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Documents Grandfathered 2021

Grandfathered Plans 2021

Plan Year:

Benefit Books

Documents	Download
BlueClassic	Benefit Book
BlueEssential	Benefit Book
BlueOptimum	Benefit Book
BluePortfolio	Benefit Book
BluePreferred Basic	Benefit Book
BluePreferred Copay	Benefit Book
BluePreferred Saver	Benefit Book
BlueValue	Benefit Book
ExecuCare	Benefit Book
Individual January	Rider

Summary of Benefits and Coverage (SBC)

The Summary of Benefits and Coverage (SBC) provides a concise description of what services your plan covers along with what you will pay for covered benefits.

Plans	Download
BluePreferred Copay 250	Summary of Benefits
BluePreferred Copay 500	Summary of Benefits
BluePreferred Copay 1000	Summary of Benefits
BluePreferred Copay 1500	Summary of Benefits
BluePreferred Copay 2500	Summary of Benefits
BluePreferred Copay 3500	Summary of Benefits
BluePreferred Copay 5000	Summary of Benefits
BluePreferred Copay 7500	Summary of Benefits
BluePreferred Copay 10000	Summary of Benefits
BluePreferred Copay Portability 500	Summary of Benefits
BluePreferred Copay Portability 1000	Summary of Benefits
BluePreferred Copay Portability 2500	Summary of Benefits
BluePreferred Copay Portability 5000	Summary of Benefits

Plans	Download
BluePreferred Basic 1500	Summary of Benefits
BluePreferred Basic 2500	Summary of Benefits
BluePreferred Basic 3500	Summary of Benefits
BluePreferred Basic 5000	Summary of Benefits
BluePreferred Basic 7500	Summary of Benefits
BluePreferred Basic 10000	Summary of Benefits
BluePreferredBasic Portability 10000	Summary of Benefits

Plans	Download
BluePreferred Saver 1500	Summary of Benefits
BluePreferred Saver 2800	Summary of Benefits
BluePreferred Saver 3500	Summary of Benefits
BluePreferred Saver 5000	Summary of Benefits
BluePreferred Saver Portability 2800	Summary of Benefits
BluePreferred Saver Portability 5000	Summary of Benefits

Plans	Download
BlueClassic 250	Summary of Benefits
BlueClassic 500	Summary of Benefits
BlueClassic 750	Summary of Benefits
BlueClassic 1250	Summary of Benefits
BlueClassic 2500	Summary of Benefits
BlueClassic 5000	Summary of Benefits
BlueClassic Portability 5000	Summary of Benefits

Plans	Download
ExecuCare 500	Summary of Benefits
ExecuCare 1000	Summary of Benefits
ExecuCare 1250	Summary of Benefits
ExecuCare 1500	Summary of Benefits
ExecuCare 2500	Summary of Benefits
ExecuCare 5000	Summary of Benefits

Plans	Download
BlueOptimum 250	Summary of Benefits
BlueOptimum 500	Summary of Benefits
BlueOptimum 1000	Summary of Benefits
BlueOptimum 2000	Summary of Benefits
BlueOptimum 3000	Summary of Benefits
BlueOptimum 5000	Summary of Benefits
BlueOptimum 7500	Summary of Benefits
BlueOptimum 10000	Summary of Benefits

Plans	Download
BlueValue 250	Summary of Benefits
BlueValue 500	Summary of Benefits
BlueValue 1000	Summary of Benefits
BlueValue 2000	Summary of Benefits
BlueValue 3000	Summary of Benefits
BlueValue 5000	Summary of Benefits
BlueValue 7500	Summary of Benefits
BlueValue 10000	Summary of Benefits
BlueValue Portability 2000	Summary of Benefits

Plans	Download
BlueEssential 1000	Summary of Benefits
BlueEssential 2000	Summary of Benefits
BlueEssential 3000	Summary of Benefits
BlueEssential 5000	Summary of Benefits
BlueEssential 7500	Summary of Benefits
BlueEssential 10000	Summary of Benefits

Plans Download
BluePortfolio 1750
Summary of Benefits
BluePortfolio 3000
Summary of Benefits
BluePortfolio 5500
Summary of Benefits