BlueChoice Opt-Out Plus Open Access Benefit Summaries - Brokers

BlueChoice Opt-Out Plus Open Access Benefit Summaries

The following benefit summaries are now available for small groups (1-50 & 51-199). The information is presented in a printer-friendly, PDF format. Please check the site frequently for summary updates.

Please select from the following:

MSGR

Non-MSGR: 1-50 & 51-199

District of Columbia: 1-50 & 51-199 Virginia: 1-50 & 51-199

MSGR

Option Features Brochure Number

Option 1 In: Copay $5/10 | Out: $300/600 Ded., 80%-20% CUT5572

Option 2 In: Copay $5/10 | Out: $500/1,000 Ded., 80%-20% CUT5573

Option 3 In: Copay $10/20 | Out: $300/600 Ded., 80%-20% CUT5574

Option 4 In: Copay $10/20 | Out: $500/1,000 Ded., 80%-20% CUT5575

Option 5 In: Copay $20/30 | Out: $300/600 Ded., 80%-20% CUT5576

Option 6 In: Copay $20/30 | Out: $500/1,000 Ded., 80%-20% CUT5577

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Non-MSGR 1-50
Option	Features	Brochure Number
Option 1	In: Copay $5/10 \| Out: $300/$600 Ded., 80%-20%	CUT5535
Option 2	In: Copay $5/10 \| Out: $500/$1000 Ded., 80%-20%	CUT5536
Option 3	In: Copay $10/20 \| Out: $300/$600 Ded., 80%-20%	CUT5537
Option 4	In: Copay $10/20 \| Out: $500/$1000 Ded., 80%-20%	CUT5538
Option 16	In: Copay $20/30 \| Out: $300/$600 Ded., 80%-20%	CUT5915
Option 17	In: Copay $30/40 \| Out: $300/$600 Ded., 80%-20%	CUT6389
Option A	Copay $10/20 $500 Ded.	CUT6497
Option B	Copay $20/30 $500 Ded.	CUT6498
Option C	Copay $30/40 $500 Ded.	CUT6499
Option D	Copay $10/20 $500 Ded.	CUT6500
Option E	Copay $20/30 $500 Ded.	CUT6501
Option F	Copay $30/40 $500 Ded.	CUT6502

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Non-MSGR 51-199
Option	Features	Brochure Number
Option 1	In: Copay $5/10 \| Out: $300/$600 Ded., 80%-20%	CUT5535
Option 2	In: Copay $5/10 \| Out: $500/$1000 Ded., 80%-20%	CUT5536
Option 3	In: Copay $10/20 \| Out: $300/$600 Ded., 80%-20%	CUT5537
Option 4	In: Copay $10/20 \| Out: $500/$1000 Ded., 80%-20%	CUT5538
Option 5	In: Copay $15/25 \| Out: $300/$600 Ded., 80%-20%	CUT5539
Option 16	In: Copay $20/30 \| Out: $300/$600 Ded., 80%-20%	CUT5915
Option 17	In: Copay $30/40 \| Out: $300/$600 Ded., 80%-20%	CUT6389
Option A	Copay $10/20 $500 Ded.	CUT6497
Option B	Copay $20/30 $500 Ded.	CUT6498
Option C	Copay $30/40 $500 Ded.	CUT6499
Option D	Copay $10/20 $500 Ded.	CUT6500
Option E	Copay $20/30 $500 Ded.	CUT6501
Option F	Copay $30/40 $500 Ded.	CUT6502

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District of Columbia 1-50
Option	Features	Brochure Number
Option 1	In: Copay $5/10 \| Out: $300/$600 Ded., 80%-20%	CUT5459
Option 2	In: Copay $5/10 \| Out: $500/$1000 Ded., 80%-20%	CUT5460
Option 3	In: Copay $10/20 \| Out: $300/$600 Ded., 80%-20%	CUT5461
Option 4	In: Copay $10/20 \| Out: $500/$1000 Ded. 80%-20%	CUT5546
Option 16	In: Copay $20/30 \| Out: $300/$600 Ded., 80%-20%	CUT5895
Option 17	In: Copay $30/40 \| Out: $300/$600 Ded., 80%-20%	CUT6388
Option A	Copay $10/20 $500 Ded.	CUT6521
Option B	Copay $20/30 $500 Ded.	CUT6522
Option C	Copay $30/40 $500 Ded.	CUT6523
Option D	Copay $10/20 $500 Ded.	CUT6524
Option E	Copay $20/30 $500 Ded.	CUT6525
Option F	Copay $30/40 $500 Ded.	CUT6526

