Skip to Main Content

Documents and Forms

« Return to previous page

Harmony with Medica and Fairview

Member Forms

There are several documents or forms you may need to review or complete from time to time. For your convenience, commonly requested member forms and documents are available below. 

If you would like paper copies of any of the forms below, you can order them online from Member Services.

Order documents online »
View 2016 summary of benefit documents »

2017 Summary of Benefits and Coverage

To see your summary of benefits and coverage (SBC), select your plan in the table below.

  Copay Plans
HSA Compatible Plans
Gold  $100 / $300 - 30% coinsurance $2,050 / $4,150 - 0% coinsurance
Silver $2,200 / $6,600 - 40% coinsurance $3,600 / $7,200 - 0% coinsurance
 Bronze $6,850 / $13,700 - 50% coinsurance

Minnesota Rate Increase Justification 2017: These ACA-compliant policies received a weighted average premium increase of 57.5%. These adjustments were made based on historical claim information, projected cost increases, and relative risk assessments by plan.


Date: 11/14/2018 11:56:01 AM Version: 4.0.30319.42000 Machine Name: PWIM4-CMSWEB01