PPO Select Blue Advantage Series III

Policy Form Number: PPO-SELBLUE-ADV-3

Office Setting Services	If using network providers Select Blue Advantage pays
Physician Services Allergy Injections (billed with the office visit)* Allergy Tests Consultation Dental Exam (within the first 48 hours after an accident) Hearing Exam Office Visit Charge Injections (except allergy injections), if billed as injections only Office Visit Routine Immunizations (age 8 and over) Routine Physical Exam Office Visit Vision Exam Well-baby Exam Well-woman exam (including pap smear if filed before $300 annual max is exhausted)	100% of allowable amount after copay Some services are subject to day or dollar maximums.
Immunizations (birth through age 7)	100% of allowable amount
Diagnostic Tests Lab – Office X-Ray – Office	100% of allowable amount after copay if performed on the same day and ordered by a network provider
Other Benefits Certain Outpatient Procedures Office Surgery Physical / Occupational Therapy**	Coinsurance after deductible

*When billed separately, medical / surgical coinsurance applies plus any applicable deductible.
**Subject to days or dollar maximums.
Note: Services requiring a return office visit, for example, lab/X-ray, on a different day will require a new copayment.

Individual & Family Plans Only

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