL 06CB
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
POS $10/90%/65%
599 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
KP2
KP3
KP4
KPA
KPB
KPC
KPD
KPP
KPY
KQ1
KQ2
KQ3
KQ4
KQA
KQB
KQC
KQD
KQP
KQY
KR2
KR3
KR4
KR5
KR6
KR7
KR8
KR9
KRF
KRP
KRY
KS2
KS3
KS4
KS5
KS6
KS7
KS8
KS9
KT2
KT3
KT4
KT5
KT6
KT7
KT8
KT9
KU2
KU3
KU4
KU5
Plan / Benefit Description
POS $10/90%/65%
COBRA
POS $10/90%/65%
POS $10/90%/65%
COBRA
POS $10/90%/65%
POS $10/90%/65% COBRA
POS $10/90%/65%
POS $10/90%/65% COBRA
POS-DB-1000
POS-DB-1000 COBRA
POS $10/80%/60&
POS $10/80%/60%
COBRA
POS $10/80%/60%
POS $10/80%/60%
COBRA
POS $10/80%/60%
POS $10/80%/60% COBRA
POS $10/80%/60%
POS $10/80%/60% COBRA
DB-1000 POS (IN-NETWK 5)
DB-1000 POS (IN-NETWK5)CBR
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
ALREADY USED
00-DB 1000 POS(IN-NETWK5)
00-DB1000POS(IN-NETWK5)CBR
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
600 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
KU6
KU7
KU8
KU9
KV2
KV3
KV4
KV5
KV6
KV7
KV8
KV9
KW2
KW3
KW4
KW5
KW6
KW7
KW8
KW9
KX2
KX3
KX4
KX5
KX6
KX7
KX8
KX9
KXF
KY2
KY3
KY4
KY5
KY6
KY7
KY8
KY9
L01
L02
L03
L04
L05
L06
L07
L08
L09
L1I
L1K
L1L
L1V
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
ALREADY USED
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
LIFE COVERAGE PLAN
LIFE COVERAGE PLAN
LIFE PLAN - SMALL GROUP
LIFE PLAN - SMALL GROUP
LIFE PLAN - SG INTERNET
LIFE PLAN - SG INTERNET
LIFE PLAN - LARGE GROUP
LIFE PLAN - LARGE GROUP
LIFE PLAN - LARGE GROUP
94-FB-1200
80/20 POS PLAN
INDIVIDUAL CONV./COMP.
80/20 POS PLAN (COBRA)
601 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
L2K
L2V
L3K
L3V
LAA
LAB
LBW
LBZ
LC3
LC4
LC5
LC6
LC7
LC8
LC9
LF1
LM1
LM2
LM3
LO6
LO7
LP1
LP2
LP3
LP4
LPA
LPB
LPC
LPD
LTD
LTM
LW5
LW6
LW7
LW8
M10
MAA
MAB
MAM
MCB
MH1
MH2
MH3
MH4
MH5
MH6
MHA
MHB
MHC
MHE
Plan / Benefit Description
80/20 POS PLAN
80/20 POS PLAN COBRA
90/20 POS PLAN
90/20 POS PLAN COBRA
SV 10/250A 06
SV 10/250A 06 CB
LASCO BATHWARE
LASCO BATHWARE COBRA
LIFE PLAN - SMALL GROUP
LIFE PLAN - SMALL GROUP
LIFE PLAN - SG INTERNET
LIFE PLAN - SG INTERNET
LIFE PLAN - LARGE GROUP
LIFE PLAN - LARGE GROUP
LIFE PLAN - LARGE GROUP
LIFE COVERAGE PLAN
$75,000 LIFETIME MAX
$250,000 LIFETIME MAXIMUM
$500,000 LIFETIME MAXIMUM
ALREADY USED
ALREADY USED
POS $20/80%/60%
POS $20/80%/60%
COBRA
POS $20/80%/60%
POS $20/80%/60%
COBRA
POS $20/80%/60%
POS $20/80%/60% COBRA
POS $20/80%/60%
POS $20/80%/60% COBRA
RESERVED FOR PPO LIFE
$2MILLION LIFETIME MAXIMUM
SV 15-30/250A 06
SV 15-30/250A 06 CB
SV 15-30/250A 06
SV 15-30/250A 06 CB
$10 MAN GEN
SV 10/100% 06
SV 10/100 STD 06 CB
AMER MED RESPONSE MH
MH/CD AGE BAND PKG PLAN
MENTAL HEALTH RIDER 1
MENTAL HEALTH-RIDER 2
OPTION A-MNTL HLTH BENEFIT
OPTION B-MNTL HLTH BENEFIT
OPTION C-MNTL HLTH BENEFIT
OPTION D-MNTL HLTH BENEFIT
CORE MENTAL HEALTH-PCWA
CORE MENTAL BHP
CORE MENTAL HEALTH-PBHI
MH IP/100%/$250/OP/45DAYS
602 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
MHF
MHK
MHN
MHO
MHP
MJ1
MJ2
MJ5
MJ6
MJ7
MJ8
MK5
MPB
MPS
MRA
MTK
MTM
MW5
MW6
MW7
MW8
N01
N02
N03
N04
N05
N06
N07
N08
N09
N0H
N0Z
N10
N11
N12
N13
N14
N15
N16
N17
N18
N19
N1H
N1I
N1N
N1Z
N20
N21
N22
N23
Plan / Benefit Description
FEDS MH IP-100%/OP$20 OV
30/200D FEDS MH06
CUSTOM MENTAL HEALTH
FEDS OP$45/IP$250 MH 2005
POS MENTAL HEALTH
ALREADY USED
ALREADY USED
SV $15/70% SG
SV $15/70% SG CB
SV $15/70% SG
SV $15/70% SG CB
ALREADY USED
PEBB MENTAL HEALTH
PEBB MH PENDING GRP RET
RITE AID MENTAL HEALTH
10/5V 1YR MSG THRPY SH07
10/5V 1YR MSG THRPY SH08
SV 20-40/400A 06
SV 20-40/400A 06 CB
SV 20-40/400A 06
SV 20-40/400A 06 CB
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
NATL $20/$400
COBRA
NATL PLAN $20/$400 COBRA
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
NATL $10/$100 COBRA
ALREADY USED
SV 5/100% NATL 06 CB
NATL PLAN $10/$100 COBRA
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
603 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
N24
N25
N26
N27
N28
N29
N2H
N2I
N2N
N2Z
N30
N3H
N3I
N3N
N3Z
N4H
N4I
N4N
N4Z
N5H
N5I
N5N
N5Z
N6H
N6N
N6Z
N7H
N7N
N7Z
N8H
N8N
N8Z
N9H
N9N
N9Z
NA1
NA2
NA3
NA4
NA5
NA6
NA8
NAA
NAB
NAC
NAD
NAE
NAF
NAG
NAH
Plan / Benefit Description
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
INDEMNITY PLANS
NATL $15/$250 COBRA
ALREADY USED
SV 10/100% NAT'L 06 CB
NATL PLAN $15/$250 COBRA
INDEMNITY PLANS
NATL $15/$400 COBRA
ALREADY USED
SV 15/100% NAT'L 06 CB
NATL PLAN $15/$400 COBRA
NATL $20/$250
COBRA
ALREADY USED
SV 10-20/100A NATL 06 CB
NATL PLAN $20/$250 COBRA
NATL $20/$400
COBRA
ALREADY USED
SV 15-30/250A NATL 06 CB
NATL PLAN $20/$400 COBRA
NATL $10/$100
COBRA
SV 15-30/400A NAT'L 06 CB
NATL PLAN $10/$100 COBRA
NATL $15/$250
COBRA
SV 20-40/250D NATL 06 CB
NATL PLAN $15/$250 COBRA
NATL $15/$400 COBRA
SV 10/250A NAT'L 06 CB
NATL PLAN $15/$400 COBRA
NATL $20/$250
COBRA
SV 15/250A NATL 06 CB
NATL PLAN $20/$250 COBRA
PHS NATL $5/100% CBRA
PHS NATL $10/100% CBRA
PHS NATL $10/$100/100%CBRA
PHS NATL $10/$250/100%CBRA
VHS NATL $15/$250/100%CBRA
PHS NATL $15/100% CBRA
PHS NAT'L $15/$100/100% CB
PHS NATL $5/100%
PHS NATL $10/100%
PHS NATL $10/$100/100%
PHS NATL $10/$250/100%
PHS NATL $15/$250/100%
PHS NATL $15/100%
NATL POS $10/100%/70%
NATL POS $10/90%/70%
604 of 640
Plan Benefit - WA
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
NAI
NAJ
NAK
NAL
NAN
NAO
NAP
NAQ
NAR
NB0
NB6
NB7
NB8
NB9
NBA
NBB
NBC
NBD
NBE
NBF
NBG
NBH
NBK
NBL
NBM
NBN
NBP
NBQ
NBR
NC1
NC2
NC3
NC4
NC5
NC6
NC7
NCG
NCH
ND1
ND2
ND3
ND4
ND5
NDA
NDB
NDC
NDD
NDE
NE1
NE2
Plan / Benefit Description
PHS NAT'L $15/$100/100%
NATL POS $10/$250/60%
NATL POS $15/80%/60%
NATL POS $15/$150/70%
NATL POS $10/100%/70%
NATL POS $10/90%/70%
NATL POS $10/$250/60%
NATL POS $15/80%/60%
NATL POS $15/$150/70%
SV $20-$40/$400D NATL CB
SV $10-$20/$100A NATL CB
SV $15-$30/$250A NATL CB
SV $15-$30/$400A NATL CB
SV $20-$40/$250D NATL CB
