Series V Products
Comprehensive Coverage Plans
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Series V Product Comparison Chart
This chart is a representation of Network benefits. Please refer to the Outline of Coverage for Out-of-Network benefits
| Benefit Highlight | PPO Select® Blue Advantage | PPO Select® Choice | PPO Select® Saver |
|---|---|---|---|
| Participating Providers | BlueChoice® or BlueCard® PPO | ||
| Individual Deductible | |||
| $250 | √ | √ | |
| $500 | √ | √ | √ |
| $1,000 | √ | √ | √ |
| $1,500 | √ | √ | √ |
| $2,500 | √ | √ | √ |
| $3,500 | √ | √ | √ |
| $5,000 | √ | √ | √ |
| $10,000 | √ | √ | √ |
| Individual Out-of-Pocket Expense Limit | Deductible plus $3,000 | Deductible plus $3,000 | Deductible plus $3,000 |
| Preventive Care | 100% of Allowable Amount (no Deductible) | 100% of Allowable Amount (no Deductible) | 100% of Allowable Amount (no Deductible) |
| Office Visit Copay | $25 (Includes Lab Work) | $25 | Deductible and Coinsurance |
| Childhood Immunizations | 100% of allowable amount to 8 years of age | 100% of allowable amount to 8 years of age | 100% of allowable amount to 8 years of age |
| Coinsurance | Plan pays 85% of allowable amount and member pays 15% after deductible | Plan pays 80% of allowable amount and member pays 20% after deductible | Plan pays 75% of allowable amount and member pays 25% after deductible |
| Optional Dental Coverage Deductible | $50 | $50 | $50 |
| Prescription Drugs | Copay — $10 generic, $30 preferred, $45 non-preferred | Copay — $10 generic, $30 preferred, $45 non-preferred | Copay — $10 generic, $40 preferred, $55 non-preferred |
| Prescription Drug Deductible | None | $200 | $200 |
| Prescription Drug Utilization/ Benefit Management Programs | Member Pay the Difference: When choosing a brand name drug over an available generic equivalent, you pay your usual share plus the difference in cost. For policies with effective dates on or after 3/1/2012: Dispensing Limits: Benefits include coverage limits on certain quantities of medications. Specialty Pharmacy Program: To be eligible for maximum benefits, specialty medications must be obtained through the preferred Specialty Pharmacy Provider. Prior Authorization/Step Therapy Requirements: Before receiving coverage. |
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Outline of Coverage  |
Outline of Coverage |
Outline of Coverage |
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