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Transitional Plans 2025

Plan Year:

Pharmacy

DOCUMENTSDOWNLOAD/ACCESS
3 & 4 Tier Standard Plans
Coinsurance & Brand-Generic Standard Plans

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.

PlansDownload
BluePortfolio Plus 70% 1750
BluePortfolio Plus 70% 3500
BluePortfolio Plus 80% 3500
BluePortfolio Plus 90% 1750
BluePortfolio Plus 100% 3500
BluePortfolio Plus 100% 5500

Benefit Books

DOCUMENTSDOWNLOAD
Individual PPO
Individual PPO Rider

BlueOptimum Plus PPO 250 80
BlueOptimum Plus PPO 500 80
BlueOptimum Plus PPO 1000 80
BlueOptimum Plus PPO 2000 80
BlueOptimum Plus PPO 3000 80
BlueOptimum Plus PPO 5000 80
BlueOptimum Plus PPO 7500 80
BlueOptimum Plus PPO 10000 80

BlueValue Plus PPO 500 70
BlueValue Plus PPO 1000 70
BlueValue Plus PPO 2000 70
BlueValue Plus PPO 3000 70
BlueValue Plus PPO 5000 70
BlueValue Plus PPO 7500 70
BlueValue Plus PPO 10000 70

BlueBasic Plus PPO 500 80
BlueBasic Plus PPO 1000 80
BlueBasic Plus PPO 2000 80
BlueBasic Plus PPO 3000 80
BlueBasic Plus PPO 5000 80
BlueBasic Plus PPO 7500 80
BlueBasic Plus PPO 10000 80

BlueEssential Plus PPO 500 60
BlueEssential Plus PPO 1000 60
BlueEssential Plus PPO 2000 60
BlueEssential Plus PPO 3000 60
BlueEssential Plus PPO 5000 60
BlueEssential Plus PPO 7500 60
BlueEssential Plus PPO 10000 60

BluePortfolio Plus PPO 1750 70
BluePortfolio Plus PPO 3500 70
BluePortfolio Plus PPO 3500 80
BluePortfolio Plus PPO 1750 90
BluePortfolio Plus PPO 3500 100
BluePortfolio Plus PPO 5500 100