SV $10-$20/$100A NATL
SV $15-$30/$250A NATL
SV $15-$30/$400A NATL
SV $20-$40/$250D NATL
SV $20-$40/$400D NATL
SV 10-20/100A NATL 06
SV 10-20/100A NATL 06 CB
SV 15-30/250A NATL 06
SV 15-30/250A NATL 06 CB
SV 15-30/400A NAT'L 06
SV 15-30/400A NAT'L 06 CB
SV 20-40/250D NATL 06
SV 20-40/250D NATL 06 CB
SV 20-40/400D NATL 06
SV 20-40/400D NATL 06 CB
NAT'L PLN 1 $5 GRP RET
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 3 $15 GRP RET
NAT'L PLN 2A $10 GRP RET
NAT'L PLN 2B $10 GRP RET
NAT'L PLN 3A $15 GRP RET
NAT'L PLN 3B $15 GRP RET
SV 20-40/250A NATL 07 CB
SV 20-40/250A NATL 07
NATL POS $10/100%/70% CBRA
NATL POS $15/$150/70% CBRA
NATL POS $10/90%/70% CBRA
NATL POS $10/$250/60% CBRA
NATL POS $15/80%/60% CBRA
NATL POS $10/100%/70%
NATL POS $15/$150/70%
NATL POS $10/90%/70%
NATL POS $10/$250/60%
NATL POS $15/80%/60%
NATL $5/100% COBRA
NATL $10/100% COBRA
605 of 640
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
NE3
NE4
NE5
NE6
NE7
NE8
NEA
NEB
NEC
NED
NEE
NEF
NEG
NEH
NF4
NF5
NF6
NF7
NF8
NFD
NFE
NFF
NFG
NFH
NGA
NGB
NGC
NGD
NGH
NGZ
NH0
NH1
NH2
NH3
NH4
NH5
NH6
NH7
NH8
NH9
NHZ
NI1
NI2
NI3
NI4
NI5
NJ1
NJ2
NJ3
NJ4
Plan / Benefit Description
NATL $15/100% COBRA
NATL $10/$100/100% COBRA
NATL $10/$250/100% COBRA
NATL $15/$250/100% COBRA
NATL $15/$100/100% COBRA
NATL $35/$500D COBRA
NATL $5/100%
NATL $10/100%
NATL $15/100%
NATL $10/$100/100%
NATL $10/$250/100%
NATL $15/$250/100%
NATL $15/$100/100%
NATL $35/$500D
SV $10-$20/$100A NATL CB
SV $15-$30/$250A NATL CB
SV $15-$30/$400A NATL CB
SV $20-$40/$250D NATL CB
SV $20-$40/$400D NATL CB
SV $10-$20/$100A NATL
SV $15-$30/$250A NATL
SV $15-$30/$400A NATL
SV $20-$40/$250D NATL
SV $20-$40/$400D NATL
NAT'L PLN 2C $20 GRP RET
NAT'L PLN 2C $20 GRP RET
NAT'L PLN 2D $20 GRP RET
NAT'L PLN 2D $20 GRP RET
SV 20-40/250A NATL 07 CB
NATL POS $10/100%/70% CBRA
NATL $20/$400
NATL $10/$100
NATL $15/$250
NATL $15/$400
NATL $20/$250
NATL $20/$400
NATL $10/$100
NATL $15/$250
NATL $15/$400
NATL $20/$250
NATL POS $10/90%/70% COBRA
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
SV $5/100% NATL CB
SV $10/100% NATL CB
SV $15/100% NATL CB
SV $10/$100A NATL CB
606 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
NJ5
NJ6
NJ7
NJ8
NJ9
NJA
NJB
NJC
NJD
NJE
NJF
NJG
NJH
NJJ
NJK
NJL
NJM
NJN
NJP
NJQ
NJR
NJS
NJT
NJU
NJV
NJW
NJX
NJY
NJZ
NK1
NK2
NK3
NK4
NK5
NK6
NK7
NK8
NKA
NKB
NKC
NKD
NKE
NKF
NKG
NKH
NKZ
NL1
NL2
NL3
NL4
Plan / Benefit Description
SV $10/$250A NATL CB
SV $15/$250A NATL CB
SV $15/100A NATL CB
SV $35/$500D NATL CB
SV 35/500D NAT'L 06 CB
SV $5/100% NATL
SV $10/100% NATL
SV $15/100% NATL
SV $10/$100A NATL
SV $10/$250A NATL
SV $15/$250A NATL
SV $15/100A NATL
SV $35/$500D NATL
SV 35/500D NAT'L 06
SV 5/100% NATL 06
SV 5/100% NATL 06 CB
SV 10/100% NAT'L 06
SV 10/100% NAT'L 06 CB
SV 15/100% NAT'L 06
SV 15/100% NAT'L 06 CB
SV 10/100A NAT'L 06
SV 10/100A NAT'L 06 CB
SV 10/250A NAT'L 06
SV 10/250A NAT'L 06 CB
SV 15/250A NATL 06
SV 15/250A NATL 06 CB
SV 15/100A NATL 06
SV 15/100A NATL 06 CB
NATL POS $10/$250/60% CBRA
NATL $5/100% COBRA
NATL $10/100% COBRA
NATL $15/100% COBRA
NATL $10/$100/100%
NATL $10/$250/100% COBRA
NATL $15/$250/100% COBRA
NATL $15/$100/100% COBRA
NATL $35/$500D COBRA
NATL $5/100%
NATL $10/100%
NATL $15/100%
NATL $10/$100/100%
NATL $10/$250/100%
NATL $15/$250/100%
NATL $15/$100/100%
NATL $35/$500D
NATL POS $15/80%/60% COBRA
NATL POS $10/100%/70% CBRA
NATL POS $15/$150/70% CBRA
NATL POS $10/90%/70% CBRA
NATL POS $10/$250/60% CBRA
607 of 640
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
NL5
NL8
NLA
NLB
NLC
NLD
NLE
NLZ
NM0
NM1
NM2
NM3
NM4
NM5
NM6
NM7
NM8
NM9
NMH
NMI
NMJ
NMK
NML
NMM
NMN
NN1
NN2
NN3
NN4
NN5
NN6
NN7
NN8
NNA
NNB
NNC
NND
NNE
NNF
NNG
NNH
NNK
NNL
NNM
NNN
NNP
NNQ
NNR
NNS
NNT
Plan / Benefit Description
NATL POS $15/80%/60% CBRA
24HR NURSLINE WL-SH/GR08
NATL POS $10/100%/70%
NATL POS $15/$150/70%
NATL POS $10/90%/70%
NATL POS $10/$250/60%
NATL POS $15/80%/60%
NATL POS $15/$150/70% CBRA
NATL PLAN $20/$400
NATL PLAN $10/$100
NATL PLAN $15/$250
NATL PLAN $15/$400
NATL PLAN $20/$250
NATL PLAN $20/$400
NATL PLAN $10/$100
NATL PLAN $15/$250
NATL PLAN $15/$400
NATL PLAN $20/$250
MH IP/100%/OP/OV 45DAY/VIS
MH IP/100%/OP$5OV 45DAYS
MH IP/100%/OP$15OV 45 DAYS
MH IP/100%/OP$20OV 45 DAYS
MH IP/100%/OP$30OV 45 DAYS
MH IP/100%/OP$40OV 45 DAYS
MH IP-100%/OP-$35 45 DAYS
SV $5/100% NATL CB
SV $10/100% NATL CB
SV $15/100% NATL CB
SV $10/100A NATL CB
SV $10/$250A NATL CB
SV $15/$250A NATL CB
SV $15/100A NATL CB
SV $35/$500D NATL CB
SV $5/100% NATL
SV $10/100% NATL
SV $15/100% NATL
SV $10/$100A NATL
SV $10/$250A NATL
SV $15/$250A NATL
SV $15/100A NATL
SV $35/$500D NATL
SV 10/250A NAT'L 06
SV 15/100A NATL 06
SV 10/100% NAT'L 06
SV 5/100% NATL 06
SV 15/250A NATL 06
SV 10-20/100A NATL 06
SV 10/100A NAT'L 06
SV 15-30/400A NAT'L 06
SV 20-40/250D NATL 06
608 of 640
Plan Benefit - WA
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
NNU
NNV
NNW
NNY
NNZ
NO4
NO5
NO6
NO7
NOZ
NPM
NPZ
NQ0
NQ1
NQ2
NQ3
NQ4
NQ5
NQ6
NQ7
NQ9
NQA
NQB
NQC
NQD
NQE
NQF
NQG
NQH
NQJ
NQK
NQL
NQM
NQN
NQP
NQQ
NQR
NQS
NQT
NQU
NQV
NQW
NQX
NQY
NQZ
NRZ
NS1
NS2
NS3
NS4
Plan / Benefit Description
SV 15/100% NAT'L 06
SV 15-30/250A NATL 06
SV 35/500D NAT'L 06
SV 20-40/400D NATL 06
NATL POS $10/100%/70% CBRA
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
NATL POS $10/90%/70% COBRA
MH IP/100%/OP/OV 45DAY/VIS
NATL POS $10/$250/60% CBRA
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
AVAIL USE IN SEATTLE ONLY
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
SV 10/100A NAT'L 06 CB
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
NATL POS $15/80%/60% COBRA
NATL POS $15/$150/70%
NAT'L PLN 1 $5 GRP RET
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 3 $15 GRP RET
NAT'L PLN 2A $10 GRP RET
609 of 640
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State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
