Plan Materials
Want to learn more about a specific plan? Here you'll find all the details about your Health Net coverage choices to find the plan that fits your needs.
All documents are in PDF format. 
Materials & Forms
Brochures
- 2023 – Plan choices by location – English (PDF) (IFP on- and off-exchange)
- 2023 – IEX Sales Brochure – English (PDF)
- 2023 – IEX Ambetter HMO Sales Brochure – English (PDF)
- 2023 – IEX Ambetter PPO Sales Brochure – English (PDF)
2023 Disclosures
Ambetter PPO
2023 – Ambetter PPO Disclosure for Covered California – English (PDF)
Ambetter HMO
2023 – Ambetter HMO Disclosure for Covered California – English (PDF)
2023 Pediatric Dental and Vision
Brochures
- 2023 – Plan choices by location – English (PDF) (IFP on- and off-exchange)
- 2023 IFP Sales Brochure – English (PDF)
Enrollment Tools
Individual & Family Plans (IFP) Enrollment Applications –
Effective January 1, 2023
Ambetter HMO
- 2023 – Ambetter HMO Enrollment Application – English (PDF)
- 2023 – Ambetter HMO Enrollment Application – En Español (Spanish) (PDF)
- 2023 – Ambetter HMO Enrollment Application – Chinese (PDF)
- 2023 – Ambetter HMO Enrollment Application – Korean (PDF)
- 2023 – Ambetter HMO Enrollment Application – Vietnamese (PDF)
Ambetter PPO
- 2023 – Ambetter PPO Enrollment Application – English (PDF)
- 2023 – Ambetter PPO Enrollment Application – En Español (Spanish) (PDF)
- 2023 – Ambetter PPO Enrollment Application – Chinese (PDF)
- 2023 – Ambetter PPO Enrollment Application – Korean (PDF)
- 2023 – Ambetter PPO Enrollment Application – Vietnamese (PDF)
2023 Disclosures
Ambetter HMO
Ambetter PPO
Dental and Vision
Brochures
- 2022 – Plan choices by location (PDF) (IFP on- and off-exchange)
- 2022 – IEX Sales Brochure (PDF)
- 2022 – IEX Ambetter HMO Sales Brochure (PDF)
- 2022 – IEX Ambetter PPO Sales Brochure (PDF)
- 2022 – IEX Ambetter HSP Sales Brochure (PDF)
- 2022 – IEX Ambetter EPO Sales Brochure (PDF)
2022 Disclosures
EPO
2022 – Ambetter EPO Disclosure for Covered California - English (PDF)
Ambetter PPO
2022 – Ambetter PPO Disclosure for Covered California - English (PDF)
HMO/HSP
2022 – Ambetter HMO and Ambetter HSP Disclosure for Covered California - English (PDF)
2022 Pediatric Dental and Vision
Brochures
- 2022 – Plan choices by location - English (PDF) (IFP on- and off-exchange)
- 2022 – Health Net PPO plan choices by location - English (PDF) (IFP off-exchange)
- 2022 IFP Sales Brochure - English (PDF)
- 2022 IFP PPO Sales Brochure - English (PDF)
Enrollment Tools
Individual & Family Plans (IFP) Enrollment Applications – Effective January 1, 2022
Ambetter HMO
- 2022 – Ambetter HMO Enrollment Application – English (PDF)
- 2022 – Ambetter HMO Enrollment Application – Spanish (PDF)
- 2022 – Ambetter HMO Enrollment Application – Chinese (PDF)
- 2022 – Ambetter HMO Enrollment Application – Korean (PDF)
- 2022 – Ambetter HMO Enrollment Application – Vietnamese (PDF)
Ambetter HSP
- 2022 – Ambetter HSP Enrollment Application – English (PDF)
- 2022 – Ambetter HSP Enrollment Application – Spanish (PDF)
