Plan
Design
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PPO Select Saver
(In Network)
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PPO Select Choice
(In Network)
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Select Blue
Advantage
(In Network)
|
|
Deductible Ranges
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$500-$10,000***
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$250-$10,000***
|
$250-$10,000***
|
|
Office Visit Copays
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None, toward deductible & coinsurance
|
$25 Consultation only
|
$25
(Includes same day lab/X-ray up to $750)
|
|
Emergency Room Copay
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None, toward deductible & coinsurance
|
None, toward deductible & coinsurance
|
$100 (facility charges only)*
|
|
Out-of-Pocket Maximum**
|
$3,000 Individual/$9,000 Family
|
$3.000 Individual /$6,000 Family
|
$3.000 Individual /$6,000 Family
|
|
Coinsurance
|
75% of allowable amount
|
80% of allowable amount
|
85% of allowable amount
|
|
Prescription Drug Program Deductible
|
$200 per person
|
$200 per person
|
No Deductible
|
|
Prescription Drug Program Copays
|
3-tier open formulary S10/$40/$55
|
3-tier open formulary $10/$30/$45
|
3-tier open formulary $10/$30/$45
|
Prescription Drug Calendar Year Maximum
(Including Mail Order)
|
$3,000 per Participant
|
$3,000 per Participant
|
$3,000 per Participant
|
|
Preventive Care
|
75% allowable amount subject to deductible and coinsurance up to $300 calendar year maximum per participant
|
100% allowable amount subject to office visit copay up to $300 calendar year maximum per participant $3,000 per Participant 100% allowable amount subject to office visit copay up
to S300 calendar year maximum per participant
|
100% allowable amount subject to office visit copay up to $300 calendar year maximum per participant $3,000 per Participant 100% allowable amount subject to office visit copay up
to S300 calendar year maximum per participant
|
Well-Child Care
(through age 7)
|
Routine physical exams and developmental assessment, subject ; to deductible and coinsurance, up to a $300 calendar year maximum per participant
|
Routine physical exams and developmental assessment, subject ; to deductible and coinsurance, up to a $300 calendar year maximum per participant
|
Routine physical exams and developmental assessment, subject ; to deductible and coinsurance, up to a $300 calendar year maximum per participant
|
Lifetime Maximum
|
$5 million per person
|
$5 million per person
|
$5 million per person
|
|
Pre-Existing Condition Clause
|
12 months
|
12 months
|
18 months
|
* Waived if admitted to hospital immediately following the visit.
* Other expenses subject to deductible and co-insurance.
** Deductible not included.
*** Based on health plan selection.
This information is intended as a brief summary of the basic elements of the plans. All benefit payments are subject to the plan provisions contained in the Master Contract.
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