NS5
NS6
NS7
NSA
NSB
NSC
NSD
NSE
NSF
NSG
NSK
NSN
NSS
NTF
NTN
NTS
NU1
NU2
NU3
NU4
NU5
NUA
NUB
NUC
NUD
NUE
NUF
NUG
NUH
NUK
NUL
NUM
NUN
NUP
NUQ
NUR
NWA
NWB
NWG
NWI
NWN
NWZ
NY1
NY2
NY3
NY4
NY5
NY6
NY8
NYA
Plan / Benefit Description
NAT'L PLN 2B $10 GRP RET
NAT'L PLN 3A $15 GRP RET
NAT'L PLN 3B $15 GRP RET
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
SV 25/80% NSHORE 06
SV 25/80% NSHORE 06 CB
SV NSHORE $25/80%/$100D
OK TO USE
SV 15/100A NATL 06 AB
0/12-1W NON-ER TRANS SH08
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
NON-WOVEN $0/100%
NON-WOVEN $10/$200
SV 20-40/250A NATL 07
ALREADY USED
SV 35/500D NAT'L 06 CB
ALREADY USED
PHS NATL $5/100% COBRA
PHS NATL $10/100% COBRA
PHS NATL $10/$100/100% CBR
PHS NATL $10/$250/100% CBR
PHS NATL $15/$250/100% CBR
PHS NATL $15/100% COBRA
PHS NAT'L $15/$100/100% CB
PHS NATL $5/100%
610 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
NYB
NYC
NYD
NYE
NYF
NYI
NYN
NZA
NZB
NZS
O1C
O1K
O1Q
O1R
O1U
O1V
O1W
O1X
O2Q
O2R
O2U
O2V
O2W
O2X
O3Q
O3R
O3U
O3V
O3W
O3X
O4Q
O4R
O4U
O4V
O4W
O4X
O5Q
O5R
O5U
O5V
O5W
O5X
O6Q
O6R
O6U
O6V
O6W
O6X
O71
O72
Plan / Benefit Description
PHS NATL $10/100%
PHS NATL $10/$100/100%
PHS NATL $10/$250/100%
PHS NATL $15/$250/100%
PHS NATL $15/100%
PHS NAT'L $15/$100/100%
SV 20-40/400D NATL 06 CB
NON-WOVEN $0/100% COBRA
NON-WOVEN $10/$200 COBRA
SV NSHORE $25/80%/$100D CB
NAT'L PLN 1 $5 GRP RET
TEST
10-20/750A T2A GR07
15-25/200D T3A GR07
15-25/200D T3A GR07
10-20/750A T2A GR07
10-15/50A T1A GR07
10-15/50A T1A GR07
10-20/750A T2A GR07
15-25/200D T3A GR07
15-25/200D T3A GR07
10-20/750A T2A GR07
10-15/50A T1A GR07
10-15/50A T1A GR07
10-20/750A T2A GR07
15-25/200D T3A GR07
15-25/200D T3A GR07
10-20/750A T2A GR07
10-15/50A T1A GR07
10-15/50A T1A GR07
15-25/130D T2B GR07
15-30/220D T3B GR07
15-30/220D T3B GR07
15-25/130D T2B GR07
5-20/100A T1B GR07
5-20/100A T1B GR07
15-25/130D T2B GR07
15-30/220D T3B GR07
15-30/220D T3B GR07
15-25/130D T2B GR07
5-20/100A T1B GR07
5-20/100A T1B GR07
15-25/130D T2B GR07
15-30/220D T3B GR07
15-30/220D T3B GR07
15-25/130D T2B GR07
5-20/100A T1B GR07
5-20/100A T1B GR07
ALREADY USED
ALREADY USED
611 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
O7Q
O7R
O7U
O7V
O7W
O7X
O81
O82
O8Q
O8R
O8U
O8V
O8W
O8X
O91
O92
O9Q
O9R
O9U
O9V
O9W
O9X
OA1
OA2
OA4
OB1
OB2
OB4
OC1
OC2
OC4
OC6
OC7
OCC
OEP
OF1
OF2
OF3
OF4
OF5
OF6
OF7
OF8
OF9
OFA
OFB
OFC
OFD
OFE
OFP
Plan / Benefit Description
10-25/150D T2C GR07
20-35/250D T3C GR07
20-35/250D T3C GR07
10-25/150D T2C GR07
10-20/200A T1C GR07
10-20/200A T1C GR07
ALREADY USED
ALREADY USED
10-25/150D T2C GR07
20-35/250D T3C GR07
20-35/250D T3C GR07
10-25/150D T2C GR07
10-20/200A T1C GR07
10-20/200A T1C GR07
ALREADY USED
ALREADY USED
10-25/150D T2C GR07
20-35/250D T3C GR07
20-35/250D T3C GR07
10-25/150D T2C GR07
10-20/200A T1C GR07
10-20/200A T1C GR07
NAT'L PLN 2C $20 GR 06
NAT'L PLN 2C $20 GR 06
NAT'L PLN 2C $20 GR 06
NAT'L PLN 2D $20 GR 06
NAT'L PLN 2D $20 GR 06
NAT'L PLN 2D $20 GR 06
NAT'L PLN 1 $5 GRP RET
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 2A $10 GRP RET
NAT'L PLN 3A $15 GRP RET
NAT'L PLN 3B $15 GRP RET
NAT'L PLN 2 $10 GRP RET
10/100% NON-AARP GR08
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
RESERVED FOR RX PPO
10/100% NON-AARP GR08
612 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
OJ1
OJ2
OJ4
OK1
OK2
OKY
OKZ
OL1
OL2
OL4
OM1
OM2
OM4
ON2
ON4
OOA
OOM
OON
OOZ
OP1
OP2
OP4
OPM
OQ2
OQ4
OQH
ORH
ORX
OS1
OS2
OS4
OS6
OS7
OSS
OT1
OT2
OT4
OU1
OU2
OU4
OV1
OV2
OV4
OVA
OVB
OVT
OW1
OW2
OW4
OWA
Plan / Benefit Description
NAT'L PLN 1 $5 GR 06
NAT'L PLN 1 $5 GR 06
NAT'L PLN 2 $10 GR 06
NAT'L PLN 2 $10 GR 06
NAT'L PLN 2 $10 GR 06
15-25/500A AARP GR08
15-25/500A AARP GR08
NAT'L PLN 2A $10 GR 06
NAT'L PLN 2A $10 GR 06
NAT'L PLN 2A $10 GR 06
NAT'L PLN 2B $10 GR 06
NAT'L PLN 2B $10 GR 06
NAT'L PLN 2B $10 GR 06
NAT'L PLN 3A $15 GR 06
NAT'L PLN 3A $15 GR 06
OUT OF AREA PLAN
10-20/250A NON-AARP GR08
POS - OUT OF AREA
OUT OF AREA PLAN (COBRA)
NAT'L PLN 3B $15 GR 06
NAT'L PLN 3B $15 GR 06
NAT'L PLN 3B $15 GRP RET
10-20/250A NON-AARP GR08
NAT'L PLN 1 $5 GR 06
NAT'L PLN 1 $5 GR 06
5/100% NON-AARP GR08
5/100% NON-AARP GR08
OTHR RX NOT THRU RX SOL
NAT'L PLN 1 $5 GRP RET
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 2A $10 GRP RET
NAT'L PLN 3A $15 GRP RET
NAT'L PLN 3B $15 GRP RET
NAT'L PLN 2 $10 GRP RET
NAT'L PLN 2A $10 GR 06
NAT'L PLN 2A $10 GR 06
NAT'L PLN 2A $10 GR 06
NAT'L PLN 2B $10 GR 06
NAT'L PLN 2B $10 GR 06
NAT'L PLN 2B $10 GR 06
NAT'L PLN 3A $15 GR 06
NAT'L PLN 3A $15 GR 06
NAT'L PLN 3A $15 GR 06
10/100% AARP GR08
15/250A NON-AARP GR08
ALREADY USED IN TX
NAT'L PLN 3B $15 GR 06
NAT'L PLN 3B $15 GR 06
NAT'L PLN 3B $15 GRP RET
CLRK PEBB-GR
613 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
OWB
OWL
OWM
OX1
OX2
OX4
OXA
OXB
OY1
OY2
OYD
OYE
OZ1
OZ2
OZ4
P1C
P1K
P1V
P1Z
P2C
P2P
P2Z
P3C
P3P
P3Z
P4P
P5P
P6H
P6P
P7E
P7F
P7P
P8C
P8K
P8L
P8P
P8S
P9P
PA2
PA3
PA4
PA5
PA6
PA7
PA8
PA9
PAC
PB1
PB2
PB3
Plan / Benefit Description
SEATTLE PEBB-GR
10/150D PEBB NO-AARP GR08
10/150D PEBB NO-AARP GR08
NAT'L PLN 2C $20 GR 06
NAT'L PLN 2C $20 GR 06
NAT'L PLN 2C $20 GR 06
10/100% AARP GR08
15/250A NON-AARP GR08
NAT'L PLN 2 $10 GR 06
NAT'L PLN 2 $10 GR 06
5/100% AARP GR08
5/100% AARP GR08
NAT'L PLN 2D $20 GR 06
NAT'L PLN 2D $20 GR 06
NAT'L PLN 2D $20 GR 06
94-CF-500
90/5 POS PLAN
90/5 POS PLAN (COBRA)
94-CF-500 COBRA
CF-500 PLAN (REVISED)
RESERVED PPO
CF500 COBRA (REVISED)
CF-500
RESERVED PPO
CF-500 COBRA
RESERVED PPO
RESERVED PPO
15-25/100A GR06
RESERVED PPO
15-30/200A PEBB GR07
15-30/200A PEBB GR07
RESERVE PPO
POS $20/80%/60%
15-30/200A PB NON-AARP GR8
15-30/200A PB NON-AARP GR8
RESERVED PPO
POS $20/80%/60%
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
PPO ADMINISTRATIVE CHARGE
7G/$7BR/$14M BOEING RET.
$0G/$0BR/$0M PEBB RET RX.
