Your Out-of-Network Blue Value PPO Benefits At A Glance

Blue Value PPO Out-of-Network Benefit Summary* (Click here for In-Network Benefit Summary)
Description of Benefits		Blue Value 1,000 Plan	Blue Value 2,000 Plan	Blue Value 3,000 Plan NEW PLAN	Blue Value 3,500 Plan	Blue Value 5,000 Plan	Blue Value 10,000 Plan
Lifetime Maximum Per Member		$5,000,000	$5,000,000	$5,000,000	$5,000,000	$5,000,000	$5,000,000
Annual Deductible Per Member (3 person maximum)		$2,000	$4,000	$6,000	$7,000	$10,000	$20,000
Annual Out-of-Pocket Maximum (3 person family maximum)		No Limit	No Limit	No Limit	No Limit	No Limit	No Limit
Office Visits - (PPO Physicians and Specialists-includes X-ray and lab work when performed and billed by the physician's office) Not subject to calendar year deductible		Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible
Preventive Care for Babies and Children (through age 5) - Not subject to calendar year deductible		Plan pays 60% with deductible waived	Plan pays 60% with deductible waived	Plan pays 60% with deductible waived	Plan pays 60% with deductible waived	Plan pays 60% with deductible waived	Plan pays 60% with deductible waived
Preventive Care for Adults ($250 benefit max. per year in addition to state mandated coverage)		Plan pays 60% with deductible waived	Plan pays 60% with deductible waived	Plan pays 60% with deductible waived	Plan pays 60% with deductible waived	Plan pays 60% with deductible waived	Plan pays 60% with deductible waived
Professional Services Including surgery, anesthesia, in-hospital physician care, diagnostic X-ray and lab processed outside of the doctors office.		Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible
Inpatient Hospital Services Surgery, x-ray, in-hospital physician visits, organ/tissue transplants		Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible
Maternity (Available on Family Contracts Only) - Note: No maternity benefits are payable for the first 12 months of coverage.		Plan pays 60% after deductible	Plan pays 60% after deductible	Family Contracts Only: $3000 Copay then 70%	NOT COVERED	NOT COVERED	NOT COVERED
Outpatient Medical Care		Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible
Physical/Occupational Therapy, Chiropractic (Limited to 30 visits per year combined)		Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible
Mental, Emotional or Functional Nervous Disorders - Hospital Inpatient Only - Outpatient care is not a covered benefit		$100/day - $3,000 maximum per year - $10,000 lifetime maximum	$100/day - $3,000 maximum per year - $10,000 lifetime maximum	$100/day - $3,000 maximum per year - $10,000 lifetime maximum	$100/day - $3,000 maximum per year - $10,000 lifetime maximum	$100/day - $3,000 maximum per year - $10,000 lifetime maximum	$100/day - $3,000 maximum per year - $10,000 lifetime maximum
Infusion Therapy/Chemotherapy		Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible
Emergency Room Care - For Medical Emergency or Serious Accidental Injury For Non-Medical Emergency or Non-serious Accidental Injury		$150 copay then 100% coverage Plan pays at 60% after deductible	$150 copay then 100% coverage Plan pays at 60% after deductible	$150 copay then 100% coverage Plan pays at 60% after deductible	$150 copay then 100% coverage Plan pays at 60% after deductible	$150 copay then 100% coverage Plan pays at 60% after deductible	$150 copay then 100% coverage Plan pays at 60% after deductible
Ambulatory Surgical Center		Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible
Ambulance Service		Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible	Plan pays 70% after deductible
Home Health Care Maximum of 100 visits per year for preferred and non-preferred providers combined		Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible
Speech/Respiratory Therapy/Skilled Nursing Maximum of 30 visits per year per specialty		Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible
Hospice Maximum lifetime covered expense of $10,000		Plan pays 80% with deductible waived	Plan pays 80% with deductible waived	Plan pays 80% with deductible waived	Plan pays 80% with deductible waived	Plan pays 80% with deductible waived	Plan pays 80% with deductible waived
Home Health Care - Maximum of 100 visits per year		Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible
Durable Medical Equipment and Prosthetics		Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible
Private Duty Nursing $2,500 per year maximum		Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible
Prescription Drugs - $200 Deductible Per Year Retail Drugs - per prescription (up to a 30-day supply)		After a $200 deductible per person, you pay:	After a $200 deductible per person, you pay:	After a $200 deductible per person, you pay{Does not apply to generic drugs}:	After a $350 deductible per person, you pay:	After a $500 deductible per person, you pay:	After a $1,000 deductible per person, you pay:
	Generic	$15 copayment	$15 copayment	$15 copayment	$15 copayment	$15 copayment	$15 copayment
	Brand Formulary	$30 copayment	$30 copayment	$30 copayment	$30 copayment	$30 copayment	$30 copayment
	Non-Brand Formulary	$45 copayment	$45 copayment	$45 copayment	$45 copayment	$45 copayment	$45 copayment
Waiting period for all pre-existing conditions is at least one year from contract effective date. *Refer to your individual certificate of coverage for more complete coverage details
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