Sample plans are samples only and may not include state specific variations.

Level 1

Level 1

Routine Wellness Care (optional)

Advanced Wellness Care (optional)

Hereditary & Congenital Conditions (If a condition is on this list, it will not be covered by Level 1 or Level 2)


Level 2

Level 2

Routine Wellness Care (optional)

Advanced Wellness Care (optional)

Hereditary & Congenital Conditions (If a condition is on this list, it will not be covered by Level 1 or Level 2)


Level 3

Level 3 (includes Congenital & Hereditary Care endorsement)

Routine Wellness Care (optional)

Advanced Wellness Care (optional)


Level 4

Level 4 (includes Congenital & Hereditary Care endorsement)

Routine Wellness Care (optional)

Advanced Wellness Care (optional)