HQ Codes

HQ Code Changes initially requested in September 2025 were discarded. Please keep using the existing SFCs

The new HQ Code rules for 2026 are as follows

• SFC02: Metal Tiers / On Exchange
  • Platinum 90
  • Gold 80
  • Silver 94
  • Silver 87
  • Silver 73
  • Silver 70
  • Bronze 60
  • Bronze 60 HDHP
  • American Indian / Alaskan Native $0 Cost Sharing
  • Minimum Coverage
• SFC03: Metal Tiers / Off Exchange
  • Platinum 90
  • Gold 80
  • Silver 94
  • Silver 87
  • Silver 73
  • Silver 70
  • Bronze 60
  • Bronze 60 HDHP
  • Minimum Coverage
• SFC04: Commercial
  • Ruby 10
  • Ruby 20
  • Ruby 40
  • Opal 25
  • Opal 50
  • Plan A
  • Plan B
  • Jade 15
  • Amber 50
  • Active Choice
  • Balance Large Group Only Plans
    • Balance 5/0 HMO
    • Balance 10/0 Premier HMO
    • Balance 10/0 Standard HMO
    • Balance 20/0 Basic HMO
    • Balance 20/0 Premier HMO
    • Balance 20/0 Standard HMO
    • Balance 30/0 HMO
    • Balance 30/2100 HMO
    • Balance 35/250 HMO
    • Balance 40/0 Premier HMO
    • Balance 40/0 Standard HMO
    • Balance 55/2500 HMO
    • Balance 65/6300 HMO
    • Balance 0/1700 HDHP HMO
    • Balance 20/1700 HDHP HMO
    • Balance 30/3000 HDHP HMO
    • Balance 30/3000 HDHP HMO
    • Balance 40/4000 HDHP HMO
    • Balance 50/5500 HDHP HMO
    • Balance 60/7050 HDHP HMO

Benefit Codes Explained

All Plans should have a {benefitcoderoot} + {yy} + {suffix}.

{yy} data comes from the year column.

If the root for Amber 50 HMO Silver is “OFA50X“, then the partial Benefit Code for 2026 is “OFA50X26“. Then, you must append a “Suffix” to get the full Benefit Code.

The final Retail benefit code for Amber 50 HMO Silver would be {benefitcoderoot} + {yy} + {suffix}, or “OFA50X26R“.

Benefit Code Root Convention Explained (starting 2026)

1st & 2nd Characters

• ON: On Exchange
• OF: Off Exchange
• SG: Small Group
• SI: Small Group w Infertility
• LG: Large Group (this will never be used after 2026 because California Requires Infertility to be offered, but wtvr)
• LI: Large Group Infertility

3rd Character

• First Letter of Plan Name

4th & 5th Character

• Plan Number
  • If Balance 5/0 HMO, this would be “05”
  • If Plan A, this would be “0A”

6th Character

• “X” for Filler
• “P” for Premier
• “S” for Standard
• “B” for Basic
• “H” for HDHP
• Num to eliminate duplicates*

*With situations like Large Group Balance 60/7050 HDHP HMO, we use the first number of the deductible value on the Balance Plan to eliminate duplicates.

• Large Group Bronze 60 HMO would have the root benefit code of “LIB60X“
• Large Group Bronze 60 HDHP HMO would have the root benefit code of “LIB60H“
• Large Group Balance 60/7050 HDHP HMO would have the root benefit code of “LIB607“

Exceptions

The following plans break the convention for the Benefit Code Root.

• Active Choice PPO Silver
  • Benefit Code Root “OFACCH”
• Minimum Coverage
  • On Exchange Benefit Code Root “ONMINX”
  • Off Exchange Benefit Code Root “OFMINX”
• American Indian / Alaskan Native
  • Benefit Code Root “ONAIAN”

Mapping Data

Even if a member or employer group signed a contract mid year, or their contract spans multiple years, their Copays/Coinsurances for their Rx stay the same as the year they signed their contract. Given we have some HQ and Benefit Code naming convention updates for 2026, let’s walk through some example word problems to make sure we configure rates correctly.

