Summary of Benefits (HMO)

The summary of benefits lists the primary features of your plan. However, it does not list every service we cover or every limitation or exclusion. For a complete list of benefits, refer to your evidence of coverage documents. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or copayments may change on January 1 of each year.