$5G/$10BR/$25NF QW
614 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
PB4
PB5
PB6
PBA
PBB
PBC
PBD
PBE
PBF
PBG
PBH
PBI
PBJ
PBK
PBL
PBN
PBR
PBS
PBU
PC8
PCA
PCB
PCC
PCE
PCF
PCG
PCH
PCI
PCJ
PCK
PCL
PCM
PCZ
PD6
PDC
PEA
PEC
PED
PEE
PEF
PEG
PEH
PEK
PEV
PEZ
PF2
PF3
PF4
PF5
PF6
Plan / Benefit Description
$10G/$20BR/$30NF
$5G/$10BR/$25NF RE
$5G/$5B TRI-MET
PPO - PFFS
PPO - PFFS
$5G/$10BR/$25NF
$10G/$20BR/50%NF
$5G/$10BR/$1500MX
RESERVED PFFS
RESERVED PFFS
SV 10/200D PEBB 2005
SV 10/200D PEBB 2005 CB
SV 10/200D PEBB 2005
SV 10/200D PEBB 2005 CB
SV 20/100% PANASONIC 06
SV 20/100% PANASONIC 06 CB
$10G/$25B/$40NF
SV 20/100% PANASONIC 06
SV 20/100% PANASONIC 06 CB
POS $20/80%/60%
PPO - PFFS
PPO - PFFS
CF-500
PPO - PFFS
SV $15-$30/$100A PHS
SV $15-$30/$100A PHS CB
SV $15-$30/$100A PHS
SV $15-$30/$100A PHS CB
DO NOT USE
SV 20-40/200A PHS 06 CB
SV 20-40/200A PHS 06
SV 20-40/200A PHS 06 CB
CF-500 COBRA
PDV CUSTOM DENTAL & VISION
DOMESTIC PARTNERS
SV 15-20/100A PRUD 06
PEBB PLAN
SV 15-20/100A PRUD 06
SV 15-20/100A PRUD 06 CB
SV 15-20/100A PRUD 06 CB
RESERVED PFFS
RESERVED PFFS
RESERVED PFFS
AVAIL FOR USE SEATTLE ONLY
PEBB PLAN COBRA
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
615 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
PF7
PF8
PF9
PFA
PFB
PFC
PFD
PFL
PGD
PGE
PGF
PGH
PH2
PH3
PH4
PH5
PH6
PH7
PH8
PH9
PIA
PIB
PIC
PID
PIE
PIF
PIG
PIH
PII
PIK
PIL
PIN
PIO
PJ5
PJ6
PJ7
PJ8
PJA
PJB
PJL
PK5
PK6
PK7
PK8
PKA
PKB
PL1
PL2
PL3
PL4
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
SP $15/100%-70%
SP $15/100%-70% CB
SP $15/100%-70%
SP $15/100%-70% CB
FEDERAL EMPLOYEES
PPO -PFFS
PPO - PFFS
RESERVED PFFS
RESERVED PFFS
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
SP $10/80%-60%
SP $10/80%-60% CB
SP $10/80%-60%
SP $10/80%-60% CB
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
RESERVED RX PFFS
SP 15/100% 06
SP 15/100% 06 CB
SP 15/100% 06
SP 15/100% 06 CB
SP $20/80%-60%
SP $20/80%-60% CB
AVAIL USE IN SEATTLE ONLY
PACKAGE PLAN
PACKAGE PLAN COBRA
PACKAGE PLAN
PACKAGE PLAN COBRA
ALREADY USED
ALREADY USED
PREFERRED $15/$350
PREFERRED $15/$350 COBRA
PREFERRED $15/$350
PREFERRED $15/$350 COBRA
616 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
PL5
PL6
PLC
PLD
PLL
PLM
PLP
PLZ
PMD
PMK
PNA
PNB
POA
POB
PP5
PP6
PPA
PPB
PPC
PPD
PPE
PPF
PPG
PPH
PPK
PPL
PPM
PPP
PPQ
PPR
PPS
PPT
PPU
PPV
PPW
PPX
PPY
PPZ
PQ5
PQ6
PQ7
PQ8
PR1
PR2
PS1
PS2
PS5
PS6
PS8
PSC
Plan / Benefit Description
SV 20/80% POLYCLINIC 05
SV 20/80% POLYCLINIC 06
POLYCLINIC
POLYCLINIC
SV 20/80% POLYCLINIC 05 CB
SV 20/80% POLYCLINIC 06 CB
PAYMENT LAG PREMIUM ALLOC
POLYCLINIC COBRA
PPO - PFFS
RESERVED PFFS
ALREADY USED
ALREADY USED
POS OUT OF AREA
POS OUT OF AREA
SP 20/80% 06
SP 20/80% 06 CB
RESERVED PPO
RESERVED PPO
PEBB PLAN - 94
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
PEBB PLAN / POS /95
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVE PPO
RESERVED PPO
PEBB / POS / 95 / COBRA
PEBB PLAN - 94 COBRA
SP 10/80% 06
SP 10/80% 06 CB
SP 10/80% 06
SP 10/80% 06 CB
PREFERRED PLAN
PREFERRED PLAN
SV 30/500A PRINT SPEC
SV 30/500A PRINT SPEC CB
SV 30/500A PRINT SPC 05
SV 30/500A PRINT SPC 05 CB
POS $20/80%/60%
$5G/$15BR RETIREE
617 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
PSD
PSG
PSP
PW2
PW5
PW8
PW9
PWA
PWB
PYI
PZ1
PZ2
PZA
PZB
PZD
Q1A
Q1K
Q1L
Q1S
Q1V
Q1X
Q1Z
Q2A
Q2Z
Q5E
Q5F
Q7C
QAC
QAJ
QAZ
QBA
QBZ
QC1
QC2
QC3
QC4
QCC
QCZ
QD1
QD2
QD3
QD4
QE1
QE2
QE3
QE4
QE5
QE6
QE7
QE8
Plan / Benefit Description
SV 30/500A PRINT SPC 06
SV 30/500A PRINT SPC 06 CB
AVAIL USE IN SEATTLE ONLY
SH-SEATTLE PEBB
PEBB-WA SECURE HORIZONS
PEBB SH
SH-CLRK PEBB
CLRK PEBB-GR
SEATTLE PEBB-GR
RESERVED PFFS
PREFERRED PLAN (COBRA)
PREFERRED PLAN (COBRA)
POS OUT OF AREA COBRA
POS OUT OF AREA COBRA
POLYCLINIC COBRA
00-FB 2500 SMALL GROUP
90/20 POS PLAN
90/20 POS PLAN (COBRA)
00-FB 2500 SG PRE-EX
90/20 POS PLAN
00-FB 2500 SG PRE-EX CBRA
00-FB 2500 SMALL COBRA
00-FB 2500
00-FB 2500 COBRA
ALREADY USED
ALREADY USED
ALREADY USED
SV 10-20/100A 06
SV 10-20/100A 06 CB
AVAIL USE IN SEALLTE ONLY
00-FB-2500
00-FB-2500 COBRA
ADVANTAGE $20/$200
ADVANTAGE $20/$200 COBRA
ADVANTAGE $20/$200
ADVANTAGE $20/$200 COBRA
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
SV 20/300D
SV 20/300D CB
SV 20/300D
SV 20/300D CB
SV $20/$500D
SV $20/$500D CB
SV $20/$500D
SV $20/$500D CB
SV $20/$500D SG
SV $20/$500D SG CB
SV $20/$500D SG
SV $20/$500D SG CB
618 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
QF1
QF2
QF3
QF4
QH1
QH2
QH3
QH4
QI1
QI2
QI3
QI4
QJ1
QJ2
QJ3
QJ4
QK1
QK2
QK3
QK4
QK5
QK6
QK7
QK8
QW2
QW3
QW4
QWB
QWC
QWD
R10
R15
R1C
R1H
R1K
R1L
R1V
R1Z
R2C
R2H
R2L
R2S
R2X
R3C
R3H
R3L
R3S
R3X
R3Z
R4C
Plan / Benefit Description
SV 20/250A
SV 20/250A CB
SV 20/250A
SV 20/250A CB
PREFERRED $20/$250
PREFERRED $20/$250 COBRA
PREFERRED $20/$250
PREFERRED $20/$250
ADVANTAGE $20/$200
ADVANTAGE $20/$200 COBRA
ADVANTAGE $20/$200
ADVANTAGE $20/$200 COBRA
ADVANTAGE $20/$300
ADVANTAGE $20/$300 COBRA
ADVANTAGE $20/$300
ADVANTAGE $20/$300 COBRA
ADVANTAGE $20/$500
ADVANTAGE $20/$500 COBRA
ADVANTAGE $20/$500
ADVANTAGE $20/$500 COBRA
ADVANTAGE $20/$500 SG
ADVANTAGE $20/$500 COBRA
ADVANTAGE $20/$500 SG
ADVANTAGE $20/$500SG COBRA
QWEST $10/$100
QWEST 15-30/150A
QWEST 15-30/150A
QWEST $10/$100 COBRA
QWEST 15-30/150A COBRA
QWEST 15-30/150A COBRA
O/P PRESCR DRUGS $100 DED
$15 OR 50%
94-DE-3000 PLAN
US WEST CUSTOM COBRA
80/10 POS PLAN
US WEST CUSTOM PLAN
80/10 POS PLAN COBRA
94-DE-3000 PLAN COBRA
BASIC HLTH PLN NON SUB
PACKAGE PLAN (COBRA)
PACKAGE PLAN
PACKAGE PLAN SG PRE-EX
PACKAGE PLAN SG PRE-EX CBR
DJ-000 BASIC HEALTH BENEFI
E/10 PLAN COBRA
E/10 PLAN
DJ-000 BHP SG PRE-EX
DJ-000 BHP SG PRE-EX CBRA
DJ-000 BASIC HEALTH-COBRA
$10/250 NAT'L ACCT PLAN
619 of 640
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WA
WA
WA
WA
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
R4H
R4L
R4Z
R50
R5H
R5L
R6C
R6H
R6L
R6Z
R7H
R7L
RA1
RA2
