BENEFIT PLAN SELECTION (BPS)

BENEFIT PLAN SELECTION (BPS)-ACA SMALL GROUP
Please complete & return this form in its entirety, including the required signatures
Account Information:
Employer Name:
BlueSTAR Account #:
Policy Effective Date:
Policy Anniversary Date:
Health Products / Benefit Plan Selection:
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This Benefit Plan Selection Form is for small group off exchange.
A group may select up to six health plan options.
All deductibles apply to Out of Pocket Maximum (OPX).
GROUP NUMBER:
PPO
Plan ID
Deductible
(In/Out)
CoIns
(In/Out)
P500PPO
$250 / $500
80% / 60%
G515PPO
G511PPO
G516PPO
G510PPO
G517PPO
G512PPO
G509PPO
G513PPO
$500 / $1,000
$1,000 / $2,000
$1,000 / $2,000
$1,500 / $3,000
$1,800 / $3,600
$2,500 / $5,000
$3,250 / $6,500
$4,000 / $8,000
80% / 60%
80% / 60%
80% / 60%
80% / 60%
90% / 70%
90% / 70%
100% / 80%
100% / 80%
S506PPO
S507PPO
S503PPO
S504PPO
S502PPO
S505PPO
$2,000 / $4,000
$2,000 / $4,000
$3,000 / $6,000
$3,500 / $7,000
$6,000 / $12,000
$6,250 / $12,500
70% / 50%
80% / 60%
80% / 60%
80% / 60%
100% / 80%
100% / 80%
B519PPO
B520PPO
$5,000 / $10,000
$6,000 / $12,000
80% / 60%
100% / 80%
Deductible
(In/Out)
CoIns
(In/Out)
OPX
(In/Out)
PCP
Copay
Platinum
$1,250 / $2,500
$25
Gold
$5,000 / $10,000
$40
$3,000 / $6,000
$30
$4,500 / $9,000
$30
$3,500 / $7,000
$10
$4,000 / $8,000
$20
$3,500 / $7,000
90%*
$3,250 / $6,500
$30
$4,000 / $8,000
100%*
Silver
$6,350 / $12,700
$40
$6,000 / $12,000
NA
$6,350 / $12,700
$35
$6,250 / $12,500
80%*
$6,000 / $12,000
$30
$6,250 / $12,500
100%*
Bronze
$6,250 / $12,500
80%*
$6,000 / $12,000
100%*
SPC Copay
ER
Copay
Rx Plan
$45
$300
$0/$10/$35/$75/$150
$60
$50
$50
$60
$40
90%*
$50
100%*
$400
$400
$400
$400
$400
90%*
$400
100%*
$15/$30/$50
$0/$10/$50/$100/$150
$0/$10/$35/$75/$150
$0/$10/$35/$75/$150
$0/$10/$35/$75/$150
90%
$0/$10/$35/$75/$150
100%
$60
NA
$55
80%*
$50
100%*
$500
$500
$500
80%*
$500
100%*
$0/$10/$50/$100/$150
$0/$10/$50/$100/$150
$0/$10/$50/$100/$150
80%
$0/$10/$50/$100/$150
100%
80%*
100%*
80%*
100%*
80%
100%
SPC Copay
ER
Copay
Rx Plan
$50
$60
$50
$400
$400
$400
$0/$10/$50/$100/$150
$0/$10/$35/$75/$150
$0/$10/$35/$75/$150
$60
80%*
$55
$50
$500
$500
$500
$500
$0/$10/$50/$100/$150
$0/$10/$50/$100/$150
$0/$10/$50/$100/$150
$0/$10/$50/$100/$150
80%*
100%*
80%*
100%*
90%/90%/80%/70%/60%
100%
Blue Choice PPO
Plan ID
OPX
(In/Out)
PCP
Copay
Gold
$3,000 / $6,000
$30
$3,500 / $7,000
$10
$3,250 / $6,500
$30
Silver
S506CHC
$2,000 / $4,000
70% / 50%
$6,350 / $12,700
$40
S507CHC
$2,000 / $4,000
80% / 60%
$6,000 / $12,000
80%*
S503CHC
$3,000 / $6,000
80% / 60%
$6,350 / $12,700
$35
S502CHC
$6,000 / $12,000 100% / 80% $6,000 / $12,000
$30
Bronze
B521CHC
$5,000 / $10,000
80% / 60%
$6,250 / $12500
80%*
B520CHC
$6,000 / $12,000 100% / 80% $6,000 / $12,000
100%*
* Indicates a coinsurance percentage instead of a copay amount
G511CHC
G510CHC
G509CHC
$1,000 / $2,000
$1,500 / $3,000
$3,250 / $6,500
80% / 60%
80% / 60%
100% / 80%
Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Fort Dearborn Life Insurance Company® (Downers Grove, IL) in all states
(excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico.
