Availity Portal

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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

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Benefit Summaries

PW_B145562

BlueChoice PPO

PPO Benefit Summaries (effective 07/01/10)  
To view specific details of each Plan, click on the English or Spanish version, as appropriate. 
100/70% Plans  

PPO Plan 4000SX 
PPO Plan 4001SX 
PPO Plan 4002SX 
PPO Plan 4003SX 
 
90/60% Plans  

PPO Plan 4201SX 
PPO Plan 4202SX 
PPO Plan 4203SX 
PPO Plan 4204SX 
 
80/60% Plans  

PPO Plan 4500SX 
PPO Plan 4501SX 
PPO Plan 4502SX 
PPO Plan 4503SX 
PPO Plan 4504SX 
PPO Plan 4505SX 
PPO Plan 4510SX 
PPO Plan 4511SX 
PPO Plan 4512SX 
PPO Plan 4513SX 
 
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