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2020 Medica with CHI Health Plan Documents

To see your summary of benefits and coverage (SBC) and policy of coverage documents, select your state and plan below.

Looking for the 2019 documents?

Iowa Plans

Document Care Type    
Summary of Benefits and Coverage (SBC) Gold Copay (PDF) Silver Copay (PDF) Bronze Copay (PDF)
Policy of Coverage
Gold Copay (PDF) Silver Copay (PDF) Bronze Copay (PDF)
Document Care Type  
Summary of Benefits and Coverage (SBC) Bronze HSA (PDF) Bronze HSA Plus (PDF)
Policy of Coverage
Bronze HSA (PDF) Bronze HSA (PDF)
Document Care Type
Summary of Benefits and Coverage (SBC) Bronze Share Plus (PDF)
Policy of Coverage
Bronze Share Plus (PDF)

Nebraska Plans

Document Care Type    
Summary of Benefits and Coverage (SBC) Gold Copay (PDF) Silver Copay (PDF) Bronze Copay (PDF)
Policy of Coverage
Gold Copay (PDF) Silver Copay (PDF) Bronze Copay (PDF)
Document Care Type  
Summary of Benefits and Coverage (SBC) Bronze HSA (PDF) Bronze HSA Plus (PDF)
Policy of Coverage
Bronze HSA (PDF) Bronze HSA Plus (PDF)
Document Care Type
Summary of Benefits and Coverage (SBC) Silver Share (PDF) Bronze Share Plus (PDF)
Policy of Coverage Silver Share (PDF) Bronze Share Plus (PDF)
Date: 10/28/2020 5:13:31 PM Version: 4.0.30319.42000 Machine Name: PWIM4-CDWEB01