On the following pages, you ll find a list of plans, along with the significant benefit changes being made.

Transcription

1 Dear Group Administrator, Plan Changes Effective Jan. 1, 2017 There are some changes to certain health plans being offered to your group. Blue Cross and Blue Shield of Texas (BCBSTX) would like to make you aware of these updates. On the following pages, you ll find a list of plans, along with the significant benefit changes being made. If you would like to change plans or select additional plan options for your employees, you are able to do so. What to Consider While Deciding to Keep or Change Plans? Call your Producer or BCBSTX Account Representative or visit the BCBSTX website ( to check which doctors, other health care providers and prescription medications are covered by the plan you are considering. This is an important step when choosing a plan that meets the needs of your employees. Enclosed is a sample member letter that will be sent to any impacted members. Thank you for doing business with BCBSTX. We appreciate your trust in our organization and strive to continue to exceed the service needs of you and your employees. Sincerely, Blue Cross and Blue Shield of Texas This notice is also available in alternative formats upon request and at no cost to persons with disabilities by calling TTY: A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

2 العربية Arabic 繁體中文 Chinese Français French Deutsch German ગ જર ત Gujarati ह द Hindi 日本語 Japanese 한국어 Korean ພາສາລາວ Laotian Diné Navajo فارسی Persian Русский Russian Español Spanish Tagalog Tagalog Urdu If you, or someone you are helping, have questions, you have the right to get help and information in your language at no cost. To talk to an interpreter, call إن كان لديك أو لدى شخص تساعده أسئلة فلديك الحق في الحصول على المساعدة والمعلومات الضرورية بلغتك من دون اية تكلفة. للتحدث مع مترجم فوري اتصل على الرقم 如果您, 或您正在協助的對象, 對此有疑問, 您有權利免費以您的母語獲得幫助和訊息 洽詢一位翻譯員, 請撥電話號碼 Si vous, ou quelqu un que vous êtes en train d aider, avez des questions, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez Falls Sie oder jemand, dem Sie helfen, Fragen haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer an. જ તમન અથવ તમ મદદ કર રહ ય હ ય એવ ક ઈ બ જ વ યક તતન એસ.બ.એમ. ક યક રમ બ બત પ રશ ન હ ય, ત તમન વવન ખર ચ, તમ ર ભ ષ મ મદદ અન મ હહત મ ળવવ ન હક ક છ. દ ભ વષય સ થ વ ત કરવ મ ટ આ ન બર પર ક લ કર. यहद आपक, य आप ज सक स यत कर र उसक, प रश न, त आपक अपन भ ष म नन श ल क स यत और नक र प र प त करन क अध क र ककस अन व दक स ब त करन क ल ए पर क कर ご本人様 またはお客様の身の回りの方でも ご質問がございましたら ご希望の言語でサポートを受けたり 情報を入手したりすることができます 料金はかかりません 通訳とお話される場合 までお電話ください 만약귀하또는귀하가돕는사람이질문이있다면귀하는무료로그러한도움과정보를귀하의언어로받을수있는권리가있습니다. 통역사가필요하시면 로전화하십시오. ຖ າທ ານ ຫ ຄ ນທ ທ ານກາລ ງໃຫ ການຊ ວຍເຫອມຄາຖາມ, ທ ານມ ສດຂເອ າການຊ ວຍເຫອ ແລະ ຂ ມ ນເປ ນນພາສາຂອງທ ານໄດ ໂດຍບມ ຄ າໃຊ ຈ າຍ. ເພ ອລ ມກ ບນາຍແປພາສາ, ໃຫ ໂທຫາເບ T 11 ni, 47 doodago [a da b7k1 an1n7lwo 7g77, na 7d7[kidgo, ts 7d1 bee n1 ah00ti i t 11 n77k e n7k1 a doolwo[ d00 b7na 7d7[kid7g77 bee ni[ hodoonih. Ata dahalne 7g77 bich 8 hod77lnih kwe اگر شما يا کسی که شما به او کمک مي کنيد سؤالی داشته باشيد حق اين را داريد که به زبان خود به طور رايگان کمک و اطالعات دريافت نماييد. جهت گفتگو با يک مترجم شفاهی با شمار تماس حاصل نماييد. اردو Tiếng Việt Vietnamese Если у вас или человека, которому вы помогаете, возникли вопросы, у вас есть право на бесплатную помощь и информацию, предоставленную на вашем языке. Чтобы связаться с переводчиком, позвоните по телефону Si usted o alguien a quien usted está ayudando tiene preguntas, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al Kung ikaw, o ang isang taong iyong tinutulungan ay may mga tanong, may karapatan kang makakuha ng tulong at impormasyon sa iyong wika nang walang bayad. Upang makipag-usap sa isang tagasalin-wika, tumawag sa اگر آپ كو يا كسی ايسے فرد كو جس كی آپ مدد كررہے ہيں كوئی سوال درپيش ہے تو آپ كو اپنی زبان ميں مفت مدد اور معلومات حاصل كرنے كا حق ہے مترجم سے بات كرنے كے ليے پر كال كريں Nếu quý vị, hoặc người mà quý vị đang giúp đỡ, có câu hỏi, thì quý vị có quyền được giúp và nhận thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi bcbstx.com