RA3
RA4
RB3
RB5
RB7
RB8
RBA
RBB
RBC
RBZ
RC5
RC6
RC7
RC8
REC
REK
REP
REV
REY
REZ
RFA
RFC
RFE
RFF
RFH
RFZ
RG0
RG1
RG2
RG3
RG4
RG6
RG7
RG8
RGC
RGZ
Plan / Benefit Description
STANDARD $10/250 PLAN CBRA
STANDARD $10/250 PLAN
$10/250 NAT'L ACCT PLANCBR
O/P PRESCR DRUGS $50 DED
PLAN B 10/250 COBRA
PLAN B 10/250
DE-3000
US WEST CUSTOM 1-00 COBRA
US WEST CUSTOM PLAN 1-00
DE-3000 COBRA
QWEST 2002
COBRA
QWEST 2002
RITE AID - SEATTLE
RITE AID-CLARK COUNTY
SV 20/250A RITE AID 05
SV 20/250A RITE AID 05
$3/$8/$23
$5/$10/$25
$7/$12/$27
$8/$13/$28
$10/$15/$30
$15/$25/$40
PEBB PLAN 96
PEBB PLAN 96
PACKAGE PLAN 2002
PACKAGE PLAN 2002 COBRA
PACKAGE PLAN 2002
PACKAGE PLAN 2002 COBRA
PEBB HMO
EFF 1-99
EVERGREEN (80/10 POS)
PEBB-POS
EVERGREEN 80/10 POS COBRA
PEBB-POS COBRA
PEBB COBRA
EFF 1-99
SV 20/250A RITE AID 06
DE-3000
SV 20/250A RITE AID 06 CB
SV 20/250A RITE AID 06
SV 20/250A RITE AID 06 CB
DE-3000 COBRA
$10G/$15B/$30NF RE
$10G/$20B RETIREE
$10G/$35B RETIREE
$15G/$25B/$40NF $200 DED
$15G/$25B/$40NF RE
$5G/$15B RETIREE
$5G/$25B RETIREE
$7G/$12B/$27NF RET
PEBB 2002
PEBB 2002 COBRA
620 of 640
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WA
WA
WA
WA
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
RH8
RHH
RHK
RHV
RJ1
RJ2
RK1
RK2
RK5
RK6
RKE
RLG
RM3
RM5
RM7
RM8
RMR
RN1
RN2
RN3
RN4
RN5
RN6
RNG
RNH
RNJ
RNK
RNL
RP1
RP5
RP8
RPA
RPB
RPC
RPE
RPH
RPL
RPP
RPX
RPY
RPZ
RSG
RSH
RSM
RT3
RT5
RT7
RT8
RTA
RTB
Plan / Benefit Description
$8 MAN GEN
CUSTOM E 10 PLAN COBRA
HARSCH INVESTMENTS POS
HARSCH INVESTMENTS POS COB
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
ALREADY USED
SV 20/90% RITE AID 07
SV 20/90% RITE AID 07
$3 MAN GEN
$5 MAN GEN
$7/$7+DIF
$8 MAN GEN
$15G/$20B/$30NF
$7G/$14B GRP RET
$10G/$20B GRP RET
$10G/$25B GRP RET
$10G/$20B/$40NF
$10G/$20B/$50NF
$15G/$25B/$40NF
$7G/$14B
$10G/$20B
$10G/$25B
$10G/$20B/$40NF
$15G/$25B/$40NF
$10G/$20B/$30NF
$5G/$15B
$8G/$13B
ALREADY USED
ALREADY USED
THRIFTY PAYLESS PLAN
RESPITE/PERS CARE SH07
CUSTOM PLAN E10 COBRA
CUSTOM PLAN E10
PEBB-POS
RESPITE/PERS CARE WL-SH08
PEBB-POS (COBRA)
THRIFY PAYLESS PLAN COBRA
SV 20/90% RITE AID 07 CB
$6G/$9BR RETIREE
$10G/$13BR RETIREE
$3G/$8B
$5G/$10B
$7/$12/$7+DIF
$8G/$13B
$5G/$10B
$10G/$20B
621 of 640
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WA
WA
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WA
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
RTC
RTD
RTH
RTL
RTN
RTS
RTW
RUC
RUZ
RW5
RW6
RW7
RW8
RWC
RX0
RX1
RX2
RX3
RX4
RX5
RX8
RXP
RZ1
RZ2
RZ3
RZ4
RZE
S10
S1H
S1K
S1L
S1P
S1V
S1Y
S2K
S2V
S3K
S3V
S4K
S4V
S52
S70
S71
S72
S7Z
S80
S81
S82
S8Z
S90
Plan / Benefit Description
$5G/$10B
$0
$0 BHP+
CUSTOM E 10 PLAN
$10G/50%B
$5G/50%B
COPAY VARIES
US WEST CUSTOM PLAN
US WEST CUSTOM CBRA PLAN
SV 20/80% 06
SV 20/80% 06 CB
SV 20/80% 06
SV 20/80% 06 CB
BHP NON SUBSIDIZED
$0
$1
$2
$3
$4
$5
$8
50% TO $50
RITE AID - SEATTLE COBRA
RITE-AID CLK COUNTY COBRA
SV 20/250A RITE AID 05 CB
SV 20/250A RITE AID 05 CB
SV 20/90% RITE AID 07 CB
SHARE PLAN 10-20
$15/$250/100%EDS COBRA
100/15 PLAN POS
$15/$250/100% EDS
POS CLARK COUNTY
100/15 PLAN POS (COBRA)
POS CLARK COUNTY COBRA
100/15 POS PLAN
100/15 POS PLAN COBRA
POS PLAN 100/15
POS PLAN 100/15 COBRA
POS $15/100%/70%
POS $15/100%/70% COBRA
STANDARD 5 PLAN
VALUE $25/70%
$25/70%
$25/70%
COBRA
VALUE $25/70% COBRA
VALUE $20/80%
$20/80%
$20/80%
COBRA
VALUE $20/80% COBRA
VALUE $15/90%
622 of 640
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WA
WA
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
S91
S92
S9Z
SA2
SAC
SAF
SAH
SAK
SAV
SAZ
SB1
SB2
SB4
SBG
SBK
SBO
SBV
SC1
SC3
SC5
SC7
SCC
SCO
SCZ
SE3
SE7
SEP
SER
SEZ
SF1
SF2
SF3
SF4
SFC
SFD
SFE
SFM
SFP
SFW
SFX
SFZ
SG1
SGA
SGC
SGH
SGL
SGM
SGZ
SH1
SH2
Plan / Benefit Description
$15/90%
$15/90%
COBRA
VALUE $15/90% COBRA
STANDARD 10 PLAN
SV 25/90%/200A SSDST 06
SAFEWAY/VONS
SV 25/90%/200A SSDST 06 CB
100/15 CUSTOM POS PLAN
100/15 CUSTOM POS COBRA
SAFEWAY/VONS COBRA
SH WESTERN WA PT B ONLY
SH WALLA WALLA PT B ONLY
SH EASTERN WA PT B ONLY
SHWA BOEING RETIREES
POS 15/100 WALLA WALLA CST
SH BOEING NORTH AMERICAN
POS 15/100 WALLA WALLA CBR
GRP RET CLRK CTY $10
GRP RET CLRK CTY $3
GRP RET CLRK CTY $5
GRP RET CLRK CTY $7
GRP RET STD $10 CLK COUNTY
SAFECO
SAFECO
COBRA
SH PLUS 3
SH PLUS 7
COLUMBIAN HMO
SUPP ELIGIBILITY RIDER
COLUMBIAN HMO COBRA
SAFEWAY/VONS $20/250A
SAFEWAY/VONS $20/250A CBRA
SAFEWAY/VONS $20/250A
SAFEWAY/VONS $20/250A CBRA
SPLIT FAMILY COVERAGE
$10/$30/$60 SF
SAFECO
STATE FARM 20-30/250A
COLUMBIAN HMO
SAFEWAY/VONS
STATE FARM 20-30/250A CBRA
COLUMBIAN HMO COBRA
SH WA GROUP RETIREE $10
SH WA RETIREE GROUP 5
SV 20/250A SFWAY 06
SV 20/250A SFWAY 06 CB
SV 20/250A SFWAY 06 CB
SV 20/250A SFWAY 06
SOUND PARTNERSHIP COBRA
SH WESTERN WASHINGTON
SH WALLA WALLA
623 of 640
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
SH3
SH4
SH5
SH6
SH7
SH8
SHA
SHB
SHP
SHZ
SK1
SK2
SKC
SKL
SLF
SNS
SNZ
SO1
SO2
SO3
SO4
SOA
SOB
SOC
SOD
SP1
SPG
SPH
SPP
SPY
SR1
SRC
SRH
SRP
SRY
SRZ
SS1
SS5
SSK
SSP
SSR
SSY
ST1
ST2
STD
STF
STX
SU8
SU9
SUW
Plan / Benefit Description
SH COWLITZ COUNTY
SH EASTERN WASHINGTON
SH WESTERN WA PT B ALONE
SH EASTERN WA PT B ALONE
SH WALLA WALLA PT B ALONE
SH COWLITZ PT B ALONE
SH GRP RETIREE PLAN ($5)
SH GRP RETIREE PLAN ($7)
PEBB SH
SOUND PARTNERSHIP COBRA
ALREADY USED
ALREADY USED
SV 25/200A + 80% SSD 07
SV 25/200A + 80% SSD 07 CB
RX SLF SOLUTIONS
NORTHSHORE SCHL DIST
NORTHSHORE SCHL DIST CB
POS $15/100%/70%
POS $15/100%/70% COBRA
POS $15/100%/70%
POS $15/100%/70% COBRA
POS $15/100%/70%
POS $15/100%/70% COBRA
POS $15/100%/70%
POS $15/100%/70% COBRA
SUPPLEMENTAL LIFE BENE
SOUND PARTNERSHIP
SOUND PARTNERSHIP
PEBB-POS $0 COPAY
PEBB-POS $0 COPAY
SEARS PLAN
PEBB HMO $0 DUAL COVERAGE
PEBB HMO $0 DUAL COBRA
COLUMBIAN POS
COLUMBIAN POS COBRA
SEARS PLAN (COBRA)
GRP RET SEATTLE $10
GRP RET SEATTLE $5
SILVER SNEAKERS SH06
COLUMBIAN POS
SLV SNEAK/FITNESS BEN GR06
COLUMBIAN POS