Example 1) Let’s say we have a Small Employer Group with a RUBY 10 HMO Platinum liability package, no fertility rider, and a start date of 06/01/2025.

• Benefit Code Root
  • As of 06/01/2025, their {benefitcoderoot} is “Ruby10”.
    • If a member under this plan goes to the Chinese Hospital Pharmacy to fill a 30 day prescription on 11/01/2025, their full benefit code would be {benefitcoderoot} + {yy} + {suffix}, or ‘RUBY1025I”
  • As of 01/01/2026, the group is still in contract. Their {benefitcoderoot} is “Ruby10” until this contract terminates/renews.
    • If a member under this plan goes to the Chinese Hospital Pharmacy to fill a 30 day prescription on 02/01/2026, their full benefit code would still be {benefitcoderoot} + {yy} + {suffix}, or ‘RUBY1025I”. They keep their rates from 2025 until their contract ends.
  • If this small employer group renews their contract on 06/01/2026, their NEW {benefitcoderoot} becomes “SGR10X”.
    • If a member under this plan goes to the Chinese Hospital Pharmacy to fill a 30 day prescription on 07/01/2026, their full benefit code would be {benefitcoderoot} + {yy} + {suffix}, or ‘SGR10X26I”

Example 2) Let’s say we have a Large Employer Group with an Opal 25 HMO Gold liability package, no fertility rider, and a start date of 09/01/2025.

• Benefit Code Root
  • As of 09/01/2025, their {benefitcoderoot} is “OPAL25”.
    • If a member under this plan goes to the Chinese Hospital Pharmacy to fill a Specialty 30 day prescription on 12/01/2025, their full benefit code would be {benefitcoderoot} + {yy} + {suffix}, or “OPAL2525IS”
  • As of 01/01/2026, the group is still in contract. Their {benefitcoderoot} is still “OPAL25” until this contract terminates/renews.
    • If a member under this plan goes to the Chinese Hospital Pharmacy to fill a Specialty 30 day prescription on 03/01/2026, their full benefit code would be {benefitcoderoot} + {yy} + {suffix}, or “OPAL2525IS”. They keep their rates from 2025 until their contract ends.
  • If this large employer group renews their contract on 09/01/2026, fertility is now required to be included in California, so their NEW {benefitcoderoot} becomes “LIO25X”.
    • If a member under this plan goes to the Chinese Hospital Pharmacy to fill a Specialty 30 day prescription on 10/01/2026, their full benefit code would be {benefitcoderoot} + {yy} + {suffix}, or ‘LIO25X26IS”

Example 3) Let’s say we have a member on an Individual & Family Plan, purchased through the Covered California Exchange, with the liability package of Platinum 90 HMO. All IFP Group Contracts renew on January 1st, so the issue of last year’s benefit code vs next years benefit code does not apply.

• Benefit Code Root
  • As of 01/01/2025, the {benefitcoderoot} is “PLAT90IF”
    • If a member under this plan goes to Costco to fill a 30 day prescription on 11/01/2025, their full benefit code would be {benefitcoderoot} + {suffix}, or “PLAT90IFC”
  • As of 01/01/2026, the {benefitcoderoot} is “ONP90X”
    • For some unknown reason, IFP plans never used {yy} in the benefit code prior to 2026.
    • If a member under this plan goes to Costco to fill a 30 day prescription on 02/01/2026, their full benefit code would be {benefitcoderoot} + {yy} + {suffix}. The full benefit code will be “ONP90X26C”.

Additional Important Notes

19 New Large Group Plans

Any plan name that starts with “Balance” is new. They will not have a Legacy HQ Code or Legacy Benefit Code Root.

Out of Network Benefits

As a blanket statement, Balance and CCHP Plans DO NOT COVER benefits for Out of Network