- 2022 – Ambetter HSP Enrollment Application – Chinese (PDF)
- 2022 – Ambetter HSP Enrollment Application – Korean (PDF)
- 2022 – Ambetter HSP Enrollment Application – Vietnamese (PDF)
Ambetter EPO
- 2022 – Ambetter EPO Enrollment Application – English (PDF)
- 2022 – Ambetter EPO Enrollment Application – Spanish (PDF)
- 2022 – Ambetter EPO Enrollment Application – Chinese (PDF)
- 2022 – Ambetter EPO Enrollment Application – Korean (PDF)
- 2022 – Ambetter EPO Enrollment Application – Vietnamese (PDF)
PPO
- 2022 – IFP PPO Enrollment Application – English (PDF)
- 2022 – IFP PPO Enrollment Application – Spanish (PDF)
- 2022 – IFP PPO Enrollment Application – Chinese (PDF)
- 2022 – IFP PPO Enrollment Application – Korean (PDF)
- 2022 – IFP PPO Enrollment Application – Vietnamese (PDF)
Ambetter PPO
- 2022 – Ambetter PPO Enrollment Application – English (PDF)
- 2022 – Ambetter PPO Enrollment Application – Spanish (PDF)
- 2022 – Ambetter PPO Enrollment Application – Chinese (PDF)
- 2022 – Ambetter PPO Enrollment Application – Korean (PDF)
- 2022 – Ambetter PPO Enrollment Application – Vietnamese (PDF)
2022 Disclosures
HMO/HSP
EPO
PPO
Ambetter PPO
Dental and Vision
Plan Overviews
Ambetter HMO
- Platinum 90 Ambetter HMO Plan Overview – English (PDF)
- Gold 80 Ambetter HMO Plan Overview – English (PDF)
- Silver 70 Ambetter HMO Plan Overview – English (PDF)
- Bronze 60 Ambetter HMO Plan Overview – English (PDF)
- Minimum Coverage Ambetter HMO Plan Overview – English (PDF)
- Silver 73 Ambetter HMO Plan Overview – English (PDF)
- Silver 87 Ambetter HMO Plan Overview – English (PDF)
- Silver 94 Ambetter HMO Plan Overview – English (PDF)
Ambetter PPO
- Platinum 90 Ambetter PPO Plan Overview – English (PDF)
- Gold 80 Ambetter PPO Plan Overview – English (PDF)
- Silver 70 Ambetter PPO Plan Overview – English (PDF)
- Bronze 60 Ambetter PPO Plan Overview – English (PDF)
- Bronze 60 HDHP Ambetter PPO Plan Overview – English (PDF)
- Minimum Coverage Ambetter PPO Plan Overview – English (PDF)
- Silver 73 Ambetter PPO Plan Overview – English (PDF)
- Silver 87 Ambetter PPO Plan Overview – English (PDF)
- Silver 94 Ambetter PPO Plan Overview – English (PDF)
Ambetter HMO
- Platinum 90 Ambetter HMO Plan Overview – English (PDF)
- Gold 80 Ambetter HMO Plan Overview – English (PDF)
- Silver 70 Ambetter HMO Plan Overview – English (PDF)
- Bronze 60 Ambetter HMO Plan Overview – English (PDF)
- Minimum Coverage Ambetter HMO Plan Overview – English (PDF)
Ambetter PPO
- Platinum 90 Ambetter PPO Plan Overview – English (PDF)
- Gold 80 Ambetter PPO Plan Overview – English (PDF)
- Silver 70 Ambetter PPO Plan Overview – English (PDF)
- Bronze 60 Ambetter PPO Plan Overview – English (PDF)
- Bronze 60 HDHP Ambetter PPO Plan Overview – English (PDF)
- Minimum Coverage Ambetter PPO Plan Overview – English (PDF)
Ambetter HMO
- Platinum 90 Ambetter HMO Plan Overview – English (PDF)
- Gold 80 Ambetter HMO Plan Overview – English (PDF)
- Silver 70 Ambetter HMO Plan Overview – English (PDF)
- Silver 73 Ambetter HMO Plan Overview – English (PDF)
