Blue Solution PPO - Individuals and Families - Looking for Insurance?

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Individuals and Families: Blue Solution PPO

Benefits at a Glance

Printable Version

Blue Solution PPO Insurance Policy At-A-Glance

Lifetime Benefit Maximum	$2 Million
Benefits	In-Network	Out-Of-Network
Deductibles Choice of four deductibles. Maximum of two deductibles per family, per calendar-year. Expenses incurred toward the deductible during the last three months of the calendar year may also be used to satisfy the deductible for the succeeding calendar year.	$ 750 $ 1,500 $ 3,000 $ 5,000	$ 1,500 $ 3,000 $ 6,000 $ 10,000

Coinsurance - What Your Plan Pays $750, $1,500, $3,000	80%	60%
$5,000	100%	80%

Calendar-Year Coinsurance Maximum $750, $1,500, $3,000	$10,000	$20,000
$5,000 Maximum of two calendar-year coinsurance maximums per family, per calendar-year.	Not applicable.	No maximum.

General Doctor Visits $750, $1,500, $3,000	$30 copayment at in-network general practitioners, pediatricians, family practitioners, and internal medicine, doctors with NO deductible for these routine office visits. (General Coverage Limitations apply.)	60% after deductible is satisfied. For out-of-network benefits, see Benefit Summary.
$5,000	$30 copayment at in-network general practitioners, pediatricians, family practitioners, and internal medicine doctors with NO deductible for these routine office visits. (General Coverage Limitations apply.)	80% after deductible is satisfied. For out-of-network benefits, see Benefit Summary.

Specialist Visits $750, $1,500, $3,000	80% after deductible is satisfied.	60% after deductible is satisfied. For out-of-network benefits, see Benefit Summary.
$5,000	100% after deductible is satisfied.	80% after deductible is satisfied. For out-of-network benefits, see Benefit Summary.

Prescription Drugs Must use participating pharmacies.	Covered 50% after a separate $250 deductible per person is satisfied.	There is no coverage if you use out-of-network pharmacies.

Wellness Benefits Routine Exams Routine PSAs Routine physical exams Routine gynecological exams Routine mammograms	$500 annual maximum (per person) with no deductible or copayment Applicable coinsurance does apply.	$500 annual maximum (per person) with no deductible or copayment Applicable coinsurance does apply.

Children's Preventive Care Well-patient services (office visits only).	100%	100%

Immunizations	100%	100%

Maternity Rider - Optional 750, $1,500, $3,000	80% after deductible is satisfied.	60% after deductible is satisfied.
$5,000	100% after deductible is satisfied.	80% after deductible is satisfied.

IMPORTANT NOTE: Your premium will be accepted after coverage has been approved and a billing statement forwarded. This outline of coverage provides a brief description of the important features of your Blue Solution PPO insurance policy. The outline is not your policy, and only the actual policy provisions will control. The policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY.

Benefit Summary

Summary of Basic Provisions

Important Note: This Web site contains a summary of benefits available to you through Blue Solution PPO; it is not your insurance contract. Refer to your policy for a complete list of limitations and exclusions.