Carrier Crosswalk

The Benefit Plan Standard maintains a carrier crosswalk that maps each issuer’s vocabulary, structure, and terminology into the normalized schema fields.
This ensures that different carriers’ representations of benefits (often inconsistent in naming, structure, and granularity) can be interpreted in a unified, machine-readable way.

Because carriers vary widely in how they describe deductibles, copays, limits, and categories, the crosswalk is a foundational component of the standard.

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📊 Crosswalk Matrix

Plan Metadata

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Ambetter	Kaiser
plan_id	FLBLUE_BLUEOPTIONS_505	GATORCARE_PRIME_EPO	SCAN_CLASSIC_HMO_LOS_ANGELES	AETNA_PPO_1500_80_50	UHC_CHOICE_PLUS_HSA_GOLD_1700	CIGNA_OAP_BOWDOIN	HUMANA_GOLD_PLUS_H1036_025_HMO	AMBETTER_CA_SILVER_94_HMO	KAISER_CA_GOLD_80_HMO
plan_identifiers	not in example	not in example	cms_contract_plan_segment: H5425-006-0; cms_contract_id: H5425; cms_pbp_id: 006	not in example	not in example	not in example	cms_contract_plan_segment: H1036-025-000; cms_contract_id: H1036; cms_pbp_id: 025	not in example	not in example
carrier	FloridaBlue	GatorCare	SCAN Health Plan	Aetna	UnitedHealthcare	Cigna	Humana	Ambetter	Kaiser
plan_name	Florida Blue BlueOptions 505	Florida Blue BlueOptions 03768 - Prime EPO Plan	SCAN Classic (HMO)	Aetna FL PPO 1500 80/50 CY V25	UnitedHealthcare® UHC Choice Plus HSA Gold 1700-4	Bowdoin College: Open Access Plus	Humana Gold Plus H1036-025 (HMO)	Health Net of CA: Silver 94 Ambetter HMO	KAISER PERMANENTE® : Gold 80 HMO
plan_type	PPO	EPO	HMO	PPO	POS	OAP	HMO	HMO	HMO
plan_year	2023	2026	2026	2026	2026	2026	2026	2026	2026
market	individual	self_funded	medicare_advantage	large_group	small_group	large_group	medicare_advantage	individual	individual

Network Tiers

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Ambetter	Kaiser
tier_id	IN / OUT	IN / OUT	IN / OUT / PHARMACY_RETAIL_STANDARD	IN / OUT	IN / OUT	IN / OUT	IN / OUT / SITE_PCP_OFFICE / SITE_SPECIALIST_OFFICE / SITE_TELEHEALTH / SITE_URGENT_CARE_CENTER / SITE_OUTPATIENT_HOSPITAL / SITE_AMBULATORY_SURGERY_CENTER / SITE_FREESTANDING_RADIOLOGY / SITE_FREESTANDING_LAB / SITE_MEMBERS_HOME / SITE_COMPREHENSIVE_OUTPATIENT_REHAB / SITE_PHARMACY / SITE_NETWORK_RETAIL_PHARMACY / SITE_DME_PROVIDER / SITE_DIABETIC_SUPPLIER / SITE_MEDICAL_SUPPLIER / SITE_PROSTHETICS_PROVIDER / SITE_PART_D_RETAIL / DESIG_PREFERRED_DIABETIC_SUPPLIER	IN / OUT	IN / OUT
name	In Network / Out of Network	GatorCare Tier 1 In-Network / BlueOptions Tier 3 Out-Of-Network	In network / Out of network / Retail, Standard	In Network / Out of Network	In-Network / Out-of-Network	In Network / Out of Network	In network / Out of network / PCP's office / Specialist's office / Telehealth / Urgent care center / Outpatient hospital / Ambulatory surgery center / Freestanding radiological facility / Freestanding laboratory / Member's home / Comprehensive outpatient rehab facility / Pharmacy / Network retail pharmacy / DME provider / Diabetic supplier / Medical supplier / Prosthetics provider / Retail Cost-Sharing / Preferred diabetic supplier	In Network / Out of Network	Plan Provider / Non-Plan Provider
description	Network Level	Three tiers; collapses to IN/OUT under v1.1 (tier_class drafted for v1.2)	Plan Network	Network Level	Three columns on SBC; collapses to IN/OUT under v1.1	Network Tier	Plan Network	OON cells read Not covered on most rows	Non-plan providers not covered

