Personal Choice — Groups 2 – 50IBC Forms Online — Contracts

Forms are in pdf format.

Option Domestic Partnership Coverage Last Updated
PPO 1 Rx $10/$20/$35 Vision $100   2013-04
PPO 1 Rx $10/$20/$35 Vision $100 x 2013-04
PPO 1 Vision $100   2013-04
PPO 1 Vision $100 x 2013-04
PPO 2 Rx $10/$20/$35 Vision $100   2013-04
PPO 2 Rx $10/$20/$35 Vision $100 x 2013-04
PPO 2 Vision $100   2013-04
PPO 2 Vision $100 x 2013-04
PPO 3 Rx $10/$20/$35 Vision $100   2013-04
PPO 3 Rx $10/$20/$35 Vision $100 x 2013-04
PPO 3 Vision $100   2013-04
PPO 3 Vision $100 x 2013-04
PPO 4 Rx $7/50%/$125 Vision $100   2013-04
PPO 4 Rx $7/50%/$125 Vision $100 x 2013-04
PPO 4 Vision $100   2013-04
PPO 4 Vision $100 x 2013-04
PPO 5 Rx $7/50%/$125 Vision $100   2013-04
PPO 5 Rx $7/50%/$125 Vision $100 x 2013-04
PPO 5 Vision $100   2013-04
PPO 5 Vision $100 x 2013-04
PPO 6 Rx $7/50%/$125 Vision $100   2013-04
PPO 6 Rx $7/50%/$125 Vision $100 x 2013-04
PPO 6 Vision $100   2013-04
PPO 6 Vision $100 x 2013-04
PPO 7 Rx $10/$45/$75 Vision $100   2013-04
PPO 7 Rx $10/$45/$75 Vision $100 x 2013-04
PPO 7 Rx $10/$45/$75 Vision $100   2013-04
PPO 7 Rx $10/$45/$75 Vision $100 x 2013-04
PPO 8 Rx $10/$45/$75 Vision $100   2013-04
PPO 8 Rx $10/$45/$75 Vision $100 x 2013-04
PPO 1.1 Rx $10/$40/$70 Vision $100   2013-04
PPO 1.1 Rx $10/$40/$70 Vision $100 x 2013-04
PPO 2.1 Rx $10/$40/$70 Vision $100   2013-04
PPO 2.1 Rx $10/$40/$70 Vision $100 x 2013-04
PPO 3.1 Rx $10/$40/$70 Vision $100   2013-04
PPO 3.1 Rx $10/$40/$70 Vision $100 x 2013-04
PPO 4.1 Rx $10/$45/$75 Vision $100   2013-04
PPO 4.1 Rx $10/$45/$75 Vision $100 x 2013-04
PPO 5.1 Rx $10/$45/$75 Vision $100   2013-04
PPO 5.1 Rx $10/$45/$75 Vision $100 x 2013-04
PPO 6.1 Rx $10/$45/$75 Vision $100   2013-04
PPO 6.1 Rx $10/$45/$75 Vision $100 x 2013-04
PPO 1.1 Rx $10/$40/$70 Vision $100   2013-04
PPO 1.1 Rx $10/$40/$70 Vision $100 x 2013-04
PPO 2.1 Rx $10/$40/$70 Vision $100   2013-04
PPO 2.1 Rx $10/$40/$70 Vision $100 x 2013-04
PPO 3.1 Rx $10/$40/$70 Vision $100   2013-04
PPO 3.1 Rx $10/$40/$70 Vision $100 x 2013-04
PPO 4.1 Rx $10/$45/$75 Vision $100   2013-04
PPO 4.1 Rx $10/$45/$75 Vision $100 x 2013-04
PPO 5.1 Rx $10/$45/$75 Vision $100   2013-04
PPO 5.1 Rx $10/$45/$75 Vision $100 x 2013-04
PPO 6.1 Rx $10/$45/$75 Vision $100   2013-04
PPO 6.1 Rx $10/$45/$75 Vision $100 x 2013-04
PPO 7.1 Rx $250/$10/$45/$75 Vision $100   2013-04
PPO 7.1 Rx $250/$10/$45/$75 Vision $100 x 2013-04
PPO 7.1 Rx $250/$10/$45/$75 Vision $100   2013-04
PPO 7.1 Rx $250/$10/$45/$75 Vision $100 x 2013-04
PPO 7.1 Contract Year Rx $250/$10/$45/$75 Vision $100   2013-04
PPO 7.1 Contract Year Rx $250/$10/$45/$75 Vision $100 x 2013-04
PPO 8.1 Rx $250/$10/$45/$75 Vision $100   2013-04
PPO 8.1 Rx $250/$10/$45/$75 Vision $100 x 2013-04
PPO 8.1 Contract Year Rx $250/$10/$45/$75 Vision $100   2013-04
