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2021 North Memorial Acclaim Plan Documents

To see your summary of benefits and coverage (SBC) and policy of coverage documents, select your state and plan below.

Minnesota Plans

Document	Care Type
Summary of Benefits and Coverage (SBC)	Gold Copay (PDF)	Silver Copay (PDF)	Bronze Copay (PDF)	Bronze Copay First 3 (PDF)
Policy of Coverage	Gold Copay (PDF)	Silver Copay (PDF)	Bronze Copay (PDF)	Bronze Copay First 3 (PDF)

Document	Care Type
Summary of Benefits and Coverage (SBC)	Silver HSA (PDF)	Bronze HSA (PDF)
Policy of Coverage	Silver HSA (PDF)	Bronze HSA (PDF)

Document	Care Type
Summary of Benefits and Coverage (SBC)	Silver Copay (94% AV Level) – (PDF)	Silver Copay (87% AV Level) – (PDF)	Silver Copay (73% AV Level) – (PDF)
Policy of Coverage	Silver Copay (94% AV Level) – (PDF)	Silver Copay (87% AV Level) – (PDF)	Silver Copay (73% AV Level) – (PDF)

Document	Care Type
Summary of Benefits and Coverage (SBC)	Silver HSA (94% AV Level) – (PDF)	Silver HSA (87% AV Level) – (PDF)	Silver HSA (73% AV Level) – (PDF)
Policy of Coverage	Silver HSA (94% AV Level) – (PDF)	Silver HSA (87% AV Level) – (PDF)	Silver HSA (73% AV Level) – (PDF)

Document	Care Type
Summary of Benefits and Coverage (SBC)	Silver Share (94% AV Level) – (PDF)	Silver Share (87% AV Level) – (PDF)	Silver Share (73% AV Level) – (PDF)
Policy of Coverage	Silver Share (94% AV Level) – (PDF)	Silver Share (87% AV Level) – (PDF)	Silver Share (73% AV Level) – (PDF)

Catastrophic
Summary of Benefits and Coverage (PDF)
Policy of Coverage (PDF)

Document	Care Type
Summary of Benefits and Coverage (SBC)	Gold Copay Limited (PDF)	Silver HSA Limited (PDF)	Silver Copay Limited (PDF)	Silver Share Limited (PDF)	Bronze Copay Limited (PDF)	Bronze Copay First 3 Limited (PDF)	Bronze HSA Limited (PDF)	Bronze Share Plus Limited (PDF)
Policy of Coverage	Gold Copay Limited (PDF)	Silver HSA Limited (PDF)	Silver Copay Limited (PDF)	Silver Share Limited (PDF)	Bronze Copay Limited (PDF)	Bronze Copay First 3 Limited (PDF)	Bronze HSA Limited (PDF)	Bronze Share Plus Limited (PDF)

Document	Care Type
Summary of Benefits and Coverage (SBC)	Gold Copay Zero (PDF)	Silver HSA Zero (PDF)	Silver Copay Zero (PDF)	Silver Share Zero (PDF)	Bronze Copay Zero (PDF)	Bronze Copay First 3 Zero (PDF)	Bronze HSA Zero (PDF)	Bronze Share Plus Zero (PDF)
Policy of Coverage	Gold Copay Zero (PDF)	Silver HSA Zero (PDF)	Silver Copay Zero (PDF)	Silver Share Zero (PDF)	Bronze Copay Zero (PDF)	Bronze Copay First 3 Zero (PDF)	Bronze HSA Zero (PDF)	Bronze Share Plus Zero (PDF)

Document	Care Type
Summary of Benefits and Coverage (SBC)	Silver Share (PDF)	Bronze Share Plus (PDF)
Policy of Coverage	Silver Share (PDF)	Bronze Share Plus (PDF)

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