Compare Series 3 Plans
Series 3 Comparison Chart
| Benefit Highlight | PPO Select® Blue Advantage | PPO Select® Choice | PPO Select® Saver |
|---|---|---|---|
| Participating Providers | BlueChoice® or BlueCard® PPO | ||
| Individual Deductible | |||
| $250 | √ | √ | |
| $500 | √ | √ | √ |
| $1,000 | √ | √ | √ |
| $1,500 | √ | √ | √ |
| $2,500 | √ | √ | √ |
| $3,500 | √ | √ | √ |
| $5,000 | √ | √ | √ |
| $10,000 | √ | √ | √ |
| Individual Out-of-Pocket Expense Limit | Deductible plus $3,000 | Deductible plus $3,000 | Deductible plus $3,000 |
| Preventive Care | 100% of allowable amount after $25 doctor office visit copay (included same day and x-ray); $300 max per member per year | 100% of allowable amount after $25 doctor office visit copay (for consultation only, all other services subject to deductible and coinsurance);$300 max per member per year | 75% of allowable amount; $300 max per member per year |
| Childhood Immunizations | 100% of allowable amount to 8 years of age | 100% of allowable amount to 8 years of age | 100% of allowable amount to 8 years of age |
| Coinsurance | We pay 85% of allowable amount and you pay 15% after deductible | We pay 80% of allowable amount and you pay 20% after deductible | We pay 75% of allowable amount and you pay 25% after deductible |
| Optional Dental Coverage Deductible | $50 | $50 | $50 |
| Prescription Drugs | Copay — $10 generic, $30 preferred, $45 non-preferred; $3,000 calendar year max per member | Copay — $10 generic, $30 preferred, $45 non-preferred; $3,000 calendar year max per member | Copay — $10 generic, $40 preferred, $55 non-preferred; $3,000 calendar year max per member |
| Prescription Drug Deductible | None | $200 | $200 |
Outline of Coverage  |
Outline of Coverage |
Outline of Coverage |
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1. The BlueChoice network allows you to save on premiums and the cost of covered services when you use a contracting BlueChoice hospital, doctor or specialist. You do not need to select a primary care physician or obtain a referral to see a specialist.