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

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Benefit Summaries - Grandfathered

PW_B150329

BlueChoice PPO

PPO Benefit Summaries (effective 10/01/2010)  
To view specific details of each Plan, click on the English version, as appropriate. 
100/70% Plans  

PPO Plan G4000SX 
PPO Plan G4001SX 
PPO Plan G4002SX 
PPO Plan G4003SX 
 
90/60% Plans  

PPO Plan G4201SX 
PPO Plan G4202SX 
PPO Plan G4203SX 
PPO Plan G4204SX 
 
80/60% Plans  

PPO Plan G4500SX 
PPO Plan G4501SX 
PPO Plan G4502SX 
PPO Plan G4503SX 
PPO Plan G4504SX 
PPO Plan G4505SX 
PPO Plan G4510SX 
PPO Plan G4511SX 
PPO Plan G4512SX 
PPO Plan G4513SX 
 
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