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Plan Documents

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2021 Plan Year

Gold Simple PPO 0/0/25 (Available in all counties except Lancaster)

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
On Pennie	On Pennie	On Pennie
On Pennie - Zero Cost Share	On Pennie - Zero Cost Share	On Pennie - Zero Cost Share
On Pennie - Limited Cost Share	On Pennie - Limited Cost Share	On Pennie - Limited Cost Share
Off Pennie	Off Pennie	Off Pennie

Gold PPO Choice 2000/0/30 (Available in Lancaster County)

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
On Pennie	On Pennie	On Pennie
On Pennie - Zero Cost Share	On Pennie - Zero Cost Share	On Pennie - Zero Cost Share
On Pennie - Limited Cost Share	On Pennie - Limited Cost Share	On Pennie - Limited Cost Share
Off Pennie	Off Pennie	Off Pennie

Gold Valley Advantage EPO 2150/10/20 (Available in Lehigh and Northampton Counties)

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
On Pennie	On Pennie	On Pennie
On Pennie - Zero Cost Share	On Pennie - Zero Cost Share	On Pennie - Zero Cost Share
On Pennie - Limited Cost Share	On Pennie - Limited Cost Share	On Pennie - Limited Cost Share
Off Pennie	Off Pennie	Off Pennie

Gold PPO 2150/10/20 (Available in all counties except Lancaster)

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
On Pennie	On Pennie	On Pennie
On Pennie - Zero Cost Share	On Pennie - Zero Cost Share	On Pennie - Zero Cost Share
On Pennie - Limited Cost Share	On Pennie - Limited Cost Share	On Pennie - Limited Cost Share
Off Pennie	Off Pennie	Off Pennie

Silver PPO Choice 3950/20/35 (Available in Lancaster County)

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
Off Pennie	Off Pennie	Off Pennie

Silver PPO Choice 4000/20/35 (Available in Lancaster County)

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
On Pennie	On Pennie	On Pennie
On Pennie - Zero Cost Share	On Pennie - Zero Cost Share	On Pennie - Zero Cost Share
On Pennie - Limited Cost Share	On Pennie - Limited Cost Share	On Pennie - Limited Cost Share
On Pennie - 73% CSR	On Pennie - 73% CSR	On Pennie - 73% CSR
On Pennie - 87% CSR	On Pennie - 87% CSR	On Pennie - 87% CSR
On Pennie - 94% CSR	On Pennie - 94% CSR	On Pennie - 94% CSR
Off Pennie	Off Pennie	Off Pennie

Silver Valley Advantage EPO 5950/20/40 (Available in Lehigh and Northampton Counties)

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
Off Pennie	Off Pennie	Off Pennie

Silver Valley Advantage EPO 6000/20/40 (Available in Lehigh and Northampton Counties)

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
On Pennie	On Pennie	On Pennie
On Pennie - Zero Cost Share	On Pennie - Zero Cost Share	On Pennie - Zero Cost Share
On Pennie - Limited Cost Share	On Pennie - Limited Cost Share	On Pennie - Limited Cost Share
On Pennie - 73% CSR	On Pennie - 73% CSR	On Pennie - 73% CSR
On Pennie - 87% CSR	On Pennie - 87% CSR	On Pennie - 87% CSR
On Pennie - 94% CSR	On Pennie - 94% CSR	On Pennie - 94% CSR
Off Pennie	Off Pennie	Off Pennie

Silver PPO 5950/20/40 (Available in all counties except Lancaster)

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
Off Pennie	Off Pennie	Off Pennie

Silver PPO 6000/20/40 (Available in all counties except Lancaster)

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
On Pennie	On Pennie	On Pennie
On Pennie - Zero Cost Share	On Pennie - Zero Cost Share	On Pennie - Zero Cost Share
On Pennie - Limited Cost Share	On Pennie - Limited Cost Share	On Pennie - Limited Cost Share
On Pennie - 73% CSR	On Pennie - 73% CSR	On Pennie - 73% CSR
On Pennie - 87% CSR	On Pennie - 87% CSR	On Pennie - 87% CSR
On Pennie - 94% CSR	On Pennie - 94% CSR	On Pennie - 94% CSR
Off Pennie	Off Pennie	Off Pennie

