PPO Select® Choice Series III
General Benefits
| In-Network Benefits | Out-of-Network Benefits |
| PPO Select Choice pays 80% and you pay 20% of covered expenses after you meet your deductible | PPO Select Choice pays 70% and you pay 30% of covered expenses after you meet your deductible |
| $25 office visit copay (physician consultation only) | Physician office visits subject to deductible and coinsurance |
| Network providers will precertify your medical care | You must precertify hospital admissions and certain services |
| No claim forms to file | You may have to submit claims for reimbursement |
