PLAN HIGHLIGHTS

PLAN OPTIONS AT A GLANCE

SELECT BLUE ADVANTAGE PROVIDES:

Affordable, cost effective health coverage
Freedom to choose doctors and hospitals
Choice of deductibles
Choice of out of pocket security provisions
Three-tier prescription drug program
Individual, spouse and child(ren) coverage available

Options

Calendar Year Deductibles

Copayment Amounts

Calendar Year Out of Pocket Maximum/Security Provisions

Coinsurance**

Individual
In-Network

Individual
Out of Network

Family
In Network

Family
Out of Network

Office Visit
(Includes
lab and
x-rays)

Emergency
Care
(Facility Only)*

Individual
In-Network

Individual
Out of Network

Family
In Network

Family
Out of Network

In
Network

Out of
Network

Plan
Pays

You
Pay

Plan
Pays

You
Pay

Plan I

$250

$500

$750

$1,500

$30

$75

$2,000

$3,000

$4,000

$6,000

Plan II

$500

$1,000

$1,500

$3,000

Plan III

$1,000

$2,000

$3,000

$6,000

$35

$75

$3,000

$5,000

$6,000

$10,000

85%

15%

75%

25%

Plan IV

$1,500

$3,000

$4,500

$9,000

Plan V

$2,500

$5,000

$7,500

$15,000

$45

$75

$5,000

$8,000

$10,000

$16,000

Plan VI

$5,000

$10,000

$15,000

$30,000

*$75 copayment applies to the Emergency Room charge only. All other services are subject to deductible and
coinsurance. copayment waived if admitted to hospital immediately following ER visit.
**Percentages apply to covered expenses after calendar year deductibles are met.
Lifetime maximum is $2 million per person.

Options	Prescription Drug card Program
	Copayment Amounts			Calendar Year Maximum Benefits
	Generic	Preferred	Non Preferred
Plan I	$12	$25	$40	$1,500
Plan II

Plan III	$15	$30	$45	$1,500
Plan IV

Plan V	$20	$35	$50	$1,500
Plan VI