Plan Documents
Find your plan year, plan and access related plan documents.
2024 Evidence of Coverage
An Evidence of Coverage (EOC) document is a detailed guide that your health insurance company gives you. It explains what your insurance covers, what it doesn’t cover, and what you and the insurance company are responsible for. It’s like a contract that lays out all the important details of your health plan.
2024 Adult Dental Rider
This document explains the dental benefits for covered persons with plans that include adult dental coverage.
2024 24/7 Medical Care Rider
This document explains that you have access to care around the clock with Antidote Health’s telehealth services.
2024 Prior Authorization Guidelines
The document outlines which services may require prior authorization as a covered service. The list includes admissions into certain behavioral health treatment facilities, some durable medical equipment, diagnostic imaging and more.
2024 List of Preventive Services
The spreadsheet contains various covered preventive services, including age guidelines, frequency and visit limitations, if applicable.
Miscellaneous Documents
Evidence of Coverage
The Evidence of Coverage (EOC) is a document that provides details about the health insurance plan, including what's covered, how much the member will pay, and how the plan works. It also includes contact information for regulatory and state departments, as well as Member Services.
24/7 Virtual Care Riders
This insurance rider is an add-on that provides additional coverage or benefits for Antidote’s 24/7 virtual care.
Dental Riders
This insurance rider is an add-on that provides additional coverage or benefits for Antidote’s dental benefits that are administered by HRI Dental.
Dental Benefit Summaries
The document outlines which services may require prior authorization as a covered service. The list includes admissions into certain behavioral health treatment facilities, some durable medical equipment, diagnostic imaging and more.
24/7 Virtual Care Riders
This insurance rider is an add-on that provides additional coverage or benefits for Antidote’s 24/7 virtual care.
Dental Rider
This insurance rider is an add-on that provides additional coverage or benefits for Antidote’s dental benefits that are administered by HRI Dental.
Dental Benefit Summaries
The document outlines which services may require prior authorization as a covered service. The list includes admissions into certain behavioral health treatment facilities, some durable medical equipment, diagnostic imaging and more.
Costco Prescription Mail Order Service
This flyer explains the benefits of using Costco's mail order services to get a 90-day supply of maintenance drugs. It's simple and you can save money. Plus, there is no requirement to be a Costco member.
Costco Prescription Mail Order Service
This flyer explains the benefits of using Costco's mail order services to get a 90-day supply of maintenance drugs. It's simple and you can save money. Plus, there is no requirement to be a Costco member.
Summary of Benefits and Coverage
This is a document gives an overview of what the plan covers and what it costs. It includes a summary of coverage details for doctor visits, hospital stays, and preventive care, plus gives coverage examples and exclusions and limitations.
Bronze Plans
Silver Plans
Gold Plans
Bronze Plans
Bronze Complete+Dental
Bronze Complete+Dental
Bronze Elite + Dental
Silver Plans
Gold Plans
Gold Standard
Gold Complete
Gold Complete
Gold Complete + Dental
Gold Complete + Dental
Gold Elite + Dental
Gold Elite + Dental
Platinum Plans
Catastrophic
Catastrophic Standard
Catastrophic Standard