Forms

Enrollment Form (PDF)

Summary of Benefits and Coverage - Choice Passport Network

$1,500 CoPay Summary and Coverage - Choice Passport Network

$3,300 HSA Summary and Coverage - Choice Passport Network

$4,500 HSA Summary and Coverage - Choice Passport Network

$6,350 HSA Summary and Coverage - Choice Passport Network

Summary of Benefits and Coverage - Park Nicollet/Health Partners Network (Minnesota Residents Only*)

$1,500 CoPay Summary and Coverage - Park Nicollet/Health Partners

$3,300 HSA Summary and Coverage - Park Nicollet/Health Partners

$4,500 HSA Summary and Coverage - Park Nicollet/Health Partners

$6,350 HSA Summary and Coverage - Park Nicollet/Health Partners

*Minnesota Residents choose between networks at the time they choose their plan.  To learn more about the networks, visit our Network Page