INDIVIDUAL COMPREHENSIVE MAJOR MEDICAL PREFERRED PROVIDER QUALIFIED HIGH DEDUCTIBLE HEALTH PLAN SUBSCRIPTION AGREEMENT IDENTIFIED AS MY PREMIER BLUE FLEX PPOIndividual Comprehensive Major Medical Preferred Provider Qualified High Deductible Health Plan Subscription Agreement • October 28th, 2016
DESCRIPTION OF COVERAGE: This Agreement sets forth a comprehensive program of inpatient and outpatient facility, professional and ancillary provider benefits provided at network and out-of-network benefit levels with cost-sharing options such as deductible and coinsurance. Most Services are covered at both network and out-of- network benefit levels. Services received from a network provider are usually provided at a higher benefit level than out-of-network services, and certain services are covered only when they are received from a network provider. This Agreement is designed for individuals who wish to purchase a qualified high deductible health plan for use with a Health Savings Account as defined by the Internal Revenue Service. Network services are limited to the Community Blue Network the PremierBlue Shield Preferred Professional Provider Network, the Highmark Blue Shield Participating Facility Provider Network and/or the Local PPO Network, depending upon where the member receive
