| 19636LA0240010 |
Blue Connect 80/60 $3400 (L) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240010 |
Blue Connect 80/60 $3400 (L) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240007 |
Blue Connect 80/60 $3400 (N) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240007 |
Blue Connect 80/60 $3400 (N) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240013 |
Blue Connect 80/60 $3400 (S) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240013 |
Blue Connect 80/60 $3400 (S) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240027 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 50/50 $7500 Standardized Plan (L) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240027 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 50/50 $7500 Standardized Plan (L) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240026 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 50/50 $7500 Standardized Plan (N) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240026 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 50/50 $7500 Standardized Plan (N) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240028 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 50/50 $7500 Standardized Plan (S) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240028 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 50/50 $7500 Standardized Plan (S) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240024 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 60/40 $5000 Standardized Plan (L) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240024 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 60/40 $5000 Standardized Plan (L) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240023 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 60/40 $5000 Standardized Plan (N) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240023 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 60/40 $5000 Standardized Plan (N) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240025 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 60/40 $5000 Standardized Plan (S) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240025 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 60/40 $5000 Standardized Plan (S) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240021 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 75/55 $1500 Standardized Plan (L) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240021 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 75/55 $1500 Standardized Plan (L) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240020 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 75/55 $1500 Standardized Plan (N) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240020 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 75/55 $1500 Standardized Plan (N) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240022 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 75/55 $1500 Standardized Plan (S) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240022 |
Blue Connect Copay (PCP, Specialist, Urgent Care) 75/55 $1500 Standardized Plan (S) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0220012 |
Blue POS 60/40 $6500 |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0220012 |
Blue POS 60/40 $6500 |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0220013 |
Blue POS 70/50 $4550 |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0220013 |
Blue POS 70/50 $4550 |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0220014 |
Blue POS 80/60 $3400 |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0220014 |
Blue POS 80/60 $3400 |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0220017 |
Blue POS Copay 50/50 $7500 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0220017 |
Blue POS Copay 50/50 $7500 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0220018 |
Blue POS Copay 60/40 $5900 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0220018 |
Blue POS Copay 60/40 $5900 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0220019 |
Blue POS Copay 75/55 $1500 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0220019 |
Blue POS Copay 75/55 $1500 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0220005 |
Blue POS Copay 80/60 $1000 |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0220005 |
Blue POS Copay 80/60 $1000 |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0230008 |
Community Blue 80/60 $3400 |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0230008 |
Community Blue 80/60 $3400 |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0230011 |
Community Blue Copay (PCP, Specialist, Urgent Care) 50/50 $7500 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0230011 |
Community Blue Copay (PCP, Specialist, Urgent Care) 50/50 $7500 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0230010 |
Community Blue Copay (PCP, Specialist, Urgent Care) 60/40 $5000 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0230010 |
Community Blue Copay (PCP, Specialist, Urgent Care) 60/40 $5000 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0230009 |
Community Blue Copay (PCP, Specialist, Urgent Care) 75/55 $1500 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0230009 |
Community Blue Copay (PCP, Specialist, Urgent Care) 75/55 $1500 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0610005 |
Precision Blue 80/60 $3400 (BR) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0610005 |
Precision Blue 80/60 $3400 (BR) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0610010 |
Precision Blue 80/60 $3400 (M) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0610010 |
Precision Blue 80/60 $3400 (M) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0610015 |
Precision Blue Copay (PCP, Specialist, Urgent Care) 50/50 $7500 Standardized Plan (BR) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0610015 |
