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Evidence of Coverage Forms

As part of the group contract, these Evidence of Coverage documents are made available for Small Business employers and brokers as part of their responsibility to provide members with the terms of coverage for their plan.

2026 Evidence of Coverage

Bronze Access PPO HSA 6000
English (PDF)

2026 KP Bronze Access PPO 8000 LX
English (PDF)

Silver Access PPO HSA 4000
English (PDF) 

2026 KP Gold Access PPO 1500 LX
English (PDF)

2026 KP Gold Access PPO 2000 LX
English (PDF)

2026 KP Gold Access PPO 600 LX
English (PDF)

2026 KP Platinum Access PPO 500 LX
English (PDF)

2026 KP Platinum Access PPO 250 LX
English (PDF)

2026 KP Silver Access PPO 5000
English (PDF)

2026 KP Silver Access PPO 2500 LX
English (PDF)

2026 KP Silver Access PPO 3500 LX
English (PDF)

Silver Access PPO 3500 LX – EO
English (PDF)

Bronze Core HSA 6000
English (PDF)

2026 KP Gold Core 1500 LX
English (PDF)

2026 KP Gold Core 600 LX
English (PDF)

KP Gold Core 600 LX – EO
English (PDF)

2026 KP Gold Core 2000 LX
English (PDF)

2026 KP Platinum Core 250 LX
English (PDF)

2026 KP Silver Core 2500 LX
English (PDF)

Silver Core 2500 LX - EO
English (PDF)

2026 KP Silver Core 5000
English (PDF)

Silver Core HSA 3500
English (PDF)

2026 KP Silver Core HSA 4500
English (PDF)

2026 KP Silver Core 1800
English (PDF)

2026 KP Bronze Summit PPO HSA 6500
English (PDF) 

Bronze Summit PPO HSA 6500
English (PDF)

2026 KP Gold Summit PPO 1500 LX
English (PDF)

2026 KP Platinum Summit PPO 300 LX
English (PDF)

2026 KP Silver Summit PPO 3500 LX
English (PDF)

2026 KP Plus Silver 2500
English (PDF)

2026 KP Plus Gold 600 LX
English (PDF)

2026 KP Plus Platinum 250
English (PDF)

2025 Evidence of Coverage

Access PPO Bronze HSA
English (PDF)

Access PPO Silver HSA
English (PDF) 

Access PPO VisitsPlus Gold HD LX
English (PDF)

Access PPO VisitsPlus Gold LX
English (PDF)

Access PPO VisitsPlus Platinum HD LX
English (PDF)

Access PPO VisitsPlus Platinum LX
English (PDF)

Access PPO VisitsPlus Silver HD
English (PDF)

Access PPO VisitsPlus Silver LD LX
English (PDF)

Access PPO VisitsPlus Silver LX – EO
English (PDF)

Access PPO VisitsPlus Silver LX
English (PDF)

Core Bronze HSA 
English (PDF)

Core Silver HSA
English (PDF)

Core Silver 
English (PDF)

Core VisitsPlus Gold LX - EO
English (PDF)

Core VisitsPlus Gold LX
English (PDF)

Core VisitsPlus Platinum LX
English (PDF)

Core VisitsPlus Silver LX - EO
English (PDF)

Core VisitsPlus Silver LX
English (PDF)

Core VisitsPlus Gold HD LX
English (PDF)

Core VisitsPlus Gold LX
English (PDF)

KP Plus Gold
English (PDF)

KP Plus Platinum
English (PDF)

KP Plus Silver
English (PDF)

Summit PPO Bronze HSA
English (PDF)

Summit PPO VisitsPlus Gold LX
English (PDF)

Summit PPO VisitsPlus Platinum LX
English (PDF)

Summit PPO VisitsPlus Silver LX
English (PDF)