Multi-Plan Page
| | B015 — S663CHC | S015 — PPO Access 60 4200 | U017 — DX-9I |
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| Plan # | B015 | S015 | U017 |
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| Plan Name | S663CHC | PPO Access 60 4200 | DX-9I |
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| Network Name | Blue Choice | Access PPO | Choice |
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| Network Type | PPO | PPO | EPO |
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| Plan Type | Copay | Copay | Copay |
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| Deductible - Individual | $3,100 | $4,200 | $4,500 |
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| Deductible - Family | $9,200 | $8,400 | $9,000 |
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| Coinsurance - Member | 30% | 40% | 0% |
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| Coinsurance - Plan | 70% | 60% | 100% |
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| Out-of-Pocket - Individual | $9,200 | $9,200 | $6,500 |
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| Out-of-Pocket - Family | $18,400 | $18,400 | $13,000 |
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| Virtual Visits | $50 | $0 | $0 |
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| PCP <19 | $50 | $0 | $0 |
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| Primary | $50 | D $45 | $10 |
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| Specialist | $100 | D $80 | $40 or $80 |
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| Urgent Care | $100 | $50 | $25 |
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| Emergency | $600 + D&C | D $750 | $500 + D&C |
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| Lab/X-Ray | D&C | D&C | $40 |
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| Imaging | $250 + D&C | D&C | D&C |
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| Inpatient Services | $350 + D&C | D&C | D&C |
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| Outpatient Surgery | $300 + D&C | D&C | D&C |
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| Prescriptions | $5-10-50-100-150-250 | $3-50-125-250 | $10-40-125-300-500 |
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| OON Deductible (Individual/Family) | $6,200 / $18,400 | $8,400 / $16,800 | N/A |
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| OON Coinsurance (Member) | 50% | 50% | N/A |
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| OON Out-of-Pocket (Individual/Family) | Unlimited / Unlimited | $27,600 / $55,200 | N/A |
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| | B013 — G9L5CHC | S019 — PPO Access 80 5000 |
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| Plan # | B013 | S019 |
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| Plan Name | G9L5CHC | PPO Access 80 5000 |
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| Network Name | Blue Choice | Access PPO |
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| Network Type | PPO | PPO |
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| Plan Type | Copay | Copay |
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| Deductible - Individual | $3,100 | $5,000 |
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| Deductible - Family | $9,300 | $10,000 |
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| Coinsurance - Member | 20% | 20% |
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| Coinsurance - Plan | 80% | 80% |
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| Out-of-Pocket - Individual | $8,800 | $9,100 |
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| Out-of-Pocket - Family | $17,600 | $18,200 |
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| Virtual Visits | $0 | $0 |
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| PCP <19 | $0 | $0 |
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| Primary | $0 | $40 |
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| Specialist | $80 | $80 |
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| Urgent Care | $150 | $50 |
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| Emergency | D&C | D $750 |
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| Lab/X-Ray | D&C | D&C |
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| Imaging | D&C | D&C |
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| Inpatient Services | D&C | D&C |
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| Outpatient Surgery | D&C | D&C |
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| Prescriptions | $0-10-50-100-150-250 | $3-50-125-250 |
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| OON Deductible (Individual/Family) | $6,200 / $18,600 | $10,000 / $20,000 |
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| OON Coinsurance (Member) | 50% | 50% |
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| OON Out-of-Pocket (Individual/Family) | Unlimited / Unlimited | $27,300 / $54,600 |
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