HMO 20 Copay

Your current plan

	HMO 20 Copay (you pay)
Benefits summary	HMO 20 Copay
Office visit	$20
Specialist visit	$30
Hospitalization	$400/day; max. 5 days/admission ($2000)

Other HMO cost-saving options

	HMO 30 Copay (you pay)	HMO 1500 Deductible (you pay)	HMO 2500 Deductible (you pay)	HMO 5000 Deductible (you pay)
Benefits summary	HMO 30 Copay	HMO 1500 Deductible	HMO 2500 Deductible	HMO 5000 Deductible
Office visit	$30	$30	$30	$30
Specialist visit	$50	$50	$50	$50
Hospitalization	$500/day; max. 5 days/admission ($2,500)	30% coinsurance, after deductible	30% coinsurance, after deductible	30% coinsurance, after deductible

Personal Choice PPO cost-saving options

	PPO 2500 Deductible		PPO 5000 Deductible		PPO 3000 HSA		PPO 5000 HSA		PPO 8000 Deductible
Benefits summary	PPO 2500 Deductible		PPO 5000 Deductible		PPO 3000 HSA		PPO 5000 HSA		PPO 8000 Deductible
Location	In-network (you pay)	Out-of-network (you pay)	In-network (you pay)	Out-of-network (you pay)	In-network (you pay)	Out-of-network (you pay)	In-network (you pay)	Out-of-network (you pay)	In-network (you pay)	Out-of-network (you pay)
Office Visit	$30, no deductible	50%, after deductible	$30, no deductible	50%, after deductible	20% after deductible	50%, after deductible	$0 after deductible	50%, after deductible	$25, no deductible	50%, after deductible
Specialist Visit	$50, no deductible	50%, after deductible	$50, no deductible	50%, after deductible	20% after deductible	50%, after deductible	$0 after deductible	50%, after deductible	20%, after deductible	50%, after deductible
Hospitalization	20% after $2,500 deductible; unlimited days	50%, after deductible/ 70 days	20% after $5,000 deductible; unlimited days	50%, after deductible/ 70 days	20% after deductible; unlimited days	50%, after deductible/ 70 days	$0 after deductible; unlimited days	50%, after deductible/ 70 days	20%, after $8,000 deductible; unlimited days	50%, after deductible/ 70 days

Once you have determined which plan is right for you, fill out the Plan Change Request Form. Sign and return the form to the address below or fax to 215-238-7067. For your new plan to be reflected in your next invoice, IBC must receive your completed plan change request form by June 4, 2012.

Independence Blue Cross
P.O. Box 41452
Philadelphia, PA 19101
Fax: 215-238-7067

If you have other questions concerning this rate adjustment, please call us at 1-888-249-2118 .