Blue Value Select PPO Plan 500

Lifetime Maximum

In-Network	$5,000,000
Out-of-Network	$5,000,000

Annual Deductible

In-Network	$500
Out-of-Network	$1,000

Coinsurance

In-Network	Plan pays 80%
Out-of-Network	Plan pays 60%

Annual Out-of-Pocket Limit

In-Network	$2,000
Out-of-Network	No Out-of-Pocket Maximum

Office Visits

In-Network	$30 office visit copayment
Out-of-Network	Plan pays 60%

Preventive care through age 5

In-Network	$30 office visit copayment
Out-of-Network	Plan pays 60% of covered charges, deductible waived

Preventive care for adults

In-Network	$30 office visit copayment
Out-of-Network	Plan pays 60% of covered charges

Lab/X-ray

In-Network	Plan pays 80%
Out-of-Network	Plan pays 60%

Hospital-Based Physicians

In-Network	Plan pays 80%
Out-of-Network	Plan pays 60%

Maternity * Family Contracts Only

In-Network	Plan pays 80%
Out-of-Network	Plan pays 60%

Outpatient Facility

In-Network	Plan pays 80%
Out-of-Network	Plan pays 60%

Physical/Occupational Therapy/Chiropractic Therapy

In-Network	Plan pays 80%, 30 visits per year*
Out-of-Network	Plan pays 60% 30 visits per year*

* In- and out-of-network visits combined

Behavioral Health/Substance Abuse

In-Network	$100 per day up to $3,000 per year; $10,000 lifetime maximum
Out-of-Network	Not Covered

Inpatient Hospital

In-Network	Plan pays 80%
Out-of-Network	Plan pays 60%

Emergency Services

a	In-Network	Out-of-Network
Life threatening medical emergency or serious accidental injury	$150 ER copayment (waived if admitted)	$150 ER copayment (waived if admitted)
Non-accidental injury or non-medical emergency	$150 ER copayment; Plan pays 80% of covered charges after copayment	$150 ER copayment; Plan pays 60% of covered charges after copayment

Prescription Drug

• $200 annual deductible per member