PPO Select® Saver Series III

Policy Form Number: PPO-SELSAVER-3

General Benefits

In-Network Benefits Out-Of-Network Benefits
PPO Select Saver pays 75% and you pay 25% of covered expenses after you meet your deductible PPO Select Saver pays 60% and you pay 40% 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 pre-certify your medical care You must pre-certify hospital admissions and certain services
Usually no claim forms to file You may have to submit claims for reimbursement

Individual & Family Plans Only

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