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District of Columbia 51-199
Option	Features	Brochure Number
Option 1	In: Copay $5/10 \| Out: $300/$600 Ded., 80%-20%	CUT5459
Option 2	In: Copay $5/10 \| Out: $500/$1000 Ded., 80%-20%	CUT5460
Option 3	In: Copay $10/20 \| Out: $300/$600 Ded., 80%-20%	CUT5461
Option 4	In: Copay $10/20 \| Out: $500/$1000 Ded. 80%-20%	CUT5546
Option 5	In: Copay $15/25 \| Out: $300/$600 Ded., 80%-20%	CUT5547
Option 16	In: Copay $20/30 \| Out: $300/$600 Ded., 80%-20%	CUT5895
Option 17	In: Copay $30/40 \| Out: $300/$600 Ded., 80%-20%	CUT6388
Option A	Copay $10/20 $500 Ded.	CUT6521
Option B	Copay $20/30 $500 Ded.	CUT6522
Option C	Copay $30/40 $500 Ded.	CUT6523
Option D	Copay $10/20 $500 Ded.	CUT6524
Option E	Copay $20/30 $500 Ded.	CUT6525
Option F	Copay $30/40 $500 Ded.	CUT6526

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Virginia 1-50
Option	Features	Brochure Number
Option 1	In: Copay $5/10 \| Out: $300/$600 Ded., 80%-20%	BRC6016
Option 2	In: Copay $5/10 \| Out: $500/$1000 Ded., 80%-20%	BRC6017
Option 3	In: Copay $10/20 \| Out: $300/$600 Ded., 80%-20%	BRC6018
Option 4	In: Copay $10/20 \| Out: $500/$1000 Ded., 80%-20%	BRC6019
Option 16	In: Copay $20/30 \| Out: $300/$600 Ded., 80%-20%	BRC6212
Option 17	In: Copay $30/40 \| Out: $300/$600 Ded., 80%-20%	BRC6318
Option A	Copay $10/20 $500 Ded.	BRC6410
Option B	Copay $20/30 $500 Ded.	BRC6411
Option C	Copay $30/40 $500 Ded.	BRC6412
Option D	Copay $10/20 $500 Ded.	BRC6413
Option E	Copay $20/30 $500 Ded.	BRC6414
Option F	Copay $30/40 $500 Ded.	BRC6415

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Virginia 51-199
Option	Features	Brochure Number
Option 1	In: Copay $5/10 \| Out: $300/$600 Ded., 80%-20%	BRC6016
Option 2	In: Copay $5/10 \| Out: $500/$1000 Ded., 80%-20%	BRC6017
Option 3	In: Copay $10/20 \| Out: $300/$600 Ded., 80%-20%	BRC6018
Option 4	In: Copay $10/20 \| Out: $500/$1000 Ded., 80%-20%	BRC6019
Option 5	In: Copay $15/25 \| Out: $300/$600 Ded., 80%-20%	BRC6020
Option 16	In: Copay $20/30 \| Out: $300/$600 Ded., 80%-20%	BRC6212
Option 17	In: Copay $30/40 \| Out: $300/$600 Ded., 80%-20%	BRC6318
Option A	Copay $10/20 $500 Ded.	BRC6410
Option B	Copay $20/30 $500 Ded.	BRC6411
Option C	Copay $30/40 $500 Ded.	BRC6412
Option D	Copay $10/20 $500 Ded.	BRC6413
Option E	Copay $20/30 $500 Ded.	BRC6414
Option F	Copay $30/40 $500 Ded.	BRC6415

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