PBP_A_HNUMBER	PBP_A_PLAN_IDENTIFIER	PBP_A_BEN_COV	PBP_A_PLAN_TYPE	ORGTYPE	PBP_D_OPT_IDENTIFIER	PBP_D_AMT_OPT_PREMIUM	PBP_D_PICK_BENEFITS	PBP_D_PICK_BENEFITS_OTHER
H0303	013	1	01	01	001	11.50	0000000000000000000000000000000000010000000000000000000	
H0303	013	1	01	01	002	20.00	0000000000000000000000000000000000000000000000011000000	
H0303	014	1	01	01	001	11.50	0000000000000000000000000000000000010000000000000000000	
H0303	014	1	01	01	002	20.00	0000000000000000000000000000000000000000000000011000000	
H0303	015	1	01	01	001	11.50	0000000000000000000000000000000000010000000000000000000	
H0303	015	1	01	01	002	20.00	0000000000000000000000000000000000000000000000011000000	
H0303	016	1	01	01	001	11.50	0000000000000000000000000000000000010000000000000000000	
H0303	016	1	01	01	002	20.00	0000000000000000000000000000000000000000000000011000000	
H0303	021	1	01	01	001	11.50	0000000000000000000000000000000000010000000000000000000	
H0303	021	1	01	01	002	20.00	0000000000000000000000000000000000000000000000011000000	
H0303	022	2	01	01	001	11.50	0000000000000000000000000000000000010000000000000000000	
H0303	022	2	01	01	002	20.00	0000000000000000000000000000000000000000000000011000000	
H0303	023	2	01	01	001	11.50	0000000000000000000000000000000000010000000000000000000	
H0303	023	2	01	01	002	20.00	0000000000000000000000000000000000000000000000011000000	
H0303	024	1	01	01	001	11.50	0000000000000000000000000000000000010000000000000000000	
H0303	024	1	01	01	002	20.00	0000000000000000000000000000000000000000000000011000000	
H0303	033	1	01	01	001	11.50	0000000000000000000000000000000000010000000000000000000	
H0303	033	1	01	01	002	20.00	0000000000000000000000000000000000000000000000011000000	
H0354	001	1	01	01	001	15.00	0000000000000000000000000000000000000000000000011000000	
H0354	001	1	01	01	002	69.00	1000000000000000000000000000000000000000000000000000000	Prescription Drugs: $69 per month member can increase their brand drug maximum from $1,000 to $2000
H0354	009	2	01	01	001	15.00	0000000000000000000000000000000000000000000000011000000	
H0354	009	2	01	01	002	69.00	1000000000000000000000000000000000000000000000000000000	Prescription Drugs: $69 per month member can increase their brand drug maximum from $1,000 to $2000
H0359	002	1	01	01	002	25.00	1000000000000000000000000000000000000000000000000000000	Transitional Care Benefit.
H0504	005	1	01	01	001	25.00	0000000000000100010000000000000001000000000000000000000	
H0504	005	1	01	01	002	10.95	1000000000000000000000000000000000000000000000000000000	Dental Plus
H0504	006	1	01	01	001	25.00	0000000000000100000000000000000001000000000000000000000	
H0504	006	1	01	01	002	10.95	1000000000000000000000000000000000000000000000000000000	Dental Plus
H0504	007	1	01	01	001	25.00	0000000000000100000000000000000001000000000000000000000	
H0504	007	1	01	01	002	10.95	1000000000000000000000000000000000000000000000000000000	Dental Plus
H0504	009	1	01	01	001	25.00	0000000000000100010000000000000001000000000000000000000	
H0504	009	1	01	01	002	25.00	0000000000000000000000000000000000000000000000011000000	
H0504	010	1	01	01	001	25.00	0000000000000100010000000000000001000000000000000000000	
H0504	010	1	01	01	002	10.95	1000000000000000000000000000000000000000000000000000000	Dental Plus
H0504	013	1	01	01	001	25.00	0000000000000100010000000000000001000000000000000000000	
H0504	013	1	01	01	002	10.95	1000000000000000000000000000000000000000000000000000000	Dental Plus
H0504	014	1	01	01	001	25.00	0000000000000100000000000000000001000000000000000000000	
H0504	014	1	01	01	002	10.95	1000000000000000000000000000000000000000000000000000000	Dental Plus
H0523	001	1	01	01	001	25.00	1000000000000000000000000000000000000000000000000000000	Transitional Care Benefit.