Precision Blue Copay (PCP, Specialist, Urgent Care) 50/50 $7500 Standardized Plan (BR) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0610016 |
Precision Blue Copay (PCP, Specialist, Urgent Care) 50/50 $7500 Standardized Plan (M) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0610016 |
Precision Blue Copay (PCP, Specialist, Urgent Care) 50/50 $7500 Standardized Plan (M) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0610013 |
Precision Blue Copay (PCP, Specialist, Urgent Care) 60/40 $5000 Standardized Plan (BR) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0610013 |
Precision Blue Copay (PCP, Specialist, Urgent Care) 60/40 $5000 Standardized Plan (BR) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0610014 |
Precision Blue Copay (PCP, Specialist, Urgent Care) 60/40 $5000 Standardized Plan (M) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0610014 |
Precision Blue Copay (PCP, Specialist, Urgent Care) 60/40 $5000 Standardized Plan (M) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0610011 |
Precision Blue Copay (PCP, Specialist, Urgent Care) 75/55 $1500 Standardized Plan (BR) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0610011 |
Precision Blue Copay (PCP, Specialist, Urgent Care) 75/55 $1500 Standardized Plan (BR) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0610012 |
Precision Blue Copay (PCP, Specialist, Urgent Care) 75/55 $1500 Standardized Plan (M) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0610012 |
Precision Blue Copay (PCP, Specialist, Urgent Care) 75/55 $1500 Standardized Plan (M) |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0590003 |
Signature Blue 80/60 $3400 |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0590003 |
Signature Blue 80/60 $3400 |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0590007 |
Signature Blue Copay (PCP, Specialist, Urgent Care) 50/50 $7500 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0590007 |
Signature Blue Copay (PCP, Specialist, Urgent Care) 50/50 $7500 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0590006 |
Signature Blue Copay (PCP, Specialist, Urgent Care) 60/40 $5000 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0590006 |
Signature Blue Copay (PCP, Specialist, Urgent Care) 60/40 $5000 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0590005 |
Signature Blue Copay (PCP, Specialist, Urgent Care) 75/55 $1500 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0590005 |
Signature Blue Copay (PCP, Specialist, Urgent Care) 75/55 $1500 Standardized Plan |
2025 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 10, 2024 |
| 19636LA0240011 |
Blue Connect 70/50 $4550 (L) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240011 |
Blue Connect 70/50 $4550 (L) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240019 |
Blue Connect 70/50 $4550 (N) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240019 |
Blue Connect 70/50 $4550 (N) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240014 |
Blue Connect 70/50 $4550 (S) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240014 |
Blue Connect 70/50 $4550 (S) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240010 |
Blue Connect 80/60 $3400 (L) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240010 |
Blue Connect 80/60 $3400 (L) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240007 |
Blue Connect 80/60 $3400 (N) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240007 |
Blue Connect 80/60 $3400 (N) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240013 |
Blue Connect 80/60 $3400 (S) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240013 |
Blue Connect 80/60 $3400 (S) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240009 |
Blue Connect Copay 70/50 $2900 (L) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240009 |
Blue Connect Copay 70/50 $2900 (L) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240012 |
Blue Connect Copay 70/50 $2900 (S) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240012 |
Blue Connect Copay 70/50 $2900 (S) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240017 |
Blue Connect Copay 80/60 $1000 (L) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240017 |
Blue Connect Copay 80/60 $1000 (L) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240002 |
Blue Connect Copay 80/60 $1000 (N) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240002 |
Blue Connect Copay 80/60 $1000 (N) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240018 |
Blue Connect Copay 80/60 $1000 (S) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240018 |
Blue Connect Copay 80/60 $1000 (S) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0220012 |
Blue POS 60/40 $6500 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0220012 |
Blue POS 60/40 $6500 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0220013 |
Blue POS 70/50 $4550 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0220013 |
Blue POS 70/50 $4550 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0220014 |
Blue POS 80/60 $3400 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0220014 |
Blue POS 80/60 $3400 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0220017 |
Blue POS Copay 50/50 $7500 Standardized Plan |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0220017 |
Blue POS Copay 50/50 $7500 Standardized Plan |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0220007 |
Blue POS Copay 60/40 $4300 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0220007 |
Blue POS Copay 60/40 $4300 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0220018 |
Blue POS Copay 60/40 $5900 Standardized Plan |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0220018 |
Blue POS Copay 60/40 $5900 Standardized Plan |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0220019 |
Blue POS Copay 75/55 $1500 Standardized Plan |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0220019 |
Blue POS Copay 75/55 $1500 Standardized Plan |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0220005 |