PPO 8.1 Contract Year Rx $250/$10/$45/$75 Vision $100 x 2013-04
PPO HDHP 1 Rx $20/$40/$60 Vision $100 Contract Year — Single   2013-04
PPO HDHP 1 Rx $20/$40/$60 Vision $100 Contract Year — Single x 2013-04
PPO HDHP 1 Rx $20/$40/$60 Vision $100 Contract Year — Family   2013-04
PPO HDHP 1 Rx $20/$40/$60 Vision $100 Contract Year — Family x 2013-04
PPO HDHP 1 Rx $20/$40/$60 Vision $100 Calendar Year — Single   2013-04
PPO HDHP 1 Rx $20/$40/$60 Vision $100 Calendar Year — Single x 2013-04
PPO HDHP 1 Rx $20/$40/$60 Vision $100 Calendar Year — Family   2013-04
PPO HDHP 1 Rx $20/$40/$60 Vision $100 Calendar Year — Family x 2013-04
PPO HDHP 1 Vision $100 Calendar Year — Single   2013-04
PPO HDHP 1 Vision $100 Calendar Year — Single x 2013-04
PPO HDHP 1 Vision $100 Calendar Year — Family   2013-04
PPO HDHP 1 Vision $100 Calendar Year — Family x 2013-04
PPO HDHP 2 Rx $20/$40/$60 Vision $100 Contract Year — Single   2013-04
PPO HDHP 2 Rx $20/$40/$60 Vision $100 Contract Year — Single x 2013-04
PPO HDHP 2 Rx $20/$40/$60 Vision $100 Contract Year — Family   2013-04
PPO HDHP 2 Rx $20/$40/$60 Vision $100 Contract Year — Family x 2013-04
PPO HDHP 3 Rx $20/$40/$60 Vision $100 Contract Year — Single   2013-04
PPO HDHP 3 Rx $20/$40/$60 Vision $100 Contract Year — Single x 2013-04
PPO HDHP 3 Rx $20/$40/$60 Vision $100 Contract Year — Family   2013-04
PPO HDHP 3 Rx $20/$40/$60 Vision $100 Contract Year — Family x 2013-04
PPO HDHP 4 Rx $20/$40/$60 Vision $100 Contract Year — Single   2013-04
PPO HDHP 4 Rx $20/$40/$60 Vision $100 Contract Year — Single x 2013-04
PPO HDHP 4 Rx $20/$40/$60 Vision $100 Contract Year — Family   2013-04
PPO HDHP 4 Rx $20/$40/$60 Vision $100 Contract Year — Family x 2013-04
PPO HDHP 5 Rx $20/$40/$60 Vision $100 Contract Year — Single   2013-04
PPO HDHP 5 Rx $20/$40/$60 Vision $100 Contract Year — Single x 2013-04
PPO HDHP 5 Rx $20/$40/$60 Vision $100 Contract Year — Family   2013-04
PPO HDHP 5 Rx $20/$40/$60 Vision $100 Contract Year — Family x 2013-04
PPO HDHP 1 Vision $100 Contract Year — Single   2013-04
PPO HDHP 1 Vision $100 Contract Year — Single x 2013-04
PPO HDHP 1 Vision $100 Contract Year — Family   2013-04
PPO HDHP 1 Vision $100 Contract Year — Family x 2013-04
PPO HDHP 2 Vision $100 Contract Year — Single   2013-04
PPO HDHP 2 Vision $100 Contract Year — Single x 2013-04
PPO HDHP 2 Vision $100 Contract Year — Family   2013-04
PPO HDHP 2 Vision $100 Contract Year — Family x 2013-04
PPO HDHP 3 Vision $100 Contract Year — Single   2013-04
PPO HDHP 3 Vision $100 Contract Year — Single x 2013-04
PPO HDHP 3 Vision $100 Contract Year — Family   2013-04
PPO HDHP 3 Vision $100 Contract Year — Family x 2013-04
PPO HDHP 4 Vision $100 Contract Year — Single   2013-04
PPO HDHP 4 Vision $100 Contract Year — Single x 2013-04
PPO HDHP 4 Vision $100 Contract Year — Family   2013-04