- Silver 87 Ambetter HMO Plan Overview – English (PDF)
- Silver 94 Ambetter HMO Plan Overview – English (PDF)
Ambetter PPO
- Platinum 90 Ambetter PPO Plan Overview – English (PDF)
- Gold 80 Ambetter PPO Plan Overview – English (PDF)
- Silver 70 Ambetter PPO Plan Overview – English (PDF)
- Bronze 60 Ambetter PPO Plan Overview – English (PDF)
- Bronze 60 HDHP Ambetter PPO Plan Overview – English (PDF)
- Silver 73 Ambetter PPO Plan Overview – English (PDF)
- Silver 87 Ambetter PPO Plan Overview – English (PDF)
- Silver 94 Ambetter PPO Plan Overview – English (PDF)
- Minimum Coverage Ambetter PPO Plan Overview – English (PDF)
Ambetter EPO
- Platinum 90 Ambetter EPO Plan Overview – English (PDF)
- Gold 80 Ambetter EPO Plan Overview – English (PDF)
- Silver 70 Ambetter EPO Plan Overview – English (PDF)
- Bronze 60 Ambetter EPO Plan Overview – English (PDF)
- Silver 73 Ambetter EPO Plan Overview – English (PDF)
- Silver 87 Ambetter EPO Plan Overview – English (PDF)
- Silver 94 Ambetter EPO Plan Overview – English (PDF)
- Minimum Coverage Ambetter EPO Plan Overview – English (PDF)
Ambetter HSP
Ambetter HMO
- Platinum 90 Ambetter HMO Plan Overview – English (PDF)
- Gold 80 Ambetter HMO Plan Overview – English (PDF)
- Silver 70 Ambetter HMO Plan Overview – English (PDF)
Ambetter PPO
- Platinum 90 Ambetter PPO Plan Overview – English (PDF)
- Gold 80 Ambetter PPO Plan Overview – English (PDF)
- Silver 70 Ambetter PPO Plan Overview – English (PDF)
- Bronze 60 Ambetter PPO Plan Overview – English (PDF)
- Bronze 60 HDHP Ambetter PPO Plan Overview – English (PDF)
- Gold Value Ambetter PPO Plan Overview – English (PDF)
- Silver Value Ambetter PPO Plan Overview – English (PDF)
- Minimum Coverage Ambetter PPO Plan Overview – English (PDF)
PPO
- Platinum 90 PPO Plan Overview – English (PDF)
- Gold 80 PPO Plan Overview – English (PDF)
- Silver 70 PPO Plan Overview – English (PDF)
- Bronze 60 PPO Plan Overview – English (PDF)
- Minimum Coverage PPO Plan Overview – English (PDF)
Ambetter EPO
- Platinum 90 Ambetter EPO Plan Overview – English (PDF)
- Gold 80 Ambetter EPO Plan Overview – English (PDF)
- Silver 70 Ambetter EPO Plan Overview – English (PDF)
- Bronze 60 Ambetter EPO Plan Overview – English (PDF)
- Minimum Coverage Ambetter EPO Plan Overview – English (PDF)
Ambetter HSP
Summary of Benefits and Coverage (SBC)
HMO
- 2023 – Platinum 90 Ambetter HMO SBC – English (PDF)
- 2023 – Gold 80 Ambetter HMO SBC – English (PDF)
- 2023 – Minimum Coverage Ambetter HMO SBC – English (PDF)
- 2023 – Bronze 60 Ambetter HMO SBC – English (PDF)
- 2023 – Silver 70 Ambetter HMO SBC – English (PDF)
- 2023 – Silver 73 Ambetter HMO SBC – English (PDF)
- 2023 – Silver 87 Ambetter HMO SBC – English (PDF)
- 2023 – Silver 94 Ambetter HMO SBC – English (PDF)
PPO
- 2023 – Silver 70 Ambetter PPO SBC – English (PDF)
- 2023 – Silver 73 Ambetter PPO SBC – English (PDF)
- 2023 – Silver 87 Ambetter PPO SBC – English (PDF)
- 2023 – Silver 94 Ambetter PPO SBC – English (PDF)
- 2023 – Gold 80 Ambetter PPO SBC – English (PDF)