Bronze PPO Choice 7100/0/50 (Available in Lancaster County)

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
On Pennie	On Pennie	On Pennie
On Pennie - Zero Cost Share	On Pennie - Zero Cost Share	On Pennie - Zero Cost Share
On Pennie - Limited Cost Share	On Pennie - Limited Cost Share	On Pennie - Limited Cost Share
Off Pennie	Off Pennie	Off Pennie

Bronze Valley Advantage EPO 8000/0/50 (Available in Lehigh and Northampton Counties)

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
On Pennie	On Pennie	On Pennie
On Pennie - Zero Cost Share	On Pennie - Zero Cost Share	On Pennie - Zero Cost Share
On Pennie - Limited Cost Share	On Pennie - Limited Cost Share	On Pennie - Limited Cost Share
Off Pennie	Off Pennie	Off Pennie

Bronze PPO 8000/0/50 (Available in all counties except Lancaster)

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
On Pennie	On Pennie	On Pennie
On Pennie - Zero Cost Share	On Pennie - Zero Cost Share	On Pennie - Zero Cost Share
On Pennie - Limited Cost Share	On Pennie - Limited Cost Share	On Pennie - Limited Cost Share
Off Pennie	Off Pennie	Off Pennie

Bronze HMO 8000/0/50 (Available in all 21 counties)

Subscriber Agreements	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
Off Pennie	Off Pennie	Off Pennie

Catastrophic PPO 8550/0/75 (Available in all 21 counties)

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
On Pennie	On Pennie	On Pennie
Off Pennie	Off Pennie	Off Pennie

Catastrophic HMO 8550/0/75 (Available in all 21 counties)

Subscriber Agreements	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
Off Pennie	Off Pennie	Off Pennie

Dental Plans (Available in all counties)

Highlight Sheet
Dental Select Basic
Dental PPO Loyalty Plan
Dental PPO Care Plan
Dental PPO Standard Plan
Dental PPO Premium Plan

Vision Plans (Available in all counties)

Highlight Sheet
Vision Essential Plan

2020 Plan Year

Gold PPO 2150/10/20

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
Standard (no Cost Share Reduction)	Standard (no Cost Share Reduction)	Standard (no Cost Share Reduction)
Zero Cost Share	Zero Cost Share	Zero Cost Share
Limited Cost Share	Limited Cost Share	Limited Cost Share
Off Marketplace	Off Marketplace	Off Marketplace

Silver PPO 5950/20/40

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
Off Marketplace	Off Marketplace	Off Marketplace

Silver PPO 6000/20/40

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
Standard (no Cost Share Reduction)	Standard (no Cost Share Reduction)	Standard (no Cost Share Reduction)
Zero Cost Share	Zero Cost Share	Zero Cost Share
Limited Cost Share	Limited Cost Share	Limited Cost Share
73% AV Level Cost Share Reduction	73% AV Level Cost Share Reduction	73% AV Level Cost Share Reduction
87% AV Level Cost Share Reduction	87% AV Level Cost Share Reduction	87% AV Level Cost Share Reduction
94% AV Level Cost Share Reduction	94% AV Level Cost Share Reduction	94% AV Level Cost Share Reduction
Off Marketplace	Off Marketplace	Off Marketplace

Bronze PPO 8000/0/60

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
Standard (no Cost Share Reduction)	Standard (no Cost Share Reduction)	Standard (no Cost Share Reduction)
Zero Cost Share	Zero Cost Share	Zero Cost Share
Limited Cost Share	Limited Cost Share	Limited Cost Share
Off Marketplace	Off Marketplace	Off Marketplace

Bronze HMO 8000/0/60

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
Off Marketplace	Off Marketplace	Off Marketplace

Catastrophic PPO 8150/0/75

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
Off Marketplace	Off Marketplace	Off Marketplace

Catastrophic HMO 8150/0/75

Benefit Contracts	Summary of Benefits and Coverage (SBCs)	Highlight Sheet
Off Marketplace	Off Marketplace	Off Marketplace

Dental Plans

Highlight Sheet
Dental Select Basic
Dental PPO Loyalty Plan
Dental PPO Care Plan
Dental PPO Standard Plan
Dental PPO Premium Plan

Vision Plans

Highlight Sheet
Vision Essential Plan

Complementary Content

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