H0523	002	1	01	01	001	25.00	1000000000000000000000000000000000000000000000000000000	Transitional Care Benefit.
H0523	004	1	01	01	001	25.00	1000000000000000000000000000000000000000000000000000000	Transitional Care Benefit.
H0523	005	1	01	01	001	25.00	1000000000000000000000000000000000000000000000000000000	Transitional Care Benefit.
H0523	021	1	01	01	001	25.00	1000000000000000000000000000000000000000000000000000000	Transitional Care Benefit.
H0523	022	1	01	01	001	25.00	1000000000000000000000000000000000000000000000000000000	Transitional Care Benefit.
H0523	023	1	01	01	001	25.00	1000000000000000000000000000000000000000000000000000000	Transitional Care Benefit.
H0523	024	1	01	01	001	25.00	1000000000000000000000000000000000000000000000000000000	Transitional Care Benefit.
H0543	001	1	01	01	001	14.50	1000000000000000000000000000000000000000000000010000000	Optional supplemental dental - High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	004	1	01	01	001	14.50	1000000000000000000000000000000000000000000000010000000	See optional supplemental High Optional Dental Plan fee schedule.
H0543	007	1	01	01	001	5.00	1000000000000000000000000000000000010000000000000000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	007	1	01	01	002	14.50	1000000000000000000000000000000000000000000000011000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	010	1	01	01	001	5.00	1000000000000000000000000000000000010000000000000000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	010	1	01	01	002	16.50	1000000000000000000000000000000000000000000000011000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	013	1	01	01	001	5.00	1000000000000000000000000000000000010000000000000000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	013	1	01	01	002	14.50	1000000000000000000000000000000000000000000000011000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	019	1	01	01	001	5.00	1000000000000000000000000000000000010000000000000000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	019	1	01	01	002	16.50	1000000000000000000000000000000000000000000000011000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	022	1	01	01	001	5.00	1000000000000000000000000000000000010000000000000000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	022	1	01	01	002	16.50	1000000000000000000000000000000000000000000000011000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	027	1	01	01	001	16.50	1000000000000000000000000000000000000000000000011000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	027	1	01	01	002	5.00	1000000000000000000000000000000000010000000000000000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	029	1	01	01	001	5.00	1000000000000000000000000000000000010000000000000000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	029	1	01	01	002	16.50	1000000000000000000000000000000000000000000000011000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	030	1	01	01	001	5.00	1000000000000000000000000000000000010000000000000000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	030	1	01	01	002	16.50	1000000000000000000000000000000000000000000000011000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	038	1	01	01	001	5.00	1000000000000000000000000000000000000000000000011000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	048	1	01	01	001	14.50	1000000000000000000000000000000000000000000000010000000	See optional supplemental High Optional Dental Plan fee schedule.
H0543	049	1	01	01	001	14.50	1000000000000000000000000000000000000000000000010000000	See optional supplemental High Optional Dental Plan fee schedule.