- 2023 – Platinum 90 Ambetter PPO SBC – English (PDF)
- 2023 – Bronze 60 Ambetter PPO SBC – English (PDF)
- 2023 – Bronze 60 HDHP Ambetter PPO SBC – English (PDF)
- 2023 – Minimum Coverage Ambetter PPO SBC – English (PDF)
HMO
- 2023 – Platinum 90 Ambetter HMO SBC – English (PDF)
- 2023 – Gold 80 Ambetter HMO SBC – English (PDF)
- 2023 – Silver 70 Off Exchange Ambetter HMO SBC – English (PDF)
- 2023 – Minimum Coverage Ambetter HMO SBC – English (PDF)
- 2023 – Bronze 60 Ambetter HMO SBC – English (PDF)
Ambetter PPO
- 2023 – Silver 70 Off Exchange Ambetter PPO SBC – English (PDF)
- 2023 – Gold 80 Ambetter PPO SBC – English (PDF)
- 2023 – Platinum 90 Ambetter PPO SBC – English (PDF)
- 2023 – Bronze 60 Ambetter PPO SBC – English (PDF)
- 2023 – Bronze 60 HDHP Ambetter PPO SBC – English (PDF)
- 2023 – Minimum Coverage Ambetter PPO SBC – English (PDF)
HMO AI-AN
- 2023 – Platinum 90 Ambetter HMO AI-AN SBC – English (PDF)
- 2023 – Gold 80 Ambetter HMO AI-AN SBC – English (PDF)
- 2023 – Silver 70 Ambetter HMO AI-AN SBC – English (PDF)
- 2023 – Bronze 60 Ambetter Limited Cost Share HMO AI-AN SBC – English (PDF)
- 2023 – Bronze 60 Ambetter $0 Cost Share HMO AI-AN SBC – English (PDF)
- 2023 – $0 Cost Share Ambetter HMO AI-AN SBC – English (PDF)
PPO AI-AN
- 2023 – Silver 70 Ambetter PPO AI-AN SBC – English (PDF)
- 2023 – Gold 80 Ambetter PPO AI-AN SBC – English (PDF)
- 2023 – Platinum 90 Ambetter PPO AI-AN SBC – English (PDF)
- 2023 – Bronze 60 Ambetter PPO AI-AN SBC – English (PDF)
- 2023 – Bronze 60 HDHP Ambetter PPO AI-AN SBC – English (PDF)
- 2023 – $0 Cost Share Ambetter PPO AI-AN SBC – English (PDF)
HMO
- 2022 – Platinum 90 Ambetter HMO SBC – English (PDF)
- 2022 – Gold 80 Ambetter HMO SBC – English (PDF)
- 2022 – Silver 70 Ambetter HMO SBC – English (PDF)
- 2022 – Silver 73 Ambetter HMO SBC – English (PDF)
- 2022 – Silver 87 Ambetter HMO SBC – English (PDF)
- 2022 – Silver 94 Ambetter HMO SBC – English (PDF)
PPO
- 2022 – Platinum 90 Ambetter PPO SBC – English (PDF)
- 2022 – Gold 80 Ambetter PPO SBC – English (PDF)
- 2022 – Silver 70 Ambetter PPO SBC – English (PDF)
- 2022 – Bronze 60 Ambetter PPO SBC – English (PDF)
- 2022 – Bronze 60 HDHP Ambetter PPO SBC – English (PDF)
- 2022 – Silver 73 Ambetter PPO SBC – English (PDF)
- 2022 – Silver 87 Ambetter PPO SBC – English (PDF)
- 2022 – Silver 94 Ambetter PPO SBC – English (PDF)
- 2022 – Minimum Coverage Ambetter PPO SBC – English (PDF)
EPO
- 2022 – Platinum 90 Ambetter EPO SBC – English (PDF)
- 2022 – Gold 80 Ambetter EPO SBC – English (PDF)
- 2022 – Silver 70 Ambetter EPO SBC – English (PDF)
- 2022 – Bronze 60 Ambetter EPO SBC – English (PDF)
- 2022 – Silver 73 Ambetter EPO SBC – English (PDF)
- 2022 – Silver 87 Ambetter EPO SBC – English (PDF)
- 2022 – Silver 94 Ambetter EPO SBC – English (PDF)
- 2022 – Minimum Coverage Ambetter EPO SBC – English (PDF)
HSP
HMO
- 2022 – Platinum 90 Ambeter HMO SBC – English (PDF)
- 2022 – Gold 80 Ambetter HMO SBC – English (PDF)
- 2022 – Silver 70 Off Exchange Ambetter HMO SBC – English (PDF)
Ambetter PPO