3 Blue Cross and Blue Shield of Texas 2017 Affordable Care Act (ACA)/Metallic Plans Small Group (1-50) To find your renewal group s 2017 benefit changes, search for the plan by pressing CTRL, then the F key; enter the plan name or 7-character MPI in the search field and press enter to locate the plan changes listed in this document. Blue Choice Platinum PPO 010; P600CHC Blue Choice Platinum PPO 011; P601CHC

4 Blue Choice Gold PPO 020; G600CHC Blue Choice Gold PPO 023; G623CHC In 2017, your out-of-network family Out-of-Pocket Maximum will change to $27,000 from $13,500. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your Imaging Services copayment will change to coinsurance after deductible. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. Blue Choice Gold PPO 022; G622CHC

5 Blue Choice Gold PPO 019; G619CHC Blue Choice Gold PPO 001; G645CHC Blue Advantage Gold HMO 022; G632ADT

6 Blue Choice Silver PPO 027; S610CHC In 2017, your in-network individual Deductible will change to $2,275 from $2,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $6,825 from $6,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,900 from $6,850. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $13,800 from $13,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, and In 2017, your out-of-network individual Deductible will change to $4,550 from $4,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network family Deductible will change to $13,650 from $12,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network individual Out-of-Pocket Maximum will change to $13,800 from $13,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network family Out-of-Pocket Maximum will change to $27,600 from $13,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, Blue Choice Silver PPO 028; S611CHC In 2017, your in-network individual Deductible will change to $2,650 from $2,500. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $7,950 from $7,500. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network individual Deductible will change to $5,300 from $5,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network family Deductible will change to $15,900 from $15,000. The deductible is the amount you must pay before the health plan starts paying for most

7 Blue Choice Silver PPO 024; S608CHC Blue Choice Silver PPO 004; S607CHC In 2017, your in-network individual Deductible will change to $3,050 from $3,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $9,150 from $9,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,500 from $6,350. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $13,000 from $12,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, and In 2017, your out-of-network individual Deductible will change to $6,100 from $6,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network family Deductible will change to $18,300 from $18,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network individual Out-of-Pocket Maximum will change to $13,000 from $12,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network family Out-of-Pocket Maximum will change to $26,000 from $25,400. The out-of-pocket maximum is the total amount of deductible, coinsurance,

8 Blue Choice Gold PPO 030; G613CHC Blue Choice Silver PPO 025; S609CHC Blue Choice Silver PPO 003; S638CHC

9 Blue Choice Bronze PPO 005; B649CHC In 2017, your in-network individual Deductible will change to $5,750 from $5,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $11,500 from $12,700. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,500 from $6,450. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $13,000 from $13,100. The out-of-pocket maximum is the total amount of deductible, coinsurance, and In 2017, your in-network Coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. In 2017, your out-of-network individual Deductible will change to $11,000 from $10,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network family Deductible will change to $23,000 from $25,400. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network individual Out-of-Pocket Maximum will change to $13,000 from $12,900. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network family Out-of-Pocket Maximum will change to $26,000 from $26,400. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network Coinsurance will change to 50% from 40%. In 2017, your Outpatient Surgery Facility coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. In 2017, your Imaging Services coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. In 2017, your Laboratory Services coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. In 2017, your X-Ray Services coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible.

