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Group Health – Sample Certificates

In addition to a Summary of Benefits and Coverage, additional information regarding covered or excluded services, as well as terms and provisions of the health plan, are available in the certificate.  Please select the sample certificate from your specific state below.

NOTE:  The actual certificate issued may vary from the samples provided based upon final plan selection or other factors. If there is any conflict between the samples provided and the certificate that is issued, the issued certificate will control.

Illinois
Small Group 1 – 50, Classic Choice (C212 IL)
Small Group 1 – 50, Choice Plus (C213 IL) – without optional prescription drug card
Small Group 1 – 50, Choice Plus (C213 IL) – with optional prescription drug card
Small Group 1 – 50, Flex Choice (C214 IL)

Large Group, Classic Choice (C207 IL)
Large Group, Choice Plus (C208 IL)
Large Group, Flex Choice (C209 IL)

Indiana
Small Group 1 – 50, Classic Choice (C212 IN)
Small Group 1 – 50, Choice Plus (C213 IN) – without optional prescription drug card
Small Group 1 – 50, Choice Plus (C213 IN) – with optional prescription drug card
Small Group 1 – 50, Flex Choice (C214 IN)

Large Group, Classic Choice (C207 IN)
Large Group, Choice Plus (C208 IN)
Large Group, Flex Choice (C209 IN)

Iowa
Small Group 1 – 50, Classic Choice (C212 IA)
Small Group 1 – 50, Choice Plus (C213 IA) – without optional prescription drug card
Small Group 1 – 50, Choice Plus (C213 IA) – with optional prescription drug card
Small Group 1 – 50, Flex Choice (C214 IA)

Large Group, Classic Choice (C207 IA)
Large Group, Choice Plus (C208 IA)
Large Group, Flex Choice (C209 IA)

Ohio
Small Group 1 – 50, Classic Choice (C212 OH)
Small Group 1 – 50, Choice Plus (C213  OH) – without optional prescription drug card
Small Group 1 – 50, Choice Plus (C213  OH) – with optional prescription drug card
Small Group 1 – 50, Flex Choice (C214 OH)

Large Group Health is not available in Ohio.

Wisconsin
Small Group 1 – 50, Classic Choice (C212 WI)
Small Group 1 – 50, Choice Plus (C213 WI) – without optional prescription drug card
Small Group 1 – 50, Choice Plus (C213 WI) – with optional prescription drug card
Small Group 1 – 50, Flex Choice (C214 WI)

Large Group, Classic Choice (C207 WI)
Large Group, Choice Plus (C208 WI)
Large Group, Flex Choice (C209 WI)

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