Grandfathered Plan Documents 2023
Pharmacy
| DOCUMENTS | DOWNLOAD/ACCESS |
|---|---|
3 & 4 Tier Standard Plans | |
Coinsurance & Brand-Generic Standard Plans |
Summary of Benefits and Coverage (SBC)
The Summary of Benefits and Coverage (SBC) provides a concise description of what services your plan covers along with what you will pay for covered benefits.
| Plans | Download |
|---|---|
BluePreferred 100 1500 | |
BluePreferred 100 2500 | |
BluePreferred 100 5000 | |
BluePreferred 90 100 | |
BluePreferred 90 250 | |
BluePreferred 90 500 | |
BluePreferred 80 250 | |
BluePreferred 80 500 | |
BluePreferred 80 1000 | |
BluePreferred 80 2000 | |
BlueSelect Plan 10 | |
BlueSelect Plan 20 | |
BluePreferred No Copay 100 | |
BluePreferred No Copay 2000 | |
BluePreferred Saver 100 1500 | |
BluePreferred Saver 100 3000 | |
BluePreferred Saver 100 5000 | |
BluePreferred Saver 80 1500 | |
BluePreferred Saver 80 3000 |
Benefit Books
| Documents | Download |
|---|---|
| BluePreferred Copay PPO 2-50 | |
| BluePreferred Copay PPO 51-99 | |
| BluePreferred Copay 100 2-50 | |
| BluePreferred Copay 100 51-99 | |
| BluePreferred No Copay PPO 2-50 | |
| BluePreferred No Copay PPO 51-99 | |
| BlueSelect Plan 10 HMO 2-50 | |
| BlueSelect Plan 10 HMO 51-99 | |
| BlueSelect Plan 20 HMO 2-50 | |
| BlueSelect Plan 20 HMO 51-99 | |
| BluePreferred Saver 80 PPO 2-50 | |
| BluePreferred Saver 80 PPO 51-99 | |
| BluePreferred Saver 100 PPO 2-50 | |
| BluePreferred Saver 100 PPO 51-99 |