Accumulators

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Ambetter	Kaiser
individual_deductible	$3,500	$350	$0	$1,500	$1,700	$1,000	$0	not in example	$0
family_deductible	$10,500	$700	not in example	$3,000	$3,400	$2,000	not in example	not in example	not in example
individual_oop_max	$3,500	$2,700	$199	$5,500	$4,500	$3,500	$2,000	$1,400	$9,200
family_oop_max	$10,500	$5,400	not in example	$11,000	$9,000	$7,000	not in example	$2,800	$18,400
oon_individual_deductible	$5,500	not in example	not in example	$3,000	$5,000	$1,000	not in example	not in example	not in example
oon_family_deductible	$11,000	not in example	not in example	$9,000	$10,000	$2,000	not in example	not in example	not in example
oon_individual_oop_max	$8,500	not in example	not in example	$13,000	$10,000	$3,500	not in example	not in example	not in example
oon_family_oop_max	$17,000	not in example	not in example	$39,000	$20,000	$7,000	not in example	not in example	not in example
pharmacy.deductible	not in example	not in example	$250 (applies_to_tiers: Tier 3, Tier 4, Tier 5)	not in example	not in example	not in example	$615 (applies_to_tiers: Tier 4, Tier 5)	not in example	not in example
pharmacy.out_of_pocket_max	not in example	not in example	$2,100	not in example	not in example	not in example	$2,100	not in example	not in example

Benefits

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Ambetter	Kaiser
category	Category Header	Category	Common Medical Event	Medical Event	Category	Benefit Category	Category	Common Medical Event	Common Medical Event
service_name	Primary care visit to treat an injury or illness	Primary care visit to treat an injury or illness	Primary Care	Primary care visit to treat an injury or illness	Primary care visit to treat an injury or illness	Primary care visit to treat an injury or illness	Primary Care Provider (PCP)	Primary care visit to treat an injury or illness	Primary care visit to treat an injury or illness
place_of_service	Office Visit	Office	Office	Office	Office / Telehealth	Office	Office / Telehealth	Office	Office
deductible	Deductible Applies?	Deductible does not apply / $X Per Visit Deductible + Deductible	Deductible Waived?	Does not apply (applies_to_deductible: false)	Applies / Waived	Does not apply (applies_to_deductible: false)	Usually Waived	Standard SBC wording	Standard SBC wording
copay	Copay	Copayment	Copay	Copay	Copay (pharmacy rows split Retail: $X / Mail-Order: $Y in one cell)	Copay	Copay	$X copay/visit	$X copay/visit
coinsurance	Coinsurance	Coinsurance	Coins	Coinsurance	Coinsurance	Coinsurance	Coinsurance	X% coinsurance; OON column reads Not covered	X% coinsurance (may carry per-prescription cap, e.g. up to $250/prescription)

Limits

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Ambetter	Kaiser
type	visits	Visits	Days	Visits	Days / Units	Visits	visits / hearing_aids / dollars / pairs_of_eyeglasses / days / one_way_trips / meals / occurrences / hours	Visits	Visits / Days
value	25 (Chiropractic care)	Visit Limit (compound: e.g. 75 visits including 26 manipulations)	Day Limit	Visit Limit	Stay Limit	Visit Limit	Allowance	Visit Limit	Visit Limit
period	Per Year / Per Stay	Annual	Benefit Period	Per Year	Per Stay / Per Year	Per Year	Annual	Per Year	Per Year

