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SummaryofBenefitsandCoverage: …

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018. SM. : Blue Choice Preferred Bronze PPO 201 Two $40 PCP Visits Coverage for: Individual/Family Plan Type: PPO. The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit 2018 or by calling 1-800-538-8833.

Limitations,Exceptions,&OtherImportant Information WhatYouWillPay ServicesYouMayNeed Common MedicalEvent Non-Participating Provider(Youwillpaythe most)

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