10 Blue Choice Bronze PPO 006; B650CHC In 2017, your in-network individual Deductible will change to $6,550 from $6,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $13,100 from $12,700. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,550 from $6,000. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $13,100 from $12,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, and In 2017, your out-of-network individual Deductible will change to $13,100 from $12,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network family Deductible will change to $26,200 from $25,400. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network individual Out-of-Pocket Maximum will change to $13,100 from $12,000. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network family Out-of-Pocket Maximum will change to $26,200 from $25,400. The out-of-pocket maximum is the total amount of deductible, coinsurance,

11 Blue Choice Bronze PPO 033; B600CHC In 2017, your in-network individual Deductible will change to $7,100 from $6,850. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $14,200 from $13,700. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $7,100 from $6,850. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $14,200 from $13,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, and In 2017, your out-of-network individual Deductible will change to $14,200 from $13,700. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network family Deductible will change to $28,400 from $27,400. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network individual Out-of-Pocket Maximum will change to $14,200 from $13,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network family Out-of-Pocket Maximum will change to $28,400 from $27,400. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your Urgent Care copayment will be $75. The copayment is a fixed dollar amount you are required to pay for covered services at the time you receive care. Blue Advantage Platinum HMO 007; P600ADT

12 Blue Advantage Platinum HMO 008; P601ADT Blue Advantage Gold HMO 014; G600ADT Blue Advantage Gold HMO 017; G623ADT Blue Advantage Gold HMO 016; G622ADT

13 Blue Advantage Gold HMO 012; G618ADT In 2017, your Urgent Care copayment will be $75. The copayment is a fixed dollar amount you are required to pay for covered services at the time you receive care. Blue Advantage Gold HMO 001; G617ADT Blue Advantage Silver HMO 020; S610ADT In 2017, your in-network individual Deductible will change to $2,850 from $2,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $8,550 from $6,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your Outpatient Surgery Facility copayment will change to coinsurance after deductible. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible.

14 Blue Advantage Silver HMO 021; S611ADT In 2017, your in-network individual Out-of-Pocket Maximum will change to $7,000 from $6,600. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $14,000 from $13,200. The out-of-pocket maximum is the total amount of deductible, coinsurance, and In 2017, your Outpatient Surgery Facility copayment will change to coinsurance after deductible. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. Blue Advantage Silver HMO 004; S639ADT In 2017, your in-network individual Deductible will change to $3,050 from $3,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $9,150 from $9,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,400 from $6,350. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $12,800 from $12,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, and

15 Blue Advantage Silver HMO 018; S608ADT Blue Advantage Silver HMO 003; S638ADT Blue Advantage Bronze HMO 006; B650ADT In 2017, your in-network individual Deductible will change to $6,550 from $6,450. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,550 from $6,450. The out-of-pocket maximum is the total amount of deductible, coinsurance,

16 Blue Choice Platinum PPO 010 with InVitro; P602CHC Blue Choice Platinum PPO 011 with InVitro; P610CHC Blue Choice Gold PPO 020 with InVitro; G601CHC

17 Blue Choice Gold PPO 023 with InVitro; G602CHC In 2017, your out-of-network family Out-of-Pocket Maximum will change to $27,000 from $13,500. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your Imaging Services copayment will change to coinsurance after deductible. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. Blue Choice Gold PPO 022 with InVitro; G603CHC Blue Choice Gold PPO 019 with InVitro; G605CHC

18 Blue Choice Gold PPO 001 with InVitro; G607CHC Blue Choice Silver PPO 027 with InVitro; S601CHC In 2017, your in-network individual Deductible will change to $2,275 from $2,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $6,825 from $6,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,900 from $6,850. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $13,800 from $13,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, and In 2017, your out-of-network individual Deductible will change to $4,550 from $4,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network family Deductible will change to $13,650 from $12,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network individual Out-of-Pocket Maximum will change to $13,800 from $13,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network family Out-of-Pocket Maximum will change to $27,600 from $13,700. The out-of-pocket maximum is the total amount of deductible, coinsurance,

19 Blue Choice Silver PPO 028 with InVitro; S602CHC In 2017, your in-network individual Deductible will change to $2,650 from $2,500. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $7,950 from $7,500. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network individual Deductible will change to $5,300 from $5,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network family Deductible will change to $15,900 from $15,000. The deductible is the amount you must pay before the health plan starts paying for most Blue Advantage Bronze HMO 006 with InVitro; B603ADT In 2017, your in-network individual Deductible will change to $6,550 from $6,450. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,550 from $6,450. The out-of-pocket maximum is the total amount of deductible, coinsurance,

20 Blue Choice Silver PPO 004 with InVitro; S604CHC In 2017, your in-network individual Deductible will change to $3,050 from $3,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $9,150 from $9,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,500 from $6,350. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $13,000 from $12,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, and In 2017, your out-of-network individual Deductible will change to $6,100 from $6,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network family Deductible will change to $18,300 from $18,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network individual Out-of-Pocket Maximum will change to $13,000 from $12,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network family Out-of-Pocket Maximum will change to $26,000 from $25,400. The out-of-pocket maximum is the total amount of deductible, coinsurance, Blue Choice Silver PPO 024 with InVitro; S605CHC

