Blue Solution PPO

For Arkansas residents under age 65 not covered by Medicare and their families

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.