Blue Cross OnePlan PPO
Summary of Medical Benefits for EOC

Covered Benefit	Blue Cross OnePlan PPO
	In-Network Providers	Out-of-Network Providers
Lifetime Maximum	$5,000,000
Deductible	None	$250 (max 3 for family)
Office Visit	$10 co-pay (ded. Waived)	30% of cov’d expense
Hospitalization	10%	$500/Admit + 30%
Outpatient Surgery	10%	30% of cov’d expense ($350 / day limit)
Diagnostic X-Ray & Lab	10%	30% of cov’d expense
Hospital Emergency Room	$100 ded. + 10%	$100 ded. + 10% (1st 48 hrs.)
Chiropractic Care	10% (24 visits / yr)	30% ($25 limit-24 visits / yr)
Prescription Drugs	$10 Generic / $20 Brand / 50% Non Formulary	See plan brochure
Out-of-Pocket Maximums	$2,000 per member	$10,000 per member