SelectBlue® Comparison Chart

(Participating Provider Coverage Shown¹)

Benefit Highlight	SelectBlue®	SelectBlue AdvantageSM	BlueChoiceSM Select
Participating providers	PPO Network 90% of IL doctors; over 200 IL hospitals		BlueChoice network2
Individual Deductible
$0	√
$250	√	√
$500	√	√
$1,000	√	√
$1,750		√
$2,500	√	√
$5,000	√	√
Individual Out-of-Pocket Expense Limit	$1,000	$3,000
Preventive Care Services (benefits covered as defined by national guidelines)	100%	100%
Coinsurance	You pay 0% or 20%	You pay 20%
Optional Maternity Coverage Coinsurance	You pay 0% or 20%	You pay 20%
Prescription Drugs	$0, $250, $500 deductible: Drug card with $10 copayment for generics	$250, $500 deductible: Drug card with $10 copayment for generics
	All other deductibles: You pay 20%	All other deductibles: You pay 20%
Prescription Drug Utilization/ Benefit Management Programs (for policies with effective dates on or after 1/1/2012)	Dispensing Limits: Benefits include coverage limits on certain quantities of medications. Specialty Pharmacy Program: To be eligible for maximum benefits, specialty medications must be obtained through the preferred Specialty Pharmacy Provider. View the Specialty Pharmacy Program List  which includes a reminder about coverage for self-administered specialty medications. Member Pay the Difference: When choosing a brand name drug over an available generic equivalent, you pay your usual share plus the difference in cost. Prior Authorization/Step Therapy Requirements: Before receiving coverage.
	The information in the Outline of Coverage does not incorporate changes mandated by the Affordable Care Act of 2010 and is not reflective of the final benefits for products with an October 1, 2010, or later effective date. Please view the Important Notice Regarding Your Benefits for additional information regarding Affordable Care Act benefits. The information in the Outline of Coverage does not incorporate Prescription Drug Utilization/ Benefit Management Programs information. RX program details are contained in the product policy book.
	Outline of Coverage	Outline of Coverage	Outline of Coverage

1. Benefits reduced when non-participating providers are used. This is a summary of highlights only. Please refer to the Outline of Coverage for each plan for additional details.

2. The BlueChoice network allows you to save on premiums and the cost of covered services when you use a contracting BlueChoice hospital, doctor or specialist. You do not need to select a primary care physician or obtain a referral to see a specialist.