Blue POS Copay 80/60 $1000 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0220005 |
Blue POS Copay 80/60 $1000 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0230006 |
Community Blue 70/50 $4550 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0230006 |
Community Blue 70/50 $4550 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0230008 |
Community Blue 80/60 $3400 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0230008 |
Community Blue 80/60 $3400 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0230002 |
Community Blue Copay 80/60 $1000 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0230002 |
Community Blue Copay 80/60 $1000 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0610002 |
Precision Blue 70/50 $4550 (BR) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0610002 |
Precision Blue 70/50 $4550 (BR) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0610007 |
Precision Blue 70/50 $4550 (M) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0610007 |
Precision Blue 70/50 $4550 (M) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0610005 |
Precision Blue 80/60 $3400 (BR) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0610005 |
Precision Blue 80/60 $3400 (BR) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0610010 |
Precision Blue 80/60 $3400 (M) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0610010 |
Precision Blue 80/60 $3400 (M) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0610006 |
Precision Blue copay 70/50 $2900 (M) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0610006 |
Precision Blue copay 70/50 $2900 (M) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0610003 |
Precision Blue Copay 80/60 $1000 (BR) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0610003 |
Precision Blue Copay 80/60 $1000 (BR) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0610008 |
Precision Blue Copay 80/60 $1000 (M) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0610008 |
Precision Blue Copay 80/60 $1000 (M) |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0590003 |
Signature Blue 80/60 $3400 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0590003 |
Signature Blue 80/60 $3400 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0590001 |
Signature Blue Copay 80/60 $1000 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0590001 |
Signature Blue Copay 80/60 $1000 |
2024 |
NOT APPLICABLE [PCP] [Dentist]
|
Oct 27, 2023 |
| 19636LA0240011 |
Blue Connect 70/50 $4550 (L) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240011 |
Blue Connect 70/50 $4550 (L) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240014 |
Blue Connect 70/50 $4550 (S) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240014 |
Blue Connect 70/50 $4550 (S) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240010 |
Blue Connect 80/60 $3400 (L) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240010 |
Blue Connect 80/60 $3400 (L) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240007 |
Blue Connect 80/60 $3400 (N) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240007 |
Blue Connect 80/60 $3400 (N) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240013 |
Blue Connect 80/60 $3400 (S) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240013 |
Blue Connect 80/60 $3400 (S) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240009 |
Blue Connect Copay 70/50 $3000 (L) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240009 |
Blue Connect Copay 70/50 $3000 (L) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240003 |
Blue Connect Copay 70/50 $3000 (N) |
2023 |
LAN006
|
Sep 16, 2022 |
| 19636LA0240012 |
Blue Connect Copay 70/50 $3000 (S) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240012 |
Blue Connect Copay 70/50 $3000 (S) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240017 |
Blue Connect Copay 80/60 $1000 (L) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240017 |
Blue Connect Copay 80/60 $1000 (L) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240002 |
Blue Connect Copay 80/60 $1000 (N) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240002 |
Blue Connect Copay 80/60 $1000 (N) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240018 |
Blue Connect Copay 80/60 $1000 (S) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240018 |
Blue Connect Copay 80/60 $1000 (S) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0220016 |
Blue POS 100/100 $9100 Standardized Plan |
2023 |
LAN005
|
Sep 16, 2022 |
| 19636LA0220012 |
Blue POS 60/40 $6500 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0220012 |
Blue POS 60/40 $6500 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0220013 |
Blue POS 70/50 $4550 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0220013 |
Blue POS 70/50 $4550 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0220014 |
Blue POS 80/60 $3400 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0220014 |
Blue POS 80/60 $3400 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0220010 |
Blue POS 90/70 $3500 |
2023 |
LAN005
|
Sep 16, 2022 |
| 19636LA0220017 |
Blue POS Copay 50/50 $7900 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0220017 |
Blue POS Copay 50/50 $7900 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0220007 |
Blue POS Copay 60/40 $4300 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0220007 |
Blue POS Copay 60/40 $4300 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0220018 |
Blue POS Copay 60/40 $5800 Standardized Plan |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0220018 |
Blue POS Copay 60/40 $5800 Standardized Plan |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0220019 |
Blue POS Copay 75/55 $2000 Standardized Plan |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0220019 |
Blue POS Copay 75/55 $2000 Standardized Plan |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0220005 |
Blue POS Copay 80/60 $1000 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0220005 |
