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	Molina (future)	Oscar (future)
plan_id	Contract Number	Plan ID	H Number	SBC ID	Plan Number	Policy Number	Contract ID	Not shown on SBC	Not shown on SBC
carrier	Florida Blue	UF Health / GatorCare	SCAN Health Plan	Aetna	UnitedHealthcare	Cigna	Humana	Health Net of CA (Ambetter product brand)	KAISER PERMANENTE (registered mark in header)
plan_name	BlueOptions 505 PPO	Prime EPO Plan (document titled "Florida Blue BlueOptions 03768", administrator branding)	Classic	PPO 1500 80/50	Header plan name (e.g. UHC Choice Plus HSA Gold 1700-4)	Preferred Plan	Gold Plus	Silver 94 Ambetter HMO	Gold 80 HMO
plan_type	PPO	EPO (SBC header prints PPO)	HMO / MA	PPO	POS / HMO / PPO / MA	PPO / HMO	HMO / MA	HMO	HMO
year	Coverage Year	Plan Year	Plan Year	SBC Year	Plan Year	Calendar Year	Calendar Year	Beginning on or after MM/DD/YYYY (single date, no end date)	Coverage Period: Beginning on or after MM/DD/YYYY (single date, no end date)
market	Group or Individual	Self-funded employer group, administered by Florida Blue	Medicare Advantage	Commercial	Small group / Commercial / MA	Commercial	Medicare Advantage	Individual (Coverage for: All Covered Members)	Individual/Family

Network Tiers

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Ambetter	Kaiser	Molina (future)	Oscar (future)
tier_id	IN / OUT	IN / OUT	IN	IN / OUT	IN / OUT	IN / OUT	IN	IN / OUT	IN (single tier)
name	In / Out of Network	GatorCare Tier 1 / BlueOptions Tier 2 / BlueOptions Tier 3 (OON)	In Network	In / Out of Network	Designated Network / Network / Out-of-Network	In / Out Network	In Network	In Network / Out-of-Network Provider	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	Molina (future)	Oscar (future)
individual_deductible	Individual Deductible	Individual Deductible (stated per tier in one cell: GatorCare Tier 1 / BlueOptions Tier 2)	Usually none	Individual Deductible	Deductible IN/OUT (three networks in one cell: Designated Network and Network / out-of-Network)	Individual Deductible	Mostly none	Not stated in SBC answer block	Overall deductible ($0 on Gold 80)
family_deductible	Family Deductible	Family Deductible	None	Family Deductible	Family Deductible	Family Deductible	Not used	Not stated	Not stated separately
individual_oop_max	Individual OOP Max	OOP Max (Ind., stated per tier in one cell)	MOOP	OOP Max (Ind.)	MOOP Ind	OOP Max	MOOP	$1,400 member per calendar year	$9,200 Individual
family_oop_max	Family OOP Max	OOP Max (Family)	None	OOP Max (Family)	MOOP Fam	Family OOP Max	Not used	$2,800 family per calendar year	$18,400 Family
oon_individual_deductible	OON Individual Deductible	OON Individual Deductible	N/A	OON Individual Deductible	Deductible OUT	OON Individual Deductible	N/A	N/A (OON not covered)	N/A (single-tier HMO)
oon_family_deductible	OON Family Deductible	OON Family Deductible	N/A	OON Family Deductible	Family Deductible OUT	OON Family Deductible	N/A	N/A	N/A
oon_individual_oop_max	OON Individual OOP Max	OON OOP Max (Ind.)	N/A	OON OOP Max (Ind.)	MOOP OUT Ind	OON OOP Max	N/A	N/A	N/A
oon_family_oop_max	OON Family OOP Max	OON OOP Max (Family)	N/A	OON OOP Max (Family)	MOOP OUT Fam	OON Family OOP Max	N/A	N/A	N/A

Benefits

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Ambetter	Kaiser	Molina (future)	Oscar (future)
category	Category Header	Category	Common Medical Event	Medical Event	Category	Benefit Category	Category	Common Medical Event	Common Medical Event
service_name	PCP Visit	Primary Care Provider	PCP Visit	Primary Care Visit	PCP Office Visit	PCP Visit	Primary Care Physician	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?	Subject to Deductible	Applies / Waived	Applies	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	Molina (future)	Oscar (future)
type	Visits / Days	Visits	Days	Visits	Days / Units	Visits	Frequency	Visits	Visits / Days
value	Visit Limit / Day Limit	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	Molina (future)	Oscar (future)
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	Molina (future)	Oscar (future)
page	SBC Page	SBC Page	SBC Page	SBC Page	SBC / EOC Page	SBC Page	SBC/EOC 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	HMO / PPO / EPO / MA
year	integer	Coverage year
market	string	Commercial, MA, Group, etc.
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	Molina (future)
Primary Care Visit	PCP Visit	PCP Office Visit	Primary Care Provider	PCP Visit	Primary Care Visit	PCP Visit	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	Specialist Visit	Spec Visit	Specialist	Specialist		Specialist visit	Specialist visit

