Insurance
Insurance Carrier
Blue Cross Blue Shield
PPO
Plan
PPO Select Plus
Member ID
BCB-987654321
Group Number
GRP-12345
Effective Date
Jan 1, 2025
Sarah Johnson
Subscriber
Annual Deductible
$450 used$1,500 total
$1,050 remaining
Out-of-Pocket Maximum
$1,200 used$6,000 total
$4,800 remaining
Copay Summary
Primary Care
$25
Specialist
$40
Urgent Care
$50
Emergency
$150
Coinsurance
80/20 after deductible
After meeting your deductible, your plan pays 80% and you pay 20% of covered services.