Personal ChoiceGroups 2 – 50

Forms are in pdf format.

Blue Solutions

Option PCP Copay
PPO 1 Rx $10/$20/$35 Vision $100 — HCR $10
PPO 2 Rx $10/$20/$35 Vision $100 — HCR $15
PPO 3 Rx $10/$20/$35 Vision $100 — HCR $20
PPO 4 Rx $7/$50/$125 Vision $100 — HCR $30
PPO 5 Rx $7/50%/$125 Vision $100 — HCR $30
PPO 6 Rx $7/50%/$125 Vision $100 — HCR $40
PPO 7 Rx $10/$45/$75 Vision $100 — HCR $20
PPO 8 Rx $10/$45/$75 Vision $100 — HCR $30
PPO 1.1 Rx $10/$40/$70 Vision $100 $10
PPO 2.1 Rx $10/$40/$70 Vision $100 $15
PPO 3.1 Rx $10/$40/$70 Vision $100 $20
PPO 4.1 Rx $10/$45/$75 Vision $100 $30
PPO 5.1 Rx $10/$45/$75 Vision $100 $30
PPO 6.1 Rx $10/$45/$75 Vision $100 $40
PPO 7.1 Rx $250/$10/$45/$75 Vision $100 $20
PPO 8.1 Rx $250/$10/$45/$75 Vision $100 $30
Personal Choice HDHP 1 Rx $20/$40/$60 Vision $100 Contract Year — HCR 100%*
Personal Choice HDHP 2 Rx $20/$40/$60 Vision $100 Contract Year — HCR 100%*
Personal Choice HDHP 3 Rx $20/$40/$60 Vision $100 Contract Year — HCR 100%*
Personal Choice HDHP 4 Rx $20/$40/$60 Vision $100 Contract Year — HCR 100%*
Personal Choice HDHP 5 Rx $20/$40/$60 Vision $100 Contract Year — HCR 80%*
Personal Choice HRA 1 100%*
Personal Choice HRA 2 100%*
Personal Choice HRA 3 100%*

Blue Solutions Choice

Option PCP Copay
BC PPO 1.1 Rx $10/$40/$70 Vision $100 $10
BC PPO 2.1 Rx $10/$40/$70 Vision $100 $15
BC PPO 3.1 Rx $10/$40/$70 Vision $100 $20
BC PPO 4 Rx $7/50% ($125) Vision $100 $30
BC PPO 5 Rx $7/50% ($125) Vision $100 $30
BC PPO 6 Rx $7/50% ($125) Vision $100 $40
BC PPO 7.1 Rx $250/$10/$45/$75 Vision $100 $20**
BC PPO 8.2 Rx $7/50% ($125) Vision $100 $30**
BC PPO HDHP 1 (single) Int. Rx $20/$40/$60 Vision $100 100%*
BC PPO HDHP 3 (single) Int. Rx $20/$40/$60 Vision $100 100%*
BC PPO HDHP 4 (single) Int. Rx $20/$40/$60 Vision $100 100%*
BC PPO HDHP 5 (single) Int. Rx $20/$40/$60 Vision $100 100%*
BC PPO HRA 3 Int. Rx $20/$40/$60 Vision $100 80%*

*after deductible
**no deductible