Pharmacy Tiers

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Kaiser (future)	Molina (future)	Oscar (future)
tier_id	generic_drugs__preventive; generic_drugs__condition_care_rx; generic_drugs; preferred_brand_drugs__condition_care_rx; preferred_brand_drugs; nonpreferred_brand_drugs; specialty_drugs (Florida Blue, public 2025 SBC)				generic_drugs; preferred_brand_drugs; nonpreferred_brand_drugs; specialty_drugs (UHC Choice Plus HSA Gold 1700-4, verified 2026 SBC)		T1; T2; T3; T4; T5 (Humana, illustrative)
name	Generic Drugs (Preventive; Condition Care Rx; All Other) … Specialty Drugs (Florida Blue, public 2025 SBC)				Tier 1 - Your Lowest-Cost Option; Tier 2 - Your Midrange-Cost Option; Tier 3 - Your Midrange-Cost Option; Tier 4 - Additional High-Cost Option (UHC Essential PDL, verified 2026 SBC)		Tier 1 Preferred Generic … Tier 5 Specialty (Humana, illustrative)
drug_class	Preventive; Condition Care Rx; All Other Generic; All Other Preferred Brand; Non-preferred brand drugs; Specialty drugs (Florida Blue, public 2025 SBC)				generic; preferred_brand; nonpreferred_brand; specialty (normalized from Essential PDL tier labels, verified 2026 SBC)		preferred_generic; generic; preferred_brand; nonpreferred_brand; specialty (Humana, illustrative)
tier_code	zero-cost-share-preventive; generic; preferred-brand; non-preferred-brand; specialty (FHIR DrugTierVS)				generic; preferred-brand; non-preferred-brand; specialty (FHIR DrugTierVS)		preferred-generic; generic; preferred-brand; non-preferred-brand; specialty (FHIR DrugTierVS)

Pharmacy Networks

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Kaiser (future)	Molina (future)	Oscar (future)
network_id	retail; mail_order (Florida Blue, public 2025 SBC)						PREF_RETAIL; STD_RETAIL; MAIL_ORDER (Humana, illustrative)
name	Retail; Mail Order (Florida Blue, public 2025 SBC)						Preferred Retail; Standard Retail; Mail Order (Humana, illustrative)
network_type	standard_retail; mail_order (Florida Blue, public 2025 SBC)						preferred_retail; standard_retail; mail_order (Humana, illustrative)
default_day_supply	30 retail; 90 mail order (Florida Blue, public 2025 SBC)						30 retail; 90 mail order (Humana, illustrative)

Coverage Stages

Normalized Field	Blue Cross	GatorCare	SCAN	Aetna	UHC	Cigna	Humana	Kaiser (future)	Molina (future)	Oscar (future)
stage_id							DEDUCTIBLE; INITIAL; CATASTROPHIC (Humana, illustrative)
name							Deductible; Initial Coverage; Catastrophic Coverage (Humana, illustrative)
stage_type							deductible; initial; catastrophic (Humana, illustrative)

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

Kaiser and Ambetter were populated in August 2026 from verified extractions of public 2026 SBCs. Molina and Oscar keep placeholder columns for expansion.

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.)

Conditions

Mappings for:

• prior authorization
• referral requirements
• contextual notes

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 v0.2.0, a draft module that is not yet wired into the core schema (it targets core v1.2.0). Like the medical tabs, the pharmacy tabs are sourced from a versioned repo file (docs/specification/pharmacy-crosswalk-data.json) and validated against the module's JSON Schema. Carrier data is accuracy-first: the Blue Cross column is populated from a verified extraction of a public 2025 Florida Blue ACA SBC (Coverage Stages remain blank for commercial plans, which have no Part D stages); the Humana column is illustrative (from the public module example); other carriers are intentionally blank pending verified public sources.

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 live version ensures that the standard remains current, accurate, and interoperable across all benefit plan formats and carriers.