- 2022 – Platinum 90 Ambetter PPO SBC – English (PDF)
- 2022 – Gold 80 Ambetter PPO SBC – English (PDF)
- 2022 – Silver 70 Off Exchange Ambetter PPO SBC – English (PDF)
- 2022 – Bronze 60 Ambetter PPO SBC – English (PDF)
- 2022 – Bronze 60 HDHP Ambetter PPO SBC – English (PDF)
- 2022 – Gold Value Ambetter PPO SBC – English (PDF)
- 2022 – Silver Value Ambetter PPO SBC – English (PDF)
- 2022 – Minimum Coverage Ambetter PPO SBC – English (PDF)
PPO
- 2022 – Platinum 90 PPO SBC – English (PDF)
- 2022 – Gold 80 PPO SBC – English (PDF)
- 2022 – Silver 70 PPO SBC – English (PDF)
- 2022 – Bronze 60 PPO SBC – English (PDF)
- 2022 – Minimum Coverage PPO SBC – English (PDF)
EPO
- 2022 – Platinum 90 Ambetter EPO SBC – English (PDF)
- 2022 – Gold 80 Ambetter EPO SBC – English (PDF)
- 2022 – Silver 70 Off Exchange Ambetter EPO SBC – English (PDF)
- 2022 – Bronze 60 Ambetter EPO SBC – English (PDF)
- 2022 – Minimum Coverage Ambetter EPO SBC – English (PDF)
HSP
HMO AI-AN
- 2022 – Platinum 90 Ambetter HMO AI-AN SBC – English (PDF)
- 2022 – Gold 80 Ambetter HMO AI-AN SBC – English (PDF)
- 2022 – Silver 70 Ambetter HMO AI-AN SBC – English (PDF)
- 2022 – $0 Cost Share Ambetter HMO AI-AN SBC – English (PDF)
PPO AI-AN
- 2022 – Platinum 90 Ambetter PPO AI-AN SBC – English (PDF)
- 2022 – Gold 80 Ambetter PPO AI-AN SBC – English (PDF)
- 2022 – Silver 70 Ambetter PPO AI-AN SBC – English (PDF)
- 2022 – Bronze 60 Ambetter PPO AI-AN SBC – English (PDF)
- 2022 – Bronze 60 HDHP Ambetter PPO AI-AN SBC – English (PDF)
- 2022 – $0 Cost Share Ambetter PPO AI-AN SBC – English (PDF)
EPO AI-AN
- 2022 – Platinum 90 Ambetter EPO AI-AN SBC – English (PDF)
- 2022 – Gold 80 Ambetter EPO AI-AN SBC – English (PDF)
- 2022 – Silver 70 Ambetter EPO AI-AN SBC – English (PDF)
- 2022 – Bronze 60 Ambetter EPO AI-AN SBC – English (PDF)
- 2022 – $0 Cost Share Ambetter EPO AI-AN SBC – English (PDF)
HSP AI-AN
Looking for a Summary of Benefits and Coverage for a specific plan? Use our SBC Search Tool
Summary of Dental Benefits and Coverage (SDBC)
Plan Contract and Evidence of Coverage/Policies
Ambetter HMO (Covered California)
- 2023 – Bronze 60 Ambetter HMO – English (PDF)
- 2023 – Gold 80 Ambetter HMO – English (PDF)
- 2023 – Minimum Coverage Ambetter HSP – English (PDF)
- 2023 – Platinum 90 Ambetter HMO – English (PDF)
- 2023 – Silver 70 Ambetter HMO – English (PDF)
- 2023 – Silver 73 (CSR) Ambetter HMO – English (PDF)
- 2023 – Silver 87 (CSR) Ambetter HMO – English (PDF)
- 2023 – Silver 94 (CSR) Ambetter HMO – English (PDF)
Ambetter PPO (Covered California)
- 2023 – Bronze 60 Ambetter PPO – English (PDF)
- 2023 – Bronze 60 HDHP Ambetter PPO – English (PDF)
- 2023 – Gold 80 Ambetter PPO – English (PDF)
- 2023 – Minimum Coverage Ambetter PPO – English (PDF)
- 2023 – Platinum 90 Ambetter PPO – English (PDF)
- 2023 – Silver 70 Ambetter PPO – English (PDF)
- 2023 – Silver 73 (CSR) Ambetter PPO – English (PDF)
- 2023 – Silver 87 (CSR) Ambetter PPO – English (PDF)
- 2023 – Silver 94 (CSR) Ambetter PPO – English (PDF)
Ambetter HMO (Off Marketplace)
