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blueCross blueShield Wellness ppO plan blueCross blueShield

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									                                                               blueCross blueShield Wellness ppO plan                                           blueCross blueShield blueChoice plan
                                                          in-network                            Out-of-network                            in-network                                Out-of-network
    plan/lifetime maximum                       $4 million/individual total maximum In-Network and Out-of-Network combined                 Unlimited                             $2 million/individual
    plan Year deductible (must be                        $400/individual                        $600/individual                         $200/individual                           $500/individual
    satisfied before benefits are paid)                 $800/family max                        $1,200 family max                       $400/family max                           $1,000/family max
    Out-of-pocket maximum (not                          $1,400/individual                       $3,400/individual                      $1,500/individual                          $3,000/individual
    including deductible, if applicable)                 $2,800/family                           $5,200/family                          $3,000/family                              $5,000/family
    physician Office visits
    Office visit/specialist/consultation/                  $20 copay
    initial Maternity Visit                                                                                                                $20 copay
    Allergy testing / serum                                 No copay
    Allergy shots                                           No copay                          30% after deductible                         $5 copay                             40% after deductible
    Maternity Services (beyond initial visit)
    Surgery, Radiology and Lab (office)               20% after deductible                                                                 No copay
    Chemotherapy
    Routine Vision Exam                                    $20 copay                              Not covered                              $20 copay                                  Not covered
    preventive Exams (office visit included)
    Flu Shots                                              $10 copay
                                                                                                                                           $20 copay                            40% after deductible
    Annual exam
                                                                                                                                                                                40% after deductible
    Child immunizations                                                                                                             No copay through age 6                        through age 6
    Adult immunizations
    Pneumococcal Immunizations
                                                                                              30% after deductible                         $20 copay                            40% after deductible
    Well baby exams                                         No copay
    Diabetes vision screening
    Mammogram
    Pap smear
                                                                                                                                      20% after deductible                       40% after deductible
    Colonoscopy
    Prostate cancer screening
    Emergency Care
    Ambulance                                       20%; deductible waived                   30%; deductible waived                                                No Copay
    Urgent care center                                     $40 copay                          30% after deductible                                                 $25 copay
    Hospital emergency room3                                                   $100 copay1                                                                         $50 copay1
    Hospital Services
    Inpatient hospital                                20%2 after deductible                   30%2 after deductible                  20%2 after deductible                      40%2 after deductible
    Outpatient surgical center                                                                                                             $50 copay
    Approved skilled nursing facility
                                                                                                                                                                                40% after deductible
    Outpatient hospital services                                                                                                     20% after deductible
                                                      20% after deductible                    30% after deductible
    (diagnostic lab., radiology)
    Durable medical equipment                                                                                                                                20% after deductible
    Home health care, Hospice care                                                                                                         No copay                             40% after deductible
    Outpatient rehabilitation services                20% after deductible                    30% after deductible                   $20 copay (maximum                        40% after deductible
    (includes OT, PT, ST and chiropractic)       (maximum 60 sessions/plan yr)           (maximum 60 sessions/plan yr)                60 sessions/plan yr)                (maximum 60 sessions/plan yr)
    behavioral Health Services
    Inpatient mental health and                       20%2 after deductible                   40%2 after deductible                  20%2 after deductible                       50%2 after deductible
    substance abuse treatment                        (up to 60 days/plan yr)                 (up to 60 days/plan yr)                (up to 30 days/plan yr)                     (up to 30 days/plan yr)
                                                         $40 copay/visit                         $50 copay/visit                        $20 copay/visit                         50% after deductible
    Outpatient mental health and                  (up to 60 visits/plan yr); 20%            (up to 60 visits/plan yr);             (up to 60 visits/plan yr);                 (up to 60 visits/plan yr);
    substance abuse treatment                       for misc. charges (i.e. lab)         30% for misc. charges (i.e. lab)       20% for misc. charges (i.e. lab)           50% for misc. charges (i.e. lab)
    Serious inpatient mental illness                                                                                                 20% after deductible
                                                      20% after deductible                    40% after deductible                                                              50% after deductible
    Serious outpatient mental illness                                                                                                      $20 copay

                     1. Waived if admitted as inpatient for the same diagnosis within 24 hours.
                     2. Insurance carrier must be notified within 24 hours of all inpatient hospital admissions. Please see SPD for details.
                     3. Facility fee only.
6
                  blueCross blueShield regular ppO plan                                          blueCross blueShield High Deductible ppO plan
         in-network                                     Out-of-network                         in-network                                 Out-of-network
$4 million/individual total maximum In-Network and Out-of-Network combined          $4 million/individual total maximum In-Network and Out-of-Network combined
        $400/individual                                 $600/individual                      $1,000/individual                            $2,000/individual
       $800/family max                                 $1,200 family max                    $2,000/family max                            $4,000 family max
       $1,400/individual                                $3,400/individual                    $2,000/individual                            $4,000/individual
      $2,800/family max                                $5,200/family max                    $4,000/family max                            $8,000/family max



          $20 copay                                                                             $25 copay



                                                      30% after deductible                                                              40% after deductible
     20% after deductible                                                                  30% after deductible




                                   Not covered                                                                       Not covered



                                   Not covered                                                                       Not covered

No copay up to $200/covered child through age 6 — total maximum for both            No copay up to $200/covered child through age 6 — total maximum for both
                In-Network and Out-of-Network combined                                              In-Network and Out-of-Network combined



                                   Not covered                                                                       Not covered




     20% after deductible                             30% after deductible                 30% after deductible                         40% after deductible


                                   Not covered                                                                       Not covered


   20%; deductible waived                           30%; deductible waived               30%; deductible waived                       40%; deductible waived
     20% after deductible                             30% after deductible                 30% after deductible                         40% after deductible
                                   $50 copay1
                                                                                                                     $100 copay1




    20%2 after deductible                            30%2 after deductible                 30%2 after deductible                       40%2 after deductible




     20% after deductible                             30% after deductible                 30% after deductible                         40% after deductible




     20% after deductible                             30% after deductible                 30% after deductible                         40% after deductible
(maximum 60 sessions/plan yr)                    (maximum 60 sessions/plan yr)        (maximum 60 sessions/plan yr)                (maximum 60 sessions/plan yr)


     20%2 after deductible                            40%2 after deductible                30%2 after deductible                        40%2 after deductible
    (up to 60 days/plan yr)                          (up to 60 days/plan yr)              (up to 60 days/plan yr)                      (up to 60 days/plan yr)
        $40 copay/visit                                  $50 copay/visit                      $40 copay/visit                              $50 copay/visit
   (up to 60 visits/plan yr);                       (up to 60 visits/plan yr);           (up to 60 visits/plan yr);                   (up to 60 visits/plan yr);
20% for misc. charges (i.e. lab)                 40% for misc. charges (i.e. lab)     20% for misc. charges (i.e. lab)             40% for misc. charges (i.e. lab)

     20% after deductible                             40% after deductible                 30% after deductible                         40% after deductible




     Important Information:               This document provides a general summary of basic benefit plan provisions and is not a substitute for the
     official certificates of coverage . This is not a contract . If there are any inconsistencies between this summary and the official certificates of
     coverage, the certificates of coverage will prevail . Please refer to the certificate of coverage for exact benefits, exclusions and limitations .               7

								
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