® A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
GA-10-9-SMGRP BPSF HCSC Rev. 01/14
Blue Precision HMO
Plan ID
Deductible
(In)
CoIns
(In)
OPX
(In)
P501PSN
$0
100%
$1500
SPC Copay
ER
Copay
Rx Plan
$25
$45
$300
$0/$10/$50/$100/$150
$30
$50
$400
$0/$10/$50/$100/$150
$30
$50
$500
$0/$10/$50/$100/$150
$25
$100
$600
70%/70%/60%/50%/50%
PCP
Copay
Platinum
Gold
G518PSN
$2,000
80%
$5,000
Silver
S508PSN
$5,000
80%
$6,350
Bronze
B522PSN
$6,000
70%
$6,250
Ancillary Product Selection:
Dental Products
GROUP NUMBER:
Blue Care Dental
Plan ID
DPFH01NATSILO
DPFH05NATSILO
DPFH07NATSILO
Ded
(In/Out)
$25/$75
$25/$25
$25/$25
$25/$75
DPFH10NATSILO
Blue Care Dental for Kids
DPKH01NATSILO
(1A)
High Allocation
Annual
Ortho Type
and Maximum
Max
Ped Only
$1500
INN & OON
Full Ortho
$1500
$1,500
Plan
Type
Plan ID
Active
PPO
Passive
PPO
$2000
Full Ortho
$2,000
Passive
PPO
In:$1250
Out:$1000
Full Ortho
$1,000
Active
PPO
$25/$75
$0
Ped Only
INN & OON
Active
PPO
DPFL01NATSILO
DPFL06NATSILO
DPFL10NATSILO
DPKL01NATSILO
(1B)
Low Allocation
Ded
Annual
Ortho Type
Max
and Maximum
(In/Out)
Ped Only
$75/$75
$1000
INN & OON
Ped Only
$75/$75
$1000
INN & OON
$75/$75
$750
Ped Only
INN & OON
$75/$75
$0
Ped Only
INN & OON
Plan Type
Active
PPO
Passive
PPO
A: Active
PPO
No Maj
C: Active
PPO
Active
PPO
Life Products
GROUP NUMBER:
If Life is a desired benefit, the Group Term Life product must be selected in order to also select Dependent Life and Short Term
Disability.
A. Group Term Life / Accidental Death & Dismemberment (AD&D)
Complete Item D below if Term Life benefits vary by class
Yes
No
Choose a Benefit:
Choose a Reduction Method:
(Only available to groups with 10 or more enrolled lives)
Flat Benefit of $
per Employee
times Basic Annual Salary (rounded to the next higher
multiple of
$1,000, if not already a multiple), up to a Maximum benefit of
$
35% of the original amount at age 65 / 50% of the original amount at age 70
50% of the original amount at age 70
per Employee
(Only applicable to groups with 2 - 9 enrolled lives)
35% of the original amount at age 65/ 50% of the original amount at age 70
75% of the original amount at age 75/ 85% of the original amount at age 80
Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Fort Dearborn Life Insurance Company® (Downers Grove, IL) in all states
(excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico.
® A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
GA-10-9-SMGRP BPSF HCSC Rev. 01/14
Excess Amounts of Life Insurance:
Evidence of Insurability will be required for individual life insurance amounts in excess of $
. Such excess insurance amounts shall become
effective on the date Evidence of Insurability is approved by Fort Dearborn Life Insurance Company. Waiver of Premium, in the event of total disability,
will terminate at age 65 or when no longer disabled, whichever is earlier. Being Actively at Work is a requirement for coverage. If an employee is not
Actively at Work on the day his coverage would otherwise be effective, the effective date of his coverage will be the date of his return to Active Work. If
an employee does not return to Active Work, he will not be covered.
B. Dependent Life
Yes
No
Spouse
Children – age birth to 14 days
Children – age 14
days to 6 months
Children – age 6
months to 26 years /
student 26
$10,000
$0
$100
$5,000
$5,000
$0
$100
$5,000
$5,000
$0
$100
$2,000
Option
1
Choose a Plan:
Option
2
Option
3
C. Short Term Disability (STD)
Yes
Complete Item D below if Short Term Disability benefits vary by class
Benefit will not exceed 66 2/3% of Basic Weekly Salary and is payable for non-occupational disabilities only
No
Choose a Benefit:
Flat $
weekly (not o exceed $250)
Salary Based (select one) 1 / 8 / 13 weeks
1 / 8 / 26 weeks
8 / 8 / 13 weeks
8 / 8 / 26 weeks
50%
60%
66 2/3% of Basic Weekly Salary up to a maximum of $
Choose a Plan: Accident/Sickness/Duration
15 / 15 / 13 weeks
* 31 / 31 / 13 weeks *Only available to groups with 10 or more lives enrolled
15 / 15 / 26 weeks
* 31 / 31 / 26 weeks
D. Classes
Please complete this chart if Term Life or Short Term Disability benefits vary by class (3 Max 2 – 9 lives) (6 Max 10+ lives)
Class Description
Term Life / AD&D
Short Term Disability
Electronic Issuance:
(Non-HMO Health and Dental Plans only) The Policyholder consents to receive, via an electronic file or access to an electronic file, a Certificate
Booklet provided by HCSC to the Policyholder for delivery to each Insured. The Policyholder further agrees that it is solely responsible for providing
each Insured access, via the internet, intranet or otherwise, to the most current version of any electronic file provided by HCSC to the Policyholder and,
upon the Insured’s request, a paper copy of the Certificate Booklet.
Additional Provisions:
Use this section to indicate if the account is retaining any plan(s) not shown above, or need to indicate any other instruction or important information.
Signatures
Employer / Authorized Purchaser
Title
Date
Underwriter
Title
Date
Products and services marketed under the Dearborn National® brand and the star logo are underwritten and/or provided by Fort Dearborn Life Insurance Company® (Downers Grove, IL) in all states
(excluding New York), the District of Columbia, the United States Virgin Islands, the British Virgin Islands, Guam and Puerto Rico.
® A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
GA-10-9-SMGRP BPSF HCSC Rev. 01/14

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