- 2023 – Bronze 60 Ambetter HMO – English (PDF)
- 2023 – Bronze 60 Ambetter HMO Plus with Dental and Vision – English (PDF)
- 2023 – Gold 80 Ambetter HMO – English (PDF)
- 2023 – Gold 80 Ambetter HMO Plus with Dental and Vision – English (PDF)
- 2023 – Minimum Coverage Ambetter HSP – English (PDF)
- 2023 – Minimum Coverage Ambetter HSP Plus with Dental and Vision – English (PDF)
- 2023 – Platinum 90 Ambetter HMO – English (PDF)
- 2023 – Platinum 90 Ambetter HMO Plus with Dental and Vision – English (PDF)
- 2023 – Silver 70 Off Exchange Ambetter HMO – English (PDF)
- 2023 – Silver 70 Off Exchange Ambetter HMO Plus with Dental and Vision – English (PDF)
Ambetter PPO (Off Marketplace)
- 2023 – Bronze 60 Ambetter PPO – English (PDF)
- 2023 – Bronze 60 Ambetter PPO with Dental and Vision – English (PDF)
- 2023 – Bronze 60 HDHP Ambetter PPO – English (PDF)
- 2023 – Bronze 60 HDHP Ambetter PPO with Dental and Vision – English (PDF)
- 2023 – Gold 80 Ambetter PPO – English (PDF)
- 2023 – Gold 80 Ambetter PPO with Dental and Vision – English (PDF)
- 2023 – Minimum Coverage Ambetter PPO – English (PDF)
- 2023 – Minimum Coverage Ambetter PPO with Dental and Vision – English (PDF)
- 2023 – Platinum 90 Ambetter PPO – English (PDF)
- 2023 – Platinum 90 Ambetter PPO with Dental and Vision – English (PDF)
- 2023 – Silver 70 Off Exchange Ambetter PPO – English (PDF)
- 2023 – Silver 70 Off Exchange Ambetter PPO with Dental and Vision – English (PDF)
Evidence of Coverage for Ambetter HMO Covered California Plans
- 2022 – Platinum 90 Ambetter HMO (PDF)
- 2022 – Gold 80 Ambetter HMO (PDF)
- 2022 – Silver 70 Ambetter HMO (PDF)
- 2022 – Silver 73 (CSR) Ambetter HMO (PDF)
- 2022 – Silver 87 (CSR) Ambetter HMO (PDF)
- 2022 – Silver 94 (CSR) Ambetter HMO (PDF)
Covered California Evidence of Coverage for Ambetter HSP Ambetter Plans
Covered California Policies for Ambetter One EPO Plans
- 2022 – Platinum 90 Ambetter One EPO (PDF)
- 2022 – Gold 80 Ambetter One EPO (PDF)
- 2022 – Silver 70 Ambetter One EPO (PDF)
- 2022 – Silver 73 (CSR) Ambetter One EPO (PDF)
- 2022 – Silver 87 (CSR) Ambetter One EPO (PDF)
- 2022 – Silver 94 (CSR) Ambetter One EPO (PDF)
- 2022 – Bronze 60 Ambetter One EPO (PDF)
- 2022 – Minimum Coverage Ambetter One EPO (PDF)
Covered California Policies for Ambetter PPO Plans
- 2022 – Platinum 90 Ambetter PPO (PDF)
- 2022 – Gold 80 Ambetter PPO (PDF)
- 2022 – Silver 70 Ambetter PPO (PDF)
- 2022 – Silver 73 (CSR) Ambetter PPO (PDF)
- 2022 – Silver 87 (CSR) Ambetter PPO (PDF)
- 2022 – Silver 94 (CSR) Ambetter PPO (PDF)
- 2022 – Bronze 60 Ambetter PPO (PDF)
- 2022 – Bronze 60 HDHP Ambetter PPO (PDF)
- 2022 – Minimum Coverage Ambetter PPO (PDF)
Evidence of Coverage for Ambetter HMO Plans (off Marketplace)
- 2022 – Platinum 90 Ambetter HMO (PDF)
- 2022 – Platinum 90 Ambetter HMO Plus with Dental and Vision (PDF)
- 2022 – Gold 80 Ambetter HMO (PDF)
- 2022 – Gold 80 Ambetter HMO Plus with Dental and Vision (PDF)
- 2022 – Silver 70 Off Exchange Ambetter HMO (PDF)
- 2022 – Silver 70 Off Exchange Ambetter HMO Plus with Dental and Vision (PDF)
