Personal ChoiceGroups 51 – 99

Forms are in pdf format.

Blue Solutions

Option PCP Copay
Personal Choice HDHP w/Integ Rx — HD1-HC1 Contract Year 100%*
Personal Choice HDHP w/Integ Rx — HD2-HC1 Contract Year 100%*
Personal Choice HDHP w/Integ Rx — HD3-HC1 Contract Year 100%*
Personal Choice HDHP w/Integ Rx — HD4-HC1 Contract Year 100%*
Personal Choice HDHP w/Integ Rx — HD4-HC2 Contract Year 80%*
Personal Choice HDHP Plus 1A w/Integ Rx 100%*
Personal Choice HDHP Plus 2A w/Integ Rx 100%*
Personal Choice HDHP Plus 3A w/Integ Rx 100%*
Personal Choice HDHP Plus 4A w/Integ Rx 100%*
Personal Choice HDHP Plus 5A w/Integ Rx 100%*
Personal Choice HRA Plus 1A w/ Integ Rx 100%*
Personal Choice HRA Plus 2A w/ Integ Rx 100%*
Personal Choice HRA Plus 3A w/ Integ Rx 100%*
Personal Choice PPO Plus 1A $10
Personal Choice PPO Plus 2A $15
Personal Choice PPO Plus 3A $20
Personal Choice PPO Plus 4A $30
Personal Choice PPO Plus 5A $20
Personal Choice PPO Plus 6A $35
Personal Choice PPO Plus 7A $20
Personal Choice PPO Plus 8A w/Integ Rx $30
Personal Choice PPO Plus 9A w/Integ Rx $40
Personal Choice PPO Plus 10A w/Integ Rx $40
Personal Choice C1-F1-O1 — HCR $10
Personal Choice C2-F2-O1 — HCR $15
Personal Choice C3-F4-O1 — HCR $20
Personal Choice C4-F5-O2 — HCR $30
Personal Choice D2-N1 — HCR $20
Personal Choice D3-N1 — HCR $20
Personal Choice D4-N2 — HCR $20

Blue Solutions Choice

Option PCP Copay
BC PPO Plus 1A $10
BC PPO Plus 2A $15
BC PPO Plus 3A $20
BC PPO Plus 4A $30
BC PPO Plus 5A $20**
BC PPO Plus 6A $35**
BC PPO Plus 7A $20**
BC PPO Plus 8A (single) w/ Integ. Rx $30*
BC PPO Plus 9A (single) w/ Integ. Rx $40*
BC PPO Plus 10A (single) w/ Integ. Rx $40*
BC HDHP Plus 1A (single) w/ Integ. Rx 100%*
BC HDHP Plus 3A (single) w/ Integ. Rx 100%*
BC HDHP Plus 4A (single) w/ Integ. Rx 100%*
BC PPO HRA Plus 3A w/ Integ. Rx 100%*

*after deductible
** no deductible