STANDARD PLAN
STANDARD PLAN
RESERVED FOR PPO LIFE
STATE FARM 20-30/250A
STATE FARM 20-30/250A CBRA
SH GRP RETIREE US WEST
SH GRP RETIREE US WEST
SH GRP RETIREE US WEST
624 of 640
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WA
WA
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
SW1
SW2
SW3
SW4
SW5
SW6
SW7
SW8
SWK
SWP
SWV
SWY
SWZ
SXP
SXY
SZ0
SZ1
SZ2
SZE
T10
T1H
T1K
T1L
T1V
T2C
T2E
T2F
T3P
T4P
TAC
TAE
TAX
TAZ
TBC
TBZ
TC1
TC2
TC3
TC4
TJA
TJB
TK1
TK2
TK3
TK4
TM6
TM7
TMJ
TNC
TP3
Plan / Benefit Description
SV 20/250A SAFEWAY
SV 20/250A SAFEWAY CB
SV 20/250A SAFEWAY
SV 20/250A SAFEWAY CB
SV 25/70% 06
SV 25/70% 06 CB
SV 25/70% 06
SV 25/70% 06 CB
WALLA WALLA
POS-SW WA MED CTR EA-480
WALLA WALLA (COBRA)
POS-SW WA MED CTR EA480 CB
SAFEWAY/VONS COBRA
SW WA MEDICAL CENTER POS
SW WA MED CENTER POS COBRA
SHARE PLAN 10-20 COBRA
STANDARD PLAN (COBRA)
STANDARD PLAN (COBRA)
SAFECO COBRA
$10G/$15B
PLAN E/10 COBRA
90/10 POS PLAN
PLAN E/10
90/10 POS PLAN (COBRA)
BASIC HLT PLN SUBSIDIZED
ALREADY USED
ALREADY USED
15-20/100A GR06
5-10/100% GR06
PEBB 10/100 PLAN 1-99
SV 20-35/90% TENET 07
PCW PREMIUM TAX
PEBB 10/100 CUSTOM1-99CBRA
PEBB 2002
PEBB 2002 COBRA
PREFERRED $10/$250
PREFERRED $10/$250 COBRA
PREFERRED $10/$250
PREFERRED $10/$250 COBRA
TMJ A
TMJ B
PREFERRED $10/$250
PREFERRED $10/$250 COBRA
PREFERRED $10/$250
PREFERRED $10/$250 COBRA
AVAIL USE IN SEATTLE ONLY
AVAIL USE IN SEATTLE ONLY
TMJ-CUSTOM BENEFIT
RESERVED FOR THINC $10/20%
TOWERS PERRIN $15 PLAN
625 of 640
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
TP4
TPA
TPB
TPE
TPF
TPH
TPK
TPL
TPV
TSA
TSB
TTH
TTL
TTT
TW5
TW6
TW7
TW8
TWC
U01
U02
U03
U04
U05
U06
U07
U08
U09
U10
U11
U12
U13
U14
U15
U16
U17
U18
U19
U1H
U1L
U20
U21
U22
U23
U24
U25
U26
U27
U28
U29
Plan / Benefit Description
TOWERS PERRIN $15 PLAN
AVAIL SEATTLE ONLY
ALREADY USED
ALREADY USED
ALREADY USED
5-10/100% GR06
PEBB
15-20/100A GR06
PEBB (COBRA)
ALREADY USED
ALREADY USED
THRIFTY PAYLESS
THRIFTY PAYLESS
TEST CODE/ DO NOT USE
SV 15/90% 06
SV 15/90% 06 CB
SV 15/90% 06
SV 15/90% 06 CB
WASH BASIC HEALTH - SUBS
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
HEALTH ALLIANCE PLN(COBRA)
HEALTH ALLIANCE PLAN
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
626 of 640
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
U30
U31
U32
U33
U34
U35
U36
U37
U38
U39
U40
U41
U42
U43
U44
U45
U46
U47
U48
U49
U50
U51
U52
U53
U54
U55
U56
U57
U58
U59
U60
UCW
UCZ
UFC
UFS
UHC
UNA
UND
UNG
UNJ
UNL
UNZ
UTC
V00
V01
V02
V03
V04
V05
V06
Plan / Benefit Description
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
USUAL & CUSTOMARY PPO
SV 15-25/250A UNITED 06
SV 15-25/250A UNITED 06 CB
SV 15-25/250A UNITED 06
SV 15-25/250A UNITED 06 CB
DUAL-OPTION - UHC 06
SV 20-30/250A UL 06
SV 20-30/250A UL 06
SV 20-30/250A UL 06 CB
SV 20-30/250A UL 06 CB
UNDERWRITERS $15/100%
UNDERWRITERS $15/100% CBR
TAKING CHARGE OF YOU
PEBB DUAL COVERAGE VISION
VSP-CUSTOM VISION BENEFIT
VSP STANDARD PLAN
VSP VISION PLAN A/10
VISION SERVICE PLAN B/10
PEBB - VISION CARE
EXAM PLUS ($5)
627 of 640
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
V07
V0E
V0H
V10
V12
V15
V1B
V1C
V1H
V1K
V1L
V1V
V1Z
V25
V27
V2A
V2B
V2C
V2F
V2H
V2K
V2L
V2S
V2V
V2Z
V3A
V3B
V3C
V3H
V3K
V3L
V3V
V3Z
V4A
V4B
V4H
V4K
V4V
V5A
V5B
V6A
V6B
V8P
V8Q
V8R
V8S
V8T
V8U
V8V
V8W
Plan / Benefit Description
VISION CARE $7 (VSP)
VSP EXAM PLUS
HIGHLINE ASO VISION
PEBB - VISION CARE
VISION CARE $12 (VSP)
VISION CARE $15 (VSP)
DUMMY
94-EB-1500
PLAN F (COBRA)
80/15 POS PLAN
PLAN F
80/15 POS PLAN (COBRA)
94-EB-1500 COBRA
VISION - THRIFTY/PAYLESS
SC 20 ELIGIBILITY ONLY
$5 OPTION A EXAM/HARDWARE
$5 OPTION B EXAM/HARDWARE
EB-1500 20% PLAN
25/70A TOWERS GR-VN06 VSP
F PLAN COBRA
80/15 POS PLAN
F PLAN
SH $10/$100 ALLOW - COLE
80/15 POS PLAN COBRA
EB-1500 20% PLAN COBRA
$10 OPTION A EXAM/HARDWARE
$10 OPTION B EXAM/HARDWARE
00-EB-1500
PLAN F COBRA
90/15 POS PLAN
PLAN F
90/15 POS PLAN COBRA
00-EB-1500 COBRA
$15 OPTION A EXAM/HARDWARE
$15 OPTION B EXAM/HARDWARE
DUMMY
POS 90/15 PLAN
POS PLAN 90/15 COBRA
$20 OPTION A EXAM/HARDWARE
$20 OPTION B EXAM/HARDWARE
$25 OPTION A EXAM/HARDWARE
$25 OPTION B EXAM/HARDWARE
0 REFRAC 1/V YR VN-GR08
5 REFRAC 1/V YR VN-GR08
10 REFRAC 1/V YR VN-GR08
15 REFRAC 1/V YR VN-GR08
20 REFRAC 1/V YR VN-GR08
25 REFRAC 1/V YR VN-GR08
30 REFRAC 1/V YR VN-GR08
35 REFRAC 1/V YR VN-GR08
628 of 640
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WA
WA
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
V8X
V9C
V9S
V9X
V9Z
VA1
VA2
VAA
VAB
VAC
VAD
VAE
VAF
VAG
VAH
VAI
VAJ
VAK
VAL
VAM
VAN
VB6
VBC
VBJ
VBK
VBL
VBM
VBS
VBX
VBZ
VC1
VC2
VC3
VC4
VCC
VCZ
VDA
VDC
VDZ
VE1
VE2
VE3
VE7
VE8
VE9
VEF
VEO
VER
VEZ
VF1
Plan / Benefit Description
40 REFRAC 1/V YR VN-GR08
EB-1500 20% PLAN SMALL GRP
EB-1500 20% SG PRE-EX
EB-1500 20% SG PRE-EX CBRA
EB-1500 20% PLAN SM GRPCBR
$5 PEBB VISION-SH PENDING
VALUE PLAN
VSP OPTION A
VSP OPTION B
VSP - CORE
VISION CARE $15 1-99
VSP - CORE - CLARK COUNTY
VSP - CORE $5 EXAM
VSP - CORE $15 EXAM
VSP - CORE $20 EXAM
VSP - CORE $25 EXAM
$5 OPTION A EXAM/HRDWARE
$15 OPTION A EXAM/HRDWARE
$20 OPTION A EXAM/HRDWARE
$25 OPTION A EXAM/HRDWARE
VSP $35 EXAM ONLY
25/150A 2 YRS SH-VN06
00-EB 1500 SMALL GROUP
$5 OPTION B EXAM/HRDWARE
$15 OPTION B EXAM/HRDWARE
$20 OPTION B EXAM/HRDWARE
$25 OPTION B EXAM/HRDWARE
00-EB 1500 SG PRE-EX
00-EB 1500 SG PRE-EX CBRA
00-EB 1500 SMALL GRP COBRA
PREMIER $15/80%
PREMIER $15/80% COBRA
PREMIER $15/80%
PREMIER $15/80% COBRA
00-EB-1500
00-EB-1500 COBRA
15/70A GR-VN07
EB-1500 20% PLAN
EB-1500 20% PLAN COBRA
SV $15/100% VERIZON
SV $15/100% VERIZON CB
SECURE HORIZONS PLUS
SECURE HORIZONS PLUS 7
SV $15/100% VERIZON
SV $15/100% VERIZON CB
SV 20/100A VERIZON 07
35 EXAM ONLY VSP
VERIZON $10/100
VERIZON $10/100 COBRA
SECURE HORIZONS B ONLY
629 of 640
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WA
WA
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