PPO HDHP 4 Vision $100 Contract Year — Family x 2013-04
PPO HDHP 5 Vision $100 Contract Year — Single   2013-04
PPO HDHP 5 Vision $100 Contract Year — Single x 2013-04
PPO HDHP 5 Vision $100 Contract Year — Family   2013-04
PPO HDHP 5 Vision $100 Contract Year — Family x 2013-04
PPO HDHP 4 Rx $20/$40/$60 Vision $100 Calendar Year — Single   2013-04
PPO HDHP 4 Rx $20/$40/$60 Vision $100 Calendar Year — Single x 2013-04
PPO HDHP 4 Rx $20/$40/$60 Vision $100 Calendar Year — Family   2013-04
PPO HDHP 4 Rx $20/$40/$60 Vision $100 Calendar Year — Family x 2013-04
PPO HDHP 4 Vision $100 Calendar Year — Single   2013-04
PPO HDHP 4 Vision $100 Calendar Year — Single x 2013-04
PPO HDHP 4 Vision $100 Calendar Year — Family   2013-04
PPO HDHP 4 Vision $100 Calendar Year — Family x 2013-04
HRA 1 Rx $20/$40/$60 Vision $100   2013-04
HRA 1 Rx $20/$40/$60 Vision $100 x 2013-04
HRA 2 Rx $20/$40/$60 Vision $100   2013-04
HRA 2 Rx $20/$40/$60 Vision $100 x 2013-04
HRA 3 Rx $20/$40/$60 Vision $100   2013-04
HRA 3 Rx $20/$40/$60 Vision $100 x 2013-04
BC PPO 1.1 Rx $10/$40/$70 Vision $100   2013-04
BC PPO 1.1 Rx $10/$40/$70 Vision $100 x 2013-04
BC PPO 2.1 Rx $10/$40/$70 Vision $100   2013-04
BC PPO 2.1 Rx $10/$40/$70 Vision $100 x 2013-04
BC PPO 3.1 Rx $10/$40/$70 Vision $100   2013-04
BC PPO 3.1 Rx $10/$40/$70 Vision $100 x 2013-04
BC PPO 4 Rx $7/50%($125) Vision $100   2013-04
BC PPO 4 Rx $7/50%($125) Vision $100 x 2013-04
BC PPO 5 Rx $7/50%($125) Vision $100   2013-04
BC PPO 5 Rx $7/50%($125) Vision $100 x 2013-04
BC PPO 6 Rx $7/50%($125) Vision $100   2013-04
BC PPO 6 Rx $7/50%($125) Vision $100 x 2013-04
BC PPO 7.1 Rx $250 Brand/$10/$45/$75 Vision $100   2013-04
BC PPO 7.1 Rx $250 Brand/$10/$45/$75 Vision $100 x 2013-04
BC PPO 8.2 Rx $7/50%($125) Vision $100   2013-04
BC PPO 8.2 Rx $7/50%($125) Vision $100 x 2013-04
BC HRA 3 Rx $20/40/60 Vision $100   2013-04
BC HRA 3 Rx $20/40/60 Vision $100 x 2013-04
BC HDHP 1 (single) Rx $20/$40/$60 Vision $100   2013-04
BC HDHP 1 (single) Rx $20/$40/$60 Vision $100 x 2013-04
BC HDHP 1 (family) Rx $20/$40/$60 Vision $100   2013-04
BC HDHP 1 (family) Rx $20/$40/$60 Vision $100 x 2013-04
BC HDHP 3 (single) Rx $20/$40/$60 Vision $100   2013-04
BC HDHP 3 (single) Rx $20/$40/$60 Vision $100 x 2013-04
BC HDHP 3 (family) Rx $20/$40/$60 Vision $100   2013-04
BC HDHP 3 (family) Rx $20/$40/$60 Vision $100 x 2013-04
BC HDHP 4 (single) Rx $20/$40/$60 w/OC & MO Vision $100   2013-04
BC HDHP 4 (single) Rx $20/$40/$60 w/OC & MO Vision $100 x 2013-04
BC HDHP 4 (family) Rx $20/$40/$60 w/OC & MO Vision $100   2013-04
BC HDHP 4 (family) Rx $20/$40/$60 w/OC & MO Vision $100 x 2013-04
BC HDHP 5 (single) Rx $20/$40/$60 Vision $100   2013-04
BC HDHP 5 (single) Rx $20/$40/$60 Vision $100 x 2013-04
BC HDHP 5 (family) Rx $20/$40/$60 Vision $100   2013-04
BC HDHP 5 (family) Rx $20/$40/$60 Vision $100 x 2013-04