H0543	050	1	01	01	001	14.50	1000000000000000000000000000000000000000000000011000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	050	1	01	01	002	5.00	1000000000000000000000000000000000010000000000000000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	051	1	01	01	001	14.50	1000000000000000000000000000000000000000000000011000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	051	1	01	01	002	5.00	1000000000000000000000000000000000010000000000000000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	053	1	01	01	001	5.00	1000000000000000000000000000000000010000000000000000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	053	1	01	01	002	16.50	1000000000000000000000000000000000000000000000011000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	054	1	01	01	001	5.00	1000000000000000000000000000000000010000000000000000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	054	1	01	01	002	16.50	1000000000000000000000000000000000000000000000011000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	056	1	01	01	001	16.50	1000000000000000000000000000000000000000000000011000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	056	1	01	01	002	5.00	1000000000000000000000000000000000010000000000000000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0543	057	1	01	01	001	5.00	1000000000000000000000000000000000000000000000011000000	See Optional Dental Plan and/or High Option Dental Plan Fee Schedules included with paper ACR copy.
H0603	006	1	01	01	001	10.00	0000000000000000000000000000000000000000000000011000000	
H0603	006	1	01	01	002	69.00	0000000000000000000000000000000000111000000000100000000	
H0609	001	1	01	01	001	13.25	0000000000000000000000000000000000000000000000011000000	
H0609	002	1	01	01	001	13.25	0000000000000000000000000000000000000000000000011000000	
H0609	003	1	01	01	001	13.25	0000000000000000000000000000000000000000000000011000000	
H0609	006	1	01	01	001	13.25	0000000000000000000000000000000000000000000000011000000	
H0609	007	1	01	01	001	13.25	0000000000000000000000000000000000000000000000011000000	
H0609	008	2	01	01	001	13.25	0000000000000000000000000000000000000000000000011000000	
H1035	002	1	01	01	001	34.00	1000000000000000000000000000000000000000000000000000000	Outpatient Prescription DrugsDental ServicesVision ServicesHearing Services
H1035	004	2	01	01	001	26.95	1000000000000000000000000000000000000000000000000000000	Outpatient Prescription DrugsDental ServicesVision ServicesHearing Services
H1506	001	1	01	01	001	39.00	1000000000000000000000000000000000000000000000100000000	There is a $500 annual maximum limited to $125 per quarter.
H1506	001	1	01	01	002	68.00	1000000000000000000000000000000000000000000000100000000	There is a $1,000 annual maximum limited to $250 per quarter.
H1751	002	1	02	01	001	45.00	1000000000000100000000000000000000100000000000000000001	See Section D-3 notes for full explanation of optional supplemental benefits.
H1751	004	2	02	01	001	45.00	1000000000000100000000000000000000100000000000000000001	See Section D-3 notes for full explanation of optional supplemental benefits.
H2312	004	1	01	01	001	48.00	1000000000000000000000000000000000000000000000000000000	ENHANCED OUTAPTIENT PRESCRIPTION DRUG PROGRAM.Call 1-800-801-1770 for information.
H2459	002	1	02	01	001	21.58	0000000000000000000000000000000000000000000000001000000	
H2960	001	1	02	01	002	25.00	0000000000000000000000000000000000000000000000011000000	
H2960	002	1	02	01	001	25.00	0000000000000000000000000000000000000000000000011000000	
H3204	001	1	01	01	001	5.00	1000000000000000000000000000000000100000000000000000000	Discounted Dental Plan
H3204	002	1	01	01	001	5.00	1000000000000000000000000000000000100000000000000000000	Discounted dental plan
H3204	004	2	01	01	001	5.00	1000000000000000000000000000000000100000000000000000000	Discounted Dental Plan
H3204	005	2	01	01	001	5.00	1000000000000000000000000000000000100000000000000000000	Discounted dental plan
H3251	002	1	01	01	001	55.00	0000000000000000000000000000000000000000000000100000000	
H3251	002	1	01	01	002	95.00	0000000000000000000000000000000000100000000000000000000	
H3251	017	2	01	01	001	55.00	0000000000000000000000000000000000000000000000100000000	
H3251	017	2	01	01	002	95.00	0000000000000000000000000000000000100000000000000000000	
H3755	001	1	01	01	001	65.00	1000000000000000000000000000000000000000000000000000000	Raises outpatient drug quarterly maximum plan benefit coverage amount from $75 to $250.
