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Series III Products

Comprehensive Coverage Plans

Series III Product Comparison Chart

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 after $25 doctor office visit copay (included same day and x-ray); $300 max per member per year	100% of allowable amount after $25 doctor office visit copay (for consultation only, all other services subject to deductible and coinsurance);$300 max per member per year	75% of allowable amount; $300 max per member per year
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	We pay 85% of allowable amount and you pay 15% after deductible	We pay 80% of allowable amount and you pay 20% after deductible	We pay 75% of allowable amount and you pay 25% after deductible
Optional Dental Coverage Deductible	$50	$50	$50
Prescription Drugs	Copay — $10 generic, $30 preferred, $45 non-preferred; $3,000 calendar year max per member	Copay — $10 generic, $30 preferred, $45 non-preferred; $3,000 calendar year max per member	Copay — $10 generic, $40 preferred, $55 non-preferred; $3,000 calendar year max per member
Prescription Drug Deductible	None	$200	$200
	Outline of Coverage	Outline of Coverage	Outline of Coverage