21 Blue Choice Gold PPO 030 with InVitro; G608CHC Blue Choice Silver PPO 025 with InVitro; S613CHC Blue Choice Silver PPO 003 with InVitro; S614CHC

22 Blue Choice Bronze PPO 005 with InVitro; B602CHC In 2017, your in-network individual Deductible will change to $5,750 from $5,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $11,500 from $12,700. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,500 from $6,450. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $13,000 from $13,100. The out-of-pocket maximum is the total amount of deductible, coinsurance, and In 2017, your in-network Coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. In 2017, your out-of-network individual Deductible will change to $11,000 from $10,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network family Deductible will change to $23,000 from $25,400. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network individual Out-of-Pocket Maximum will change to $13,000 from $12,900. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network family Out-of-Pocket Maximum will change to $26,000 from $26,400. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network Coinsurance will change to 50% from 40%. In 2017, your Outpatient Surgery Facility coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. In 2017, your Imaging Services coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. In 2017, your Laboratory Services coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. In 2017, your X-Ray Services coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible.

23 Blue Choice Bronze PPO 006 with InVitro; B603CHC In 2017, your in-network individual Deductible will change to $6,550 from $6,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $13,100 from $12,700. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,550 from $6,000. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $13,100 from $12,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, and In 2017, your out-of-network individual Deductible will change to $13,100 from $12,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network family Deductible will change to $26,200 from $25,400. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network individual Out-of-Pocket Maximum will change to $13,100 from $12,000. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network family Out-of-Pocket Maximum will change to $26,200 from $25,400. The out-of-pocket maximum is the total amount of deductible, coinsurance,

24 Blue Choice Bronze PPO 033 with InVitro; B604CHC In 2017, your in-network individual Deductible will change to $7,100 from $6,850. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $14,200 from $13,700. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $7,100 from $6,850. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $14,200 from $13,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, and In 2017, your out-of-network individual Deductible will change to $14,200 from $13,700. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network family Deductible will change to $28,400 from $27,400. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network individual Out-of-Pocket Maximum will change to $14,200 from $13,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network family Out-of-Pocket Maximum will change to $28,400 from $27,400. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your Urgent Care copayment will be $75. The copayment is a fixed dollar amount you are required to pay for covered services at the time you receive care. Blue Advantage Gold HMO 022 with InVitro; G603ADT

25 Blue Advantage Platinum HMO 007 with InVitro; P602ADT Blue Advantage Platinum HMO 008 with InVitro; P604ADT Blue Advantage Gold HMO 014 with InVitro; G604ADT Blue Advantage Gold HMO 017 with InVitro; G605ADT

26 Blue Advantage Gold HMO 016 with InVitro; G606ADT Blue Advantage Gold HMO 012 with InVitro; G608ADT In 2017, your Urgent Care copayment will be $75. The copayment is a fixed dollar amount you are required to pay for covered services at the time you receive care. Blue Advantage Gold HMO 001 with InVitro; G610ADT

27 Blue Advantage Silver HMO 020 with InVitro; S600ADT In 2017, your in-network individual Deductible will change to $2,850 from $2,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $8,550 from $6,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your Outpatient Surgery Facility copayment will change to coinsurance after deductible. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. Blue Advantage Silver HMO 021 with InVitro; S601ADT In 2017, your in-network individual Out-of-Pocket Maximum will change to $7,000 from $6,600. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $14,000 from $13,200. The out-of-pocket maximum is the total amount of deductible, coinsurance, and In 2017, your Outpatient Surgery Facility copayment will change to coinsurance after deductible. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible.

