PPO Select Blue Advantage Series III

Policy Form Number: PPO-SELBLUE-ADV-3

General Benefits

In-Network Benefits Out-of-Network Benefits
PPO Select Blue Advantage pays 85% and you pay 15% of covered expenses after you meet your deductible PPO Select Blue Advantage pays 75% and you pay 25% of covered expenses after you meet your deductible
$25 office visit copay includes same day lab and x-ray, up to annual max of $750 Physician office visits subject to deductible and coinsurance
Network providers will precertify your medical care You must precertify 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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