Conditions

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Ambetter	Kaiser
prior_authorization	Prior Auth	Prior Authorization	Prior Auth	Prior Auth	Prior Auth	Prior Auth	Prior Auth	Prior Auth	Prior Auth
referral_required	Referral Required	Referral Required	Referral	Referral	Referral Required	Referral Required	Referral Required	Referral Required	Referral Required
notes	Notes / Limitations	Limitations	Notes	Notes	Limitations	Notes	Plan Notes	Limitations and Exceptions column	Limitations and Exceptions column

Source Reference

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Ambetter	Kaiser
page	SBC Page	SBC Page	Summary of Benefits Page	SBC Page	SBC Page	SBC Page	Summary of Benefits Page	SBC Page	SBC Page
excerpt	Text Snippet	Text Snippet	Snippet	Snippet	Snippet	Snippet	Snippet	Text Snippet	Text Snippet

Field Definitions

Field	Type	Description
plan_id	string	Normalized unique identifier of the plan
carrier	string	Carrier or issuer name
plan_name	string	Marketing name
plan_type	string	Free-form string, no enum in schema v1.1.0. Recommended codes are in vocabularies/plan-types.json, for example HMO, PPO, EPO, POS.
plan_year	integer	Coverage year
market	string	Free-form string, no enum in schema v1.1.0. Recommended codes are in vocabularies/markets.json, for example individual, small_group, large_group, self_funded, medicare_advantage.
individual_deductible	money	Deductible for individual
family_deductible	money	Deductible for family

Carrier Vocabulary

Concept	Normalized Term	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Ambetter	Kaiser
Primary Care Visit	PCP Visit	Primary care visit to treat an injury or illness	Primary care visit to treat an injury or illness	Primary Care	Primary care visit to treat an injury or illness	Primary care visit to treat an injury or illness	Primary care visit to treat an injury or illness	Primary Care Provider (PCP)	Primary care visit to treat an injury or illness	Primary care visit to treat an injury or illness
Specialist Visit	Specialist Visit	Specialist visit	Specialist visit	Specialists	Specialist visit	Specialist visit	Specialist visit	Specialist	Specialist visit	Specialist visit

Pharmacy Tiers

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Ambetter	Kaiser
tier_id	not in example	not in example	not in example	not in example	not in example	not in example	not in example	not in example	not in example
name	Generic drugs; Preferred brand drugs; Non-preferred brand drugs; Specialty drugs	Generic drugs; Preferred brand drugs; Non-preferred brand drugs; Specialty drugs	Tier 1 (Preferred Generic); Tier 2 (Generic); Tier 3 (Preferred Brand) Insulin; Tier 3 (Preferred Brand) Other Drugs; Tier 4 (Non-Preferred Drug); Tier 5 (Specialty Tier)	Preferred generic drugs; Preferred brand drugs; Specialty drugs	Tier 1 - Your Lowest- Cost Option; Tier 2 - Your Midrange-Cost Option; Tier 3 - Your Midrange-Cost Option; Tier 4 - Additional High-Cost Options	Generic drugs (Tier 1); Preferred brand drugs (Tier 2); Non-preferred brand drugs (Tier 3)	Tier 1: Preferred Generic; Tier 2: Generic; Tier 3: Preferred Brand; Tier 4: Non-Preferred Drug; Tier 5: Specialty Tier	Generic drugs (Tier 1); Preferred brand drugs (Tier 2); Non-preferred brand drugs (Tier 3); Specialty drugs (Tier 4)	Generic drugs (Tier 1); Preferred brand drugs (Tier 2); Non-preferred brand drugs (Tier 2); Specialty drugs (Tier 4)
drug_class	not in example	not in example	not in example	not in example	not in example	not in example	not in example	not in example	not in example
tier_code	not in example	not in example	not in example	not in example	not in example	not in example	not in example	not in example	not in example

Pharmacy Networks

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Ambetter	Kaiser
network_id	not in example	not in example	not in example	not in example	not in example	not in example	not in example	not in example	not in example
name	not in example	not in example	not in example	not in example	not in example	not in example	not in example	not in example	not in example
network_type	not in example	not in example	not in example	not in example	not in example	not in example	not in example	not in example	not in example
default_day_supply	not in example	not in example	not in example	not in example	not in example	not in example	not in example	not in example	not in example