28 Blue Advantage Silver HMO 004 with InVitro; S602ADT In 2017, your in-network individual Deductible will change to $3,050 from $3,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $9,150 from $9,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,400 from $6,350. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $12,800 from $12,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, and Blue Advantage Silver HMO 018 with InVitro; S603ADT Blue Advantage Silver HMO 003 with InVitro; S604ADT

29 Blue Advantage Bronze HMO 006 with InVitro; B602ADT In 2017, your in-network individual Deductible will change to $6,550 from $6,450. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,550 from $6,450. The out-of-pocket maximum is the total amount of deductible, coinsurance, Blue Choice Gold PPO 020; G620CHC Blue Choice Gold PPO 001; G617CHC

30 Blue Choice Silver PPO 003; S606CHC Blue Choice Bronze PPO 006; B634CHC In 2017, your in-network individual Deductible will change to $6,550 from $6,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $13,100 from $12,700. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,550 from $6,000. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $13,100 from $12,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, and In 2017, your out-of-network individual Deductible will change to $13,100 from $12,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network family Deductible will change to $26,200 from $25,400. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network individual Out-of-Pocket Maximum will change to $13,100 from $12,000. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network family Out-of-Pocket Maximum will change to $26,200 from $25,400. The out-of-pocket maximum is the total amount of deductible, coinsurance,

31 Blue Choice Bronze PPO 005; B633CHC In 2017, your in-network individual Deductible will change to $5,750 from $5,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $11,500 from $12,700. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,500 from $6,450. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $13,000 from $13,100. The out-of-pocket maximum is the total amount of deductible, coinsurance, and In 2017, your in-network Coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. In 2017, your out-of-network individual Deductible will change to $11,000 from $10,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network family Deductible will change to $23,000 from $25,400. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network individual Out-of-Pocket Maximum will change to $13,000 from $12,900. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network family Out-of-Pocket Maximum will change to $26,000 from $26,400. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network Coinsurance will change to 50% from 40%. In 2017, your Outpatient Surgery Facility coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. In 2017, your Imaging Services coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. In 2017, your Laboratory Services coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. In 2017, your X-Ray Services coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible.

32 Blue Advantage Gold HMO 014; G620ADT Blue Advantage Silver HMO 004; S607ADT In 2017, your in-network individual Deductible will change to $3,050 from $3,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $9,150 from $9,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,400 from $6,350. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $12,800 from $12,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, and Blue Advantage Silver HMO 003; S606ADT

33 Blue Advantage Bronze HMO 006; B634ADT In 2017, your in-network individual Deductible will change to $6,550 from $6,450. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,550 from $6,450. The out-of-pocket maximum is the total amount of deductible, coinsurance, Blue Choice Gold PPO 020 with InVitro; G609CHC Blue Choice Gold PPO 001 with InVitro; G610CHC

34 Blue Choice Silver PPO 003 with InVitro; S616CHC Blue Advantage Silver HMO 003 with InVitro; S609ADT Blue Advantage Gold HMO 014 with InVitro; G611ADT

35 Blue Choice Bronze PPO 005 with InVitro; B606CHC In 2017, your in-network individual Deductible will change to $5,750 from $5,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $11,500 from $12,700. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,500 from $6,450. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $13,000 from $13,100. The out-of-pocket maximum is the total amount of deductible, coinsurance, and In 2017, your in-network Coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. In 2017, your out-of-network individual Deductible will change to $11,000 from $10,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network family Deductible will change to $23,000 from $25,400. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network individual Out-of-Pocket Maximum will change to $13,000 from $12,900. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network family Out-of-Pocket Maximum will change to $26,000 from $26,400. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network Coinsurance will change to 50% from 40%. In 2017, your Outpatient Surgery Facility coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. In 2017, your Imaging Services coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. In 2017, your Laboratory Services coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible. In 2017, your X-Ray Services coinsurance will change to 30% from 20%. The coinsurance is the percentage of the cost that you must pay for a covered service. It applies after you meet your deductible.

36 Blue Choice Bronze PPO 006 with InVitro; B607CHC In 2017, your in-network individual Deductible will change to $6,550 from $6,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $13,100 from $12,700. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,550 from $6,000. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $13,100 from $12,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, and In 2017, your out-of-network individual Deductible will change to $13,100 from $12,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network family Deductible will change to $26,200 from $25,400. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your out-of-network individual Out-of-Pocket Maximum will change to $13,100 from $12,000. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your out-of-network family Out-of-Pocket Maximum will change to $26,200 from $25,400. The out-of-pocket maximum is the total amount of deductible, coinsurance, Blue Advantage Silver HMO 004 with InVitro; S605ADT In 2017, your in-network individual Deductible will change to $3,050 from $3,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network family Deductible will change to $9,150 from $9,000. The deductible is the amount you must pay before the health plan starts paying for most In 2017, your in-network individual Out-of-Pocket Maximum will change to $6,400 from $6,350. The out-of-pocket maximum is the total amount of deductible, coinsurance, In 2017, your in-network family Out-of-Pocket Maximum will change to $12,800 from $12,700. The out-of-pocket maximum is the total amount of deductible, coinsurance, and