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Documents Grandfathered 2022

Grandfathered Plans 2022

Plan Year:

Benefit Books

Documents	Download
BlueClassic	Benefit Book (Opens in a new tab)
BlueEssential	Benefit Book (Opens in a new tab)
BlueOptimum	Benefit Book (Opens in a new tab)
BluePortfolio	Benefit Book (Opens in a new tab)
BluePreferred Basic	Benefit Book (Opens in a new tab)
BluePreferred Copay	Benefit Book (Opens in a new tab)
BluePreferred Saver	Benefit Book (Opens in a new tab)
BlueValue	Benefit Book (Opens in a new tab)
ExecuCare	Benefit Book (Opens in a new tab)
PPO January	Rider (Opens in a new tab)

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 (Opens in a new tab)
BluePreferred Copay 500	Summary of Benefits (Opens in a new tab)
BluePreferred Copay 1000	Summary of Benefits (Opens in a new tab)
BluePreferred Copay 1500	Summary of Benefits (Opens in a new tab)
BluePreferred Copay 2500	Summary of Benefits (Opens in a new tab)
BluePreferred Copay 3500	Summary of Benefits (Opens in a new tab)
BluePreferred Copay 5000	Summary of Benefits (Opens in a new tab)
BluePreferred Copay 7500	Summary of Benefits (Opens in a new tab)
BluePreferred Copay 10000	Summary of Benefits (Opens in a new tab)
BluePreferred Copay Portability 500	Summary of Benefits (Opens in a new tab)
BluePreferred Copay Portability 1000	Summary of Benefits (Opens in a new tab)
BluePreferred Copay Portability 2500	Summary of Benefits (Opens in a new tab)
BluePreferred Copay Portability 5000	Summary of Benefits (Opens in a new tab)

Plans	Download
BluePreferred Basic 1500	Summary of Benefits (Opens in a new tab)
BluePreferred Basic 2500	Summary of Benefits (Opens in a new tab)
BluePreferred Basic 3500	Summary of Benefits (Opens in a new tab)
BluePreferred Basic 5000	Summary of Benefits (Opens in a new tab)
BluePreferred Basic 7500	Summary of Benefits (Opens in a new tab)
BluePreferred Basic 10000	Summary of Benefits (Opens in a new tab)
BluePreferredBasic Portability 10000	Summary of Benefits (Opens in a new tab)

Plans	Download
BluePreferred Saver 1500	Summary of Benefits (Opens in a new tab)
BluePreferred Saver 2800	Summary of Benefits (Opens in a new tab)
BluePreferred Saver 3500	Summary of Benefits (Opens in a new tab)
BluePreferred Saver 5000	Summary of Benefits (Opens in a new tab)
BluePreferred Saver Portability 2800	Summary of Benefits (Opens in a new tab)
BluePreferred Saver Portability 5000	Summary of Benefits (Opens in a new tab)

Plans	Download
BlueClassic 250	Summary of Benefits (Opens in a new tab)
BlueClassic 500	Summary of Benefits (Opens in a new tab)
BlueClassic 750	Summary of Benefits (Opens in a new tab)
BlueClassic 1250	Summary of Benefits (Opens in a new tab)
BlueClassic 2500	Summary of Benefits (Opens in a new tab)
BlueClassic 5000	Summary of Benefits (Opens in a new tab)
BlueClassic Portability 5000	Summary of Benefits (Opens in a new tab)

Plans	Download
ExecuCare 500	Summary of Benefits (Opens in a new tab)
ExecuCare 1000	Summary of Benefits (Opens in a new tab)
ExecuCare 1250	Summary of Benefits (Opens in a new tab)
ExecuCare 1500	Summary of Benefits (Opens in a new tab)
ExecuCare 2500	Summary of Benefits (Opens in a new tab)
ExecuCare 5000	Summary of Benefits (Opens in a new tab)

Plans	Download
BlueOptimum 250	Summary of Benefits (Opens in a new tab)
BlueOptimum 500	Summary of Benefits (Opens in a new tab)
BlueOptimum 1000	Summary of Benefits (Opens in a new tab)
BlueOptimum 2000	Summary of Benefits (Opens in a new tab)
BlueOptimum 3000	Summary of Benefits (Opens in a new tab)
BlueOptimum 5000	Summary of Benefits (Opens in a new tab)
BlueOptimum 7500	Summary of Benefits (Opens in a new tab)
BlueOptimum 10000	Summary of Benefits (Opens in a new tab)

Plans	Download
BlueValue 250	Summary of Benefits (Opens in a new tab)
BlueValue 500	Summary of Benefits (Opens in a new tab)
BlueValue 1000	Summary of Benefits (Opens in a new tab)
BlueValue 2000	Summary of Benefits (Opens in a new tab)
BlueValue 3000	Summary of Benefits (Opens in a new tab)
BlueValue 5000	Summary of Benefits (Opens in a new tab)
BlueValue 7500	Summary of Benefits (Opens in a new tab)
BlueValue 10000	Summary of Benefits (Opens in a new tab)
BlueValue Portability 2000	Summary of Benefits (Opens in a new tab)

Plans	Download
BlueEssential 1000	Summary of Benefits (Opens in a new tab)
BlueEssential 2000	Summary of Benefits (Opens in a new tab)
BlueEssential 3000	Summary of Benefits (Opens in a new tab)
BlueEssential 5000	Summary of Benefits (Opens in a new tab)
BlueEssential 7500	Summary of Benefits (Opens in a new tab)
BlueEssential 10000	Summary of Benefits (Opens in a new tab)

Plans Download
BluePortfolio 1750
Summary of Benefits (Opens in a new tab)
BluePortfolio 3000
Summary of Benefits (Opens in a new tab)
BluePortfolio 5500
Summary of Benefits (Opens in a new tab)