H3756	002	1	01	01	001	29.00	0000000000000000000000000000000000000000000000100000000	
H3952	008	1	02	01	001	30.00	0000000000000000000000000000000000000000000000100000000	
H3952	008	1	02	01	002	65.00	1000000000000000000000000000000000000000000000100000000	Prescription Drug Option 2: As described in Section 15, Outpatient Drugs, Base 4, Notes Section.
H3952	008	1	02	01	003	75.00	1000000000000000000000000000000000000000000000100000000	Prescription Drug Option 3: As described in Section 15, Outpatient Drugs, Base 4, Notes Section.
H3952	008	1	02	01	004	25.00	0000000000000000000000000000000000000000000000000000001	
H3952	009	1	02	01	001	30.00	0000000000000000000000000000000000000000000000100000000	
H3952	009	1	02	01	002	65.00	1000000000000000000000000000000000000000000000100000000	Prescription Drug Option 2: As described in Section 15, Outpatient Drugs, Base 4, Notes Section.
H3952	009	1	02	01	003	75.00	1000000000000000000000000000000000000000000000100000000	Prescription Drug Option 3: As described in Section 15, Outpatient Drugs, Base 4, Notes Section.
H3952	009	1	02	01	004	25.00	0000000000000000000000000000000000000000000000000000001	
H3957	011	1	01	01	001	8.00	1000000000000100010000000000000000100000000000010000000	Unlimited, direct access to rheumatologists, dermatologists and ear, nose & throat (ENT) providers
H3963	001	1	04	01	001	35.00	1000000000000000000000000000000000000000000000000000000	Prescription Drug Option 1: As described in Section 15, Outpatient Drugs, Base 4, Notes Section.
H4003	001	1	01	01	001	69.00	1000000000000000000000000000000000000000000000000000000	Prescription drug coverage enhanced eyewear benefitenhanced hearing aid benefitTravel Benefit
H4003	002	1	01	01	001	69.00	1000000000000000000000000000000000000000000000100000010	$100 add eyewear benefit$200 add hearing aid benefit
H4102	001	1	01	01	001	39.00	0000000000000000000000000000000000000000000000011010100	
H4102	002	1	01	01	001	39.00	0000000000000000000000000000000000000000000000011010100	
H4102	004	2	01	01	001	39.00	0000000000000000000000000000000000000000000000011010100	
H4454	007	1	01	01	001	50.00	1000000000000000000000000000000000000000000000000000000	NO PCP Referral or authorization required
H5050	001	1	02	01	001	19.00	0000010000010000000000000000000000000000000000011000000	
H5050	002	1	02	01	001	19.00	0000010000010000000000000000000000000000000000011000000	
H5050	005	2	02	01	001	19.00	0000000000010000000000000000000000000000000000011000000	
H5063	005	1	02	01	001	28.00	0000000000000000000000000000000000000000000000011000001	
H5063	006	1	02	01	001	28.00	0000000000000000000000000000000000000000000000011000001	
H5063	007	2	02	01	001	28.00	0000000000000000000000000000000000000000000000011000001	
H9005	004	1	01	01	001	224.50	0000000000000000000000000000000000000000000000100000000	
H1555	001	1	18	06	001	34.00	0000000000000000000000000000000000000000000000100000000	
H2461	001	1	18	06	001	199.00	1000000000000000000000000000000000000000000000000000000	80% Prescription Drug Benefit
H3356	002	1	18	06	001	45.54	0000000000000000000000000000000000000000000000100000000	
H5264	001	1	18	06	001	27.00	0000010000000000000000000000000000000000000000000000000	
H9104	006	1	10	05	001	10.00	0000000000000100000000000000000000000000000000000000000	
H9104	006	1	10	05	002	19.00	0000000000000000000000000000000000010000000000000000000	
H9104	006	1	10	05	003	25.00	0000000000000000000000000000000000001000000000000000000	
