PPO Select BasicSM
General Benefits
| In-Network Benefits | Out-Of-Network Benefits |
| PPO Select Basic pays 75% and you pay 25% of covered expenses after you meet your deductible | PPO Select Basic pay 50% and you pay 50% of covered expenses after you meet your deductible |
| All physician office visits will be subject to deductible and coinsurance | All physician office visits will be subject to deductible and coinsurance |
| Network providers will preauthorize your medical care | You must preauthorize hospital admissions and certain services |
| No claim forms to file | You may have to submit claims for reimbursement |
| Emergency Room visit subject to deductible and coinsurance - 75/25 | Emergency Room visit subject to deductible and coinsurance - 50/50 |
