Your Out-of-Network BlueValue Select PPO Benefits At A Glance

Blue Value Select PPO Out-of-Network Benefit Summary* (Click here for In-Network Benefit Summary)
Description of Benefits		Blue Value Select 500 Plan	Blue Value Select 750 Plan	Blue Value Select 1000 Plan	Blue Value Select 1500 Plan
Lifetime Maximum Per Member		$5,000,000	$5,000,000	$5,000,000	$5,000,000
Annual Deductible Per Member (3 person maximum)		$1,000	$1,500	$2,000	$3,000
Annual Out-of-Pocket Maximum (3 person family maximum)		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
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
Preventive Care for Adults ($250 benefit max. per year) -		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
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
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	Plan pays 60% after deductible	Plan pays 60% after deductible
Outpatient Medical Care		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
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
Infusion Therapy/Chemotherapy		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
Ambulatory Surgical Center		Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible	Plan pays 60% after deductible
Ambulance Service		Plan pays 80% after deductible	Plan pays 80% after deductible	Plan pays 80% after deductible	Plan pays 80% after deductible
Home Health Care Maximum of 60 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
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
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
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
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
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
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:	After a $200 deductible per person, you pay:
	Generic	$15 copayment	$15 copayment	$15 copayment	$15 copayment
	Brand Formulary	$30 copayment	$30 copayment	$30 copayment	$30 copayment
	Non-Brand Formulary	$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 complete benefit details
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