VF5
VF6
VF7
VF8
VF9
VFA
VFD
VFF
VFP
VFQ
VG1
VG3
VG5
VG6
VG7
VGP
VGQ
VH1
VH6
VHF
VHN
VI1
VI2
VI3
VI4
VI5
VI6
VI7
VI8
VJ1
VJ3
VJ5
VJ7
VJB
VJQ
VK1
VK2
VK3
VK4
VKC
VKF
VKP
VL6
VMB
VMQ
VN1
VN2
VN5
VNQ
VNW
Plan / Benefit Description
SECURE HORIZONS B ONLY
SECURE HORIZONS B ONLY
SECURE HORIZONS B ONLY
SH CLARK COUNTY B ONLY
SH CLARK COUNTY B ONLY
30 EXAM FEDS VN06-PDV
PDV $40 EXAM ONLY FED 2005
SV 20/100A VERIZON 07
0/75A 2YRS VN-GR08
0/125A 2YRS VN-GR08
SECURE HORIZONS PLUS 10
SECURE HORIZONS PLUS 3
SECURE HORIZONS PLUS 5
25/75A VN-GR06
SECURE HORIZONS PLUS 7
5/75A 2YRS VN-GR08
5/125A 2YRS VN-GR08
CUSTOM VISION-EXAM ONLY
10/70A 2 YRS VN06 VSP
SV 20/100A VERIZON 07 CB
HONEYWELL VSN $15 EXAM
ADVANTAGE $15/$200
ADVANTAGE $15/$200 COBRA
ADVANTAGE $15/$200
ADVANTAGE $15/$200 COBRA
ADVANTAGE $15/$200 SG
ADVANTAGE $15/$200 SG COBR
ADVANTAGE $15/$200 SG
ADVANTAGE $15/$200 SG COBR
SECURE HORIZONS RET GRP 10
SECURE HORIZONS RET GRP 3
SECURE HORIZONS RET GRP 5
SECURE HORIZONS RET GRP 7
SV 20/100A VERIZON 08
10/75A 2YRS VN-GR08
PREMIER $15/80%
PREMIER $15/80% COBRA
PREMIER $15/80%
PREMIER $15/80% COBRA
VISION KING CNTY SHERIFFS
SV 20/100A VERIZON 07 CB
10/125A 2YRS VN-GR08
ADV WELLNESS LITE SH-WL06
SV 20/100A VERIZON 08 CB
15/125A 2YRS VN-GR08
GRP RET $5OV/$125 ALLOWNCE
GRP RET $10OV/$75 ALLOWNCE
GRP RET $20V/$75 ALLOWANCE
20/75A 2YRS VN-GR08
NON-WOVEN $0 EXAM/HARDWARE
630 of 640
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
VO1
VO2
VO3
VO4
VOA
VOB
VOC
VOD
VP1
VP2
VP3
VP4
VP5
VP7
VPA
VPB
VPE
VPP
VPS
VPV
VPZ
VQC
VQD
VQH
VQP
VQR
VR3
VR5
VR7
VS1
VS5
VS6
VS7
VS8
VS9
VSA
VSB
VSC
VSN
VSQ
VST
VSX
VVB
VVP
VVQ
VWB
VWP
VX1
VX3
VX5
Plan / Benefit Description
POS $15/90%/65%
POS $15/90%/65
COBRA
POS $15/90%/65%
POS $15/90%/65%
COBRA
POS $15/90%/65%
POS $15/90%/65% COBRA
POS $15/90%/65%
POS $15/90%/65% COBRA
PEBB SH PNDING EFF1-00 WA1
PEBB SH PNDING VSN EFF1-00
SECURE HORIZONS PLUS 3
HONEYWELL VSN $10 EXAM
SECURE HORIZONS PLUS 5
SECURE HORIZONS PLUS 7
VISION PREMIUM ALLOCATION
PEBB VISION (VSP)
RESERVED PFFS
20/125A 2YRS VN-GR08
$30 PRINT SPEC VSP
10/150A 2YRS PEBB GR-VN07
25/150A 1YR PEBB GR-VN07
15/130A 1YR DLX VN-SH08
30/70A 2YRS VN-GR08
30/70A 2YRS VN-SH08
25/70A 2YRS VN-GR08
0/70A 2YRS VN-SH08
SECURE HORIZONS PLUS 3
SECURE HORIZONS PLUS 5
SECURE HORIZONS PLUS 7
SECURE HORIZONS STANDARD
SECURE HORIZONS STANDARD
SECURE HORIZONS STANDARD
SECURE HORIZONS STANDARD
SH CLARK COUNTY
SH CLARK COUNTY
VSP OPTION A - CLARK CNTY
VSP OPTION B - CLARK CNTY
VISTA OPTICAL SUMMARY CORE
VISTA OPTICAL
30/70A 2YRS SH-VN07
VISTA CUSTOM PLAN
15/130A 1YR DLX SH-VN07
SV 20/100A VERIZON 08
15/75A 2YRS VN-GR08
25/75A 2YRS VN-GR08
SV 20/100A VERIZON 08 CB
25/125A 2YRS VN-GR08
SECURE HORIZONS RET GRP 10
SECURE HORIZONS RET GRP 3
SECURE HORIZONS RET GRP 5
631 of 640
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
VX7
VYP
VZ2
VZC
W1C
W1H
W1K
W1L
W1V
W1Z
W2H
W2L
W3H
W3L
W4C
W4Z
W5C
WA1
WA2
WA3
WA4
WA5
WA6
WAB
WAC
WAJ
WAL
WAP
WAZ
WBA
WBC
WBJ
WBL
WBN
WBU
WBW
WBY
WC1
WC2
WC3
WC5
WC6
WC7
WC8
WCA
WCB
WCC
WCD
WCE
WCH
Plan / Benefit Description
SECURE HORIZONS RET GRP 7
10/150A 2YRS PEBB VN-GR08
VALUE PLAN (COBRA)
25/150A 2YRS PEBB VN-GR08
94-EE-3000 PLAN
PLAN E/15 COBRA
90/15 POS PLAN
PLAN E/15
90/15 POS PLAN (COBRA)
94-EE-3000 PLAN COBRA
E/15 PLAN COBRA
E/15 PLAN
PLAN E/15 COBRA
PLAN E/15
EE-3000
EE-3000
COBRA
ALREADY USED
SH KING COUNTY
SH KING COUNTY PT B ONLY
SH LEW/PIER/SNO/THUR
SH LEW/PIER/SNO/THUR PT B
SH COWLITZ/WALLA
SH COWLITZ/WALLA PT B ONLY
SV 10/100% 06
10-20/100D COWLITZ SH05
SV 10/100% 06 CB
WALGREENS $25/$40/$250A
WEIGHT ALTERATION PROGRAMS
WALGREENS $25/$40/$250A CB
SV 20/80% SG 08
SV 20/80% WELLS FRGO 06
SV 20/80% WELLS FRGO 06 CB
SV 25-40/250A WALGRN 05
SV 25-40/250A WALGRN 05 CB
ARP MCC ES CWTZ PP SH08
ARP MCC ES CWTZ SH08
ARP MCC ES CWTZ EP SH08
SH CLARK COUNTY
SH CLARK COUNTY PRT B ONLY
CLARK SH STD PLAN
PREMIER $15/70% SG
PREMIER $15/70% SG COBRA
PREMIER $15/70% SG
PREMIER $15/70% SG COBRA
CLARK - SH STD PLAN
SOUTHERN SH $10/$20/$100
WA SH SOUTHERN STD PLAN
WA SH SOUTHERN STD PLAN 05
10-20 COWLITZ C SH06 EPO
ALREADY USED
632 of 640
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WA
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
WCL
WCN
WCP
WD1
WD2
WD3
WD4
WDA
WDB
WDC
WDZ
WE1
WE2
WE3
WE4
WE5
WE6
WE7
WE8
WEA
WF1
WF2
WF3
WF4
WF5
WF6
WF7
WF8
WFB
WFC
WFD
WFE
WFF
WFG
WFJ
WFS
WFX
WFZ
WG5
WG6
WG7
WG8
WGA
WGN
WGR
WH5
WH6
WH7
WH8
WHB
Plan / Benefit Description
ALREADY USED
10-20 COWLITZ C SH06
10-20 COWLITZ C SH06 ODP
SV 15/90%
SV 15/90% CB
SV 15/90%
SV 15/90% CB
SV 20/80% SG 08 AB
NO GOOD DO NOT USE
EE-3000
EE-3000 COBRA
SV $20/80%
SV $20/80% CB
SV $20/80%
SV $20/80% CB
SV $20/80% SG
SV $20/80% SG CB
SV $20/80% SG
SV $20/80% SG CB
SV 25/70% SG 08
SV $25/70%
SV $25/70% CB
SV $25/70%
SV $25/70% CB
SV $25/70% SG
SV $25/70% SG CB
SV $25/70% SG
SV $25/70% SG CB
WELLS FARGO BANK
WELLS FARGO BANK
SV $20/80% WELLS FARGO
SV $20/80% WELLS FARGO CB
SV $20/80% WELLS FARGO
SV $20/80% WELLS FARGO CB
SV 20/80% WELLS FRGO 06
WELLS FARGO BANK
SV 20/80% WELLS FRGO 06 CB
WELLS FARGO BANK COBRA
SV 20/80 SG06
SV 20/80 SG06 CB
SV 20/80 SG06
SV 20/80 SG06 CB
SV 25/70% SG 08 CB
SV 25-40/250A WALGRN 05 CB
SV 25-40/250A WALGRN 05
SV 25/70% SG06
SV 25/70% SG06 CB
SV 25/70% SG06
SV 25/70% SG06 CB
SV 20/80% SG 08
633 of 640
Plan Benefit - WA
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
WIT
WJ1
WJ2
WJA
WJB
WK1
WK2
WK5
WK6
WK7
WK8
WKA
WKB
WKC
WKD
WL6
WLA
WLC
WLE
WLF
WLG
WLS
WLZ
WMA
WME
WMN
WMP
WNA
WNU
WNW
WNY
WP1
WPR
WPS
WPT
WQB
WQR
WQS
WQT
WRR
WRS
WRT
WS0
WS1
WS2
WS3
WS4
WS5
WS6
WS7
Plan / Benefit Description
WA INFERTILITY TREATMENT
ALREADY USED
ALREADY USED
SV 25-40/250A WLGRN 08
SV 20/80% SG 08 CB
ALREADY USED
ALREADY USED
PREMIER $15/70% SG
PREMIER $15/70% SG COBRA
PREMIER $15/70% SG
PREMIER $15/70% SG COBRA
SV 25-40/250A WLGRN 08 CB
SV 25/70% SG 08
SV 10/100% 06