Coverage Stages

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Ambetter	Kaiser
stage_id	not in example	not in example	DEDUCTIBLE; INITIAL; CATASTROPHIC	not in example	not in example	not in example	DEDUCTIBLE; INITIAL; CATASTROPHIC	not in example	not in example
name	not in example	not in example	Part D Deductible; Initial Coverage Stage; Catastrophic Coverage Stage	not in example	not in example	not in example	DEDUCTIBLE; INITIAL COVERAGE; CATASTROPHIC COVERAGE	not in example	not in example
stage_type	not in example	not in example	deductible; initial; catastrophic	not in example	not in example	not in example	deductible; initial; catastrophic	not in example	not in example

Pharmacy Tier Codes

drug_class	tier_code (FHIR DrugTierVS)
preferred_generic	preferred-generic
generic	generic
preferred_brand	preferred-brand
nonpreferred_brand	non-preferred-brand
preferred_specialty	specialty
nonpreferred_specialty	specialty
preventive	zero-cost-share-preventive

Each carrier column is read from that carrier's example file in the schema repo's examples/ directory. The Aetna column uses aetna_example.json, one of the two Aetna examples.

Purpose

Carriers do not use consistent terminology.
For example:

• One carrier may label a row “Office Visit - Primary Care (PCP)”,
  while another writes “Primary Care Provider: You pay $25”,
  and another uses “PCP Copay per encounter”.

• Deductible applicability might be written as:

  • “After deductible”
  • “Subject to deductible”
  • “Copay does not apply to deductible”
  • “Ded waived”
  • Combined expressions such as “$25 copay + 20% coinsurance after deductible”

Without a standardized crosswalk, ingestion pipelines must be hand-tuned for every carrier.

The crosswalk solves this by documenting, for each normalized field:

• How each carrier expresses the value
• Semantics that must be preserved
• Parsing notes and exceptions
• Mappings into the normalized JSON structure

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Structure of the Crosswalk

The crosswalk contains multiple tabs, including:

Plan Metadata

Maps identifiers such as:

• plan_id
• carrier
• plan_type
• market

Network Tiers

Mappings for:

• In-network / out-of-network naming
• Tier structures
• Carrier-specific vocabulary

Accumulators

How each carrier expresses:

• individual_deductible
• family_deductible
• individual_oop_max
• family_oop_max
• oon_individual_deductible (v1.1.0)
• oon_family_deductible (v1.1.0)
• oon_individual_oop_max (v1.1.0)
• oon_family_oop_max (v1.1.0)

Benefits

Mappings for:

• categories
• service names
• copays
• coinsurance expressions
• deductible applicability

Limits

Mappings for:

• visit/day limits
• period definitions (annual, per stay, lifetime, etc.)

In the matrix, the Limits cells describe how each source document lays out its limits. Among the ten examples, the two Summary of Benefits files carry structured limits[] (on 17 benefits for Humana and 18 for SCAN), one SBC file (bluecross_example.json) carries a single visit limit, and the other seven carry none.

Conditions

Mappings for:

• prior authorization
• referral requirements
• contextual notes

In the matrix, the Conditions cells describe how each source document lays out its conditions. Among the ten examples, only the two Summary of Benefits files carry structured conditions[].

Source Reference

Extracts and page references used for ingestion traceability.

Pharmacy Module (draft v0.2.0)

Draft, non-normative

The pharmacy crosswalk tabs render the BPS pharmacy module, a draft module whose shapes the core v1.2.0 draft carries since draft 6. The module schemas are served at their $id addresses, https://benefitplanstandard.org/modules/pharmacy/v0.2.0/pharmacy.schema.json and https://benefitplanstandard.org/modules/pharmacy/v0.2.1/pharmacy.schema.json. Like the medical tabs, the pharmacy tabs are sourced from a versioned repo file (docs/specification/pharmacy-crosswalk-data.json), and each carrier column is read from that carrier's example file in the schema repo's examples/ directory. Pharmacy Tiers shows the drug tier labels each example file records. Coverage Stages is filled only for Humana and SCAN, the two Summary of Benefits examples, because only they carry pharmacy.coverage_stages. A cell that reads "not in example" is a value the example file does not carry.