Evidence of Coverage for HSP Ambetter Plans (off Marketplace)
- 2022 – Bronze 60 Ambetter HSP (PDF)
- 2022 – Bronze 60 Ambetter HSP Plus with Dental and Vision (PDF)
- 2022 – Minimum Coverage Ambetter HSP (PDF)
- 2022 – Minimum Coverage Ambetter HSP Plus with Dental and Vision (PDF)
Policies for EPO Ambetter One Plans (off Marketplace)
- 2022 – Platinum 90 EPO (PDF)
- 2022 – Platinum 90 EPO with Dental and Vision (PDF)
- 2022 – Gold 80 EPO (PDF)
- 2022 – Gold 80 EPO with Dental and Vision (PDF)
- 2022 – Silver 70 Off Exchange EPO (PDF)
- 2022 – Silver 70 Off Exchange EPO with Dental and Vision (PDF)
- 2022 – Bronze 60 EPO (PDF)
- 2022 – Bronze 60 EPO with Dental and Vision (PDF)
- 2022 – Minimum Coverage EPO (PDF)
- 2022 – Minimum Coverage EPO with Dental and Vision (PDF)
Policies for PPO Plans (off Marketplace)
- 2022 – Platinum 90 PPO (PDF)
- 2022 – Platinum 90 PPO with Dental and Vision (PDF)
- 2022 – Gold 80 PPO (PDF)
- 2022 – Gold 80 PPO with Dental and Vision (PDF)
- 2022 – Silver 70 PPO (PDF)
- 2022 – Silver 70 PPO with Dental and Vision (PDF)
- 2022 – Bronze 60 PPO (PDF)
- 2022 – Bronze 60 PPO with Dental and Vision (PDF)
- 2022 – Minimum Coverage PPO (PDF)
- 2022 – Minimum Coverage PPO with Dental and Vision (PDF)
Policies for Ambetter PPO Plans (off Marketplace)
- 2022 – Platinum 90 Ambetter PPO (PDF)
- 2022 – Platinum 90 Ambetter PPO with Dental and Vision (PDF)
- 2022 – Gold 80 Ambetter PPO (PDF)
- 2022 – Gold 80 Ambetter PPO with Dental and Vision (PDF)
- 2022 – Gold Value Ambetter PPO (PDF)
- 2022 – Gold Value Ambetter PPO with Dental and Vision (PDF)
- 2022 – Silver 70 Off Exchange Ambetter PPO (PDF)
- 2022 – Silver 70 Off Exchange Ambetter PPO with Dental and Vision (PDF)
- 2022 – Silver Value Ambetter PPO (PDF)
- 2022 – Silver Value Ambetter PPO with Dental and Vision (PDF)
- 2022 – Bronze 60 Ambetter PPO (PDF)
- 2022 – Bronze 60 Ambetter PPO with Dental and Vision (PDF)
- 2022 – Bronze 60 HDHP Ambetter PPO (PDF)
- 2022 – Bronze 60 HDHP Ambetter PPO with Dental and Vision (PDF)
- 2022 – Minimum Coverage Ambetter PPO (PDF)
- 2022 – Minimum Coverage Ambetter PPO with Dental and Vision (PDF)
Other Documents
Compliance Forms
- Authorization for Disclosure of Protected Health Information - English (PDF)
- Authorization for Disclosure of Protected Health Information - Spanish (PDF)
- Authorization for Disclosure of Protected Health Information - Chinese (PDF)
- Authorization for Disclosure of Protected Health Information - Korean (PDF)
- Glossary of Health Coverage and Medical Terms - English (PDF)
- Glossary of Health Coverage and Medical Terms - Spanish (PDF)
- Glossary of Health Coverage and Medical Terms - Chinese (PDF)
- Glossary of Health Coverage and Medical Terms - Korean (PDF)
- Glossary of Health Coverage and Medical Terms - Navajo (PDF)
Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer understand some of the most common language used in health insurance documents. Please log in to request a hardcopy of the document by mail.