SV 10/100% 06 CB
AVAIL USE IN SEATTLE ONLY
SV 25-40/250A WLGRN 06
SV 25-40/250A WLGRN 06 CB
SV 25-40/250A WLGRN 06
SV 25-40/250A WLGRN 06 CB
WALGREENS $25/$40/$250A
WELLS FARGO BANK
WELLS FARGO BANK COBRA
SV 25-40/250A WLGRN 08
10-20 COWLITZ M SH06 EPO
10-20 COWLITZ M SH06
10-20 COWLITZ M SH06 ODP
SV 25-40/250A WLGRN 08 CB
ARP MCC ES CLRK PP SH08
ARP MCC ES NO SH08
ARP MCC ES CLRK EP SH08
SECURE HORIZON LKWD PLAN
10-15/50A T1A GR07
5-20/100A T1B GR07
10-20/200A T1C GR07
SV 25/70% SG 08 CB
10-20/750A T2A GR07
15-25/130D T2B GR07
10-25/150D T2C GR07
15-25/200D T3A GR07
15-30/220D T3B GR07
20-35/250D T3C GR07
WA-SH STD PLAN PART B
SH KING COUNTY
SH KING COUNTY PRT B
SH PIERCE/SNOHOMISH
SH PIERCE/SNOHOMISH PRT B
SH COWLITZ
SH COWLITZ PART B
SH LEWIS/THURSTON
634 of 640
Plan Benefit - WA
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WA
WA
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WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
WS8
WS9
WSA
WSB
WSC
WSD
WSE
WSF
WSG
WSH
WSI
WSJ
WSK
WSL
WSM
WSN
WSV
WT6
WT7
WT9
WTE
WTN
WTP
WU6
WU7
WU9
WUE
WUN
WUP
WUR
WUS
WUT
WV1
WV2
WVR
WVS
WVT
WXR
WXS
WXT
WZC
WZG
WZS
X10
X15
X1A
XA1
XA2
XA3
XA4
Plan / Benefit Description
SH LEWIS/THURSTON PRT B
WA-SH STD PLAN
WA - SH STD PLAN
WA - SH STD PLAN PART B
WA - SH STD PLAN LAKEWOOD
NORTHERN SH $15/$30/$200
CENTRAL SH $15/$30/$200
LAKEWOOD SH $20/$30/$200
SH INDIVIDUAL PART B
WA SH NORTHERN STD PLAN
WA SH CENTRAL STD PLAN
WA SH CENTRAL STD PLAN 05
STEVENS MEDIUM (ASO)
WA SH VALUE PLAN 05
WA SH NORTHERN STD PLAN 05
WA SH STD PLAN PART B 05
STEVENS MEDIUM (ASO) COBRA
MCC COWLITZ PP-PL SH07
MCC COWLITZ EP-PL SH07
MCC COWLITZ PLUS SH07
MCC COWLITZ EP SH07
MC COMP COWLITZ SH07
MCC COWLITZ PP SH07
MCC ESS COWLITZ PP-PL SH07
MCC ESS COWLITZ EP-PL SH07
MCC ESS COWLITZ PLUS SH07
MCC ESS COWLITZ EP SH07
MC COMP ESS COWLITZ SH07
MCC ESS COWLITZ PP SH07
15-25/200D T3A GR07
15-30/220D T3B GR07
20-35/250D T3C GR07
SH CLARK COUNTY
SH CLARK COUNTY PT B ONLY
10-20/750A T2A GR07
15-25/130D T2B GR07
10-25/150D T2C GR07
10-15/50A T1A GR07
5-20/100A T1B GR07
10-20/200A T1C GR07
WELLS FARGO BANK COBRA
WALGREENS $25/$40/$250A CB
WELLS FARGO BANK COBRA
$10
$15
$10
$10
$8
$10G/50%B
$10
635 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
XA5
XA7
XA8
XA9
XAA
XAB
XAD
XAF
XAG
XAH
XAI
XAJ
XAK
XAL
XAM
XAN
XAO
XAP
XAQ
XAR
XAS
XAT
XAU
XAV
XAW
XAX
XAY
XAZ
XB1
XB2
XB3
XB4
XB5
XB6
XB7
XB8
XBB
XBC
XBD
XBE
XBF
XBG
XBH
XBI
XBJ
XBK
XBL
XBM
XBN
XBO
Plan / Benefit Description
$10G/$20B
$10
20%
$10G/$10BR CUSTOM
$5
$10G/50%B
$8
$10
$7G/$7B
$10
$5
$5
$8
$6G/$12B
$8
$12
$12
$15
$15
$5G/$10B
$5G/$10B
$8
$5G/$12B
$5G/$15B
$5
DUMMY
$3
$5
50%
50%
$10G/50%B
$0
$0
$0
50%
20%
$0
$5G/$15B
50%
$0
RX VARIES
$5
$3
$5
$5G/$15B
$5
$5/$10/$25
$5
RX VARIES
PACKAGE RX CO-PAY VARIES
636 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
XBP
XBQ
XBS
XBU
XBV
XBW
XBX
XBY
XCE
XCN
XCP
XDE
XED
XEE
XEN
XEP
XLD
XLE
XLN
XLP
XM1
XM5
XM7
XM8
XND
XNE
XNN
XNP
XS1
XS2
XS7
XXX
Y1H
Y1K
Y1L
Y1V
Y2H
Y2L
Y3H
Y3L
Y4H
Y4L
YA3
YA5
YA8
YAA
YAB
YB5
YBA
YBB
Plan / Benefit Description
$0G/$5B
$10G/$20B
RX VARIES
ARP MCC 1 NO PP SH08
$5G/$15B
ARP MCC 1 NO SH08
ARP MCC 1 NO DLX SH08
ARP MCC 1 NO EP SH08
15-30 NORTH C SH06 EPO
15-30 NORTH C SH06
15-30 NORTH C SH06 ODP
$10
MCC 1 NO DELUXE SH07
MCC 1 NO EP SH07
MC COMP 1 NO SH07
MCC 1 NO PP SH07
MCC 3 NO DELUXE SH07
MCC 3 NO EP SH07
MC COMP 3 NO SH07
MCC 3 NO PP SH07
$10/10+DIF
$5/$5+DIF
$7/$7+DIF
$8/$8+DIF
MCC ESS NO DELUXE SH07
MCC ESS NO EP SH07
MC COMP ESS NO SH07
MCC ESS NO PP SH07
DISCOUNT ONLY PLAN
$10
$7
NO BENEFIT
PREFERRED $5 (COBRA)
90/5 POS PLAN
PREFERRED $5
90/5 POS PLAN COBRA
PLAN C (COBRA)
PLAN C
C PLAN COBRA
C PLAN
PLAN C COBRA
PLAN C
$3/$8/$23
$5/$10/$25
$8/$13/$28
$10/$15/$30
CSTM RX $10/$20/$30
$5/$10/$25
$10/$15/$30
$15G/$25B/$40NF
637 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
Z1L
Z2P
Z2T
Z2U
Z2X
Z8P
Z8X
ZA2
ZA3
ZA4
ZA5
ZA6
ZA7
ZA8
ZA9
ZAU
ZAW
ZAX
ZAY
ZB2
ZB3
ZB4
ZB5
ZB6
ZB7
ZB8
ZB9
ZBD
ZBE
ZBN
ZBP
ZC2
ZC3
ZC4
ZC5
ZC6
ZC7
ZC8
ZC9
ZCE
ZCN
ZCP
ZD2
ZD3
ZD4
ZD5
ZD6
ZD7
ZD8
ZD9
Plan / Benefit Description
INDIVIDUAL CONV. MAJOR
10-15/50A T1A NON-AARP GR8
15-25/200D T3A NO-AARP GR8
15-25/200D T3A NO-AARP GR8
10-15/50A T1A NON-AARP GR8
10-20/200A T1C NO-AARP GR8
10-20/200A T1C NO-AARP GR8
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
ARP MCC 1 SO PP SH08
ARP MCC 1 SO SH08
ARP MCC 1 SO DLX SH08
ARP MCC 1 SO EP SH08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
MCC 1 SO DELUXE SH07
MCC 1 SO EP SH07
MC COMP 1 SO SH07
MCC 1 SO PP SH07
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
10-20 SOUTH C SH06 EPO
10-20 SOUTH C SH06
10-20 SOUTH C SH06 ODP
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
638 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
ZE2
ZE3
ZE4
ZE5
ZE6
ZE7
ZE8
ZE9
ZF2
ZF3
ZF4
ZF5
ZF6
ZF7
ZF8
ZF9
ZG2
ZG3
ZG4
ZG5
ZG7
ZG8
ZG9
ZH2
ZH3
ZH4
ZH5
ZH6
ZH7
ZH8
ZH9
ZHD
ZHE
ZHI
ZHN
ZHP
ZHQ
ZHU
ZHV
ZHW
ZHY
ZJ2
ZJ3
ZJ4
ZJ5
ZJ6
ZJ7
ZJ8
ZJ9
ZJD
Plan / Benefit Description
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
MCC 3 SO DELUXE SH07
MCC 3 SO EP SH07
ARP MCC 2 KING EP-PL SH08
MC COMP 3 SO SH07
MCC 3 SO PP SH07
ARP MCC 2 KING PP-PL SH08
ARP MCC 2 KING PP SH08
ARP MCC 2 KING PLUS SH08
ARP MCC 2 KING SH08
ARP MCC 2 KING EP SH08
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
MCC ESS SO DELUXE SH07
639 of 640
Plan Benefit - WA
State
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
WA
Plan / Benefit
ZJE
ZJN
ZJP
ZK2
ZK3
ZK4
ZK5
ZK6
ZK7
ZK8
ZK9
ZM2
ZM3
ZM4
ZM5
ZM6
ZM7
ZM8
ZM9
ZN2
ZN3
ZN4
ZN5
ZN6
ZN7
ZN8
ZN9
ZP2
ZP3
ZP4
ZP5
ZP6
ZP7
ZP8
ZP9
ZR2
ZR3
ZR4
ZR5
ZR6
ZR7
ZR8
ZR9
ZSK
ZSV
ZZZ
Plan / Benefit Description
MCC ESS SO EP SH07
MC COMP ESS SO SH07
MCC ESS SO PP SH07
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
RESERVED PPO
STEVENS LOW (ASO)
STEVENS LOW (ASO) COBRA
HISTORICAL PLAN
640 of 640