The pharmacy module adds crosswalk coverage for the pharmacy concepts that appear in carrier SBCs/EOCs. Because the crosswalk is a carrier-SBC-vocabulary map, only those concepts get carrier-matrix tabs:

• Pharmacy Tiers: formulary tier structure (tier_id, name, drug_class, tier_code). Maps how each carrier labels its drug tiers (e.g., Tier 1 Preferred Generic … Tier 5 Specialty).
• Pharmacy Networks: pharmacy network structure (network_id, name, network_type, default_day_supply). Distinct from the medical Network Tiers tab; covers preferred retail / standard retail / mail order / specialty pharmacy.
• Coverage Stages: Medicare Part D coverage phases (stage_id, name, stage_type). Post-2025 (IRA redesign): Deductible / Initial Coverage / Catastrophic Coverage. (The pre-2025 Coverage Gap is retained only for historical plan years.)
• Pharmacy Tier Codes: a reference table (not a carrier matrix) mapping the module's drug_class values to the canonical FHIR DrugTierVS tier_code (e.g., preferred_brand → preferred-brand, preferred_specialty → specialty, preventive → zero-cost-share-preventive).

Not in the crosswalk: the module's drug-level formulary data: individual drugs (rxcui, drug_name, ndc), utilization-management flags, and indication-dependent coverage_exceptions[]. That data comes from formulary files (CMS QHP / Medicare Part D / FHIR DaVinci US Drug Formulary), not from SBCs/EOCs, so it is documented in the module schema as a field reference rather than mapped here as carrier vocabulary.

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Using the Crosswalk

When integrating a new carrier:

1. Identify each benefit entry

Locate the carrier’s terms in the crosswalk (or add them when necessary).

2. Map each value to the normalized field

Examples:

• Copay differences

  • Blue Cross: “$25 per visit”
  • SCAN: “$0 copay, coinsurance does not apply”
    These map to benefits[].cost_shares.copay.

• Deductible expressions

  • GatorCare lists medical and pharmacy separately
  • Aetna merges them
    The crosswalk clarifies how to populate individual_deductible, family_deductible, and related fields.

3. Capture exceptions and conditions

Ambiguous phrasing such as:

• “after facility fee”
• “per admission deductible”
• “ded waived for virtual visits”

should be documented in the crosswalk’s notes column.

4. Extend when necessary

If a carrier introduces:

• new cost-share terminology
• split benefit categories
• multi-tier networks

add a row or column to the versioned crosswalk data files in docs/specification/ and update the ingestion rules accordingly.

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Updating the Crosswalk

The versioned repo data files (docs/specification/medical-crosswalk-data.json and docs/specification/pharmacy-crosswalk-data.json) are the canonical source of truth for carrier mappings; changes ship as normal pull requests. The original Google Sheet is retained as a historical reference and is no longer load-bearing.
Updates follow these principles:

• Accuracy first: No changes without verification against the SBC/EOC.
• Non-breaking additions: New carriers and vocabulary should not break prior mappings.
• Schema alignment: Crosswalk rows correspond exactly to the normalized fields.

For contributors assisting with ingestion logic or analysis, changes are proposed as pull requests against the data files.

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Summary

The Carrier Crosswalk is essential for:

• Translating carrier-specific formats into a unified schema
• Ensuring ingestion is deterministic and predictable
• Maintaining consistency across carriers
• Supporting extension as new carriers and plan types are analyzed

The matrix is regenerated from the data files on every site build. The schemas it maps to are served at their $id addresses, for example https://benefitplanstandard.org/schema/v1.2.0/benefit-plan.schema.json.