Blue POS Copay 80/60 $1000 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0230006 |
Community Blue 70/50 $4550 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0230006 |
Community Blue 70/50 $4550 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0230008 |
Community Blue 80/60 $3400 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0230008 |
Community Blue 80/60 $3400 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0230003 |
Community Blue copay 70/50 $3000 |
2023 |
LAN007
|
Sep 16, 2022 |
| 19636LA0230002 |
Community Blue Copay 80/60 $1000 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0230002 |
Community Blue Copay 80/60 $1000 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0610002 |
Precision Blue 70/50 $4550 (BR) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0610002 |
Precision Blue 70/50 $4550 (BR) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0610007 |
Precision Blue 70/50 $4550 (M) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0610007 |
Precision Blue 70/50 $4550 (M) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0610005 |
Precision Blue 80/60 $3400 (BR) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0610005 |
Precision Blue 80/60 $3400 (BR) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0610010 |
Precision Blue 80/60 $3400 (M) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0610010 |
Precision Blue 80/60 $3400 (M) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0610001 |
Precision Blue copay 70/50 $3100 (BR) |
2023 |
LAN009
|
Sep 16, 2022 |
| 19636LA0610006 |
Precision Blue copay 70/50 $3100 (M) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0610006 |
Precision Blue copay 70/50 $3100 (M) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0610003 |
Precision Blue Copay 80/60 $1000 (BR) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0610003 |
Precision Blue Copay 80/60 $1000 (BR) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0610008 |
Precision Blue Copay 80/60 $1000 (M) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0610008 |
Precision Blue Copay 80/60 $1000 (M) |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0590003 |
Signature Blue 80/60 $3400 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0590003 |
Signature Blue 80/60 $3400 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0590002 |
Signature Blue Copay 70/50 $3000 |
2023 |
LAN008
|
Sep 16, 2022 |
| 19636LA0590001 |
Signature Blue Copay 80/60 $1000 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0590001 |
Signature Blue Copay 80/60 $1000 |
2023 |
NOT APPLICABLE [PCP] [Dentist]
|
Sep 16, 2022 |
| 19636LA0240011 |
Blue Connect 70/50 $4550 (L) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240011 |
Blue Connect 70/50 $4550 (L) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240014 |
Blue Connect 70/50 $4550 (S) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240014 |
Blue Connect 70/50 $4550 (S) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240010 |
Blue Connect 80/60 $3400 (L) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240010 |
Blue Connect 80/60 $3400 (L) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240007 |
Blue Connect 80/60 $3400 (N) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240007 |
Blue Connect 80/60 $3400 (N) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240013 |
Blue Connect 80/60 $3400 (S) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240013 |
Blue Connect 80/60 $3400 (S) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240009 |
Blue Connect Copay 70/50 $2800 (L) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240009 |
Blue Connect Copay 70/50 $2800 (L) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240003 |
Blue Connect Copay 70/50 $2800 (N) |
2022 |
LAN006
|
Aug 19, 2021 |
| 19636LA0240012 |
Blue Connect Copay 70/50 $2800 (S) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240012 |
Blue Connect Copay 70/50 $2800 (S) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240017 |
Blue Connect Copay 80/60 $1000 (L) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240017 |
Blue Connect Copay 80/60 $1000 (L) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240002 |
Blue Connect Copay 80/60 $1000 (N) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240002 |
Blue Connect Copay 80/60 $1000 (N) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240018 |
Blue Connect Copay 80/60 $1000 (S) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0240018 |
Blue Connect Copay 80/60 $1000 (S) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0220010 |
Blue POS 100/80 $3500 |
2022 |
LAN005
|
Aug 19, 2021 |
| 19636LA0220012 |
Blue POS 60/40 $6500 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0220012 |
Blue POS 60/40 $6500 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0220013 |
Blue POS 70/50 $4550 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0220013 |
Blue POS 70/50 $4550 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0220014 |
Blue POS 80/60 $3400 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0220014 |
Blue POS 80/60 $3400 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0220007 |
Blue POS Copay 60/40 $4300 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0220007 |
Blue POS Copay 60/40 $4300 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0220005 |
Blue POS Copay 80/60 $1000 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0220005 |
Blue POS Copay 80/60 $1000 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0230006 |
Community Blue 70/50 $4550 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0230006 |
Community Blue 70/50 $4550 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0230003 |
Community Blue copay 70/50 $2800 |
2022 |
LAN007
|
Aug 19, 2021 |
| 19636LA0230002 |
Community Blue Copay 80/60 $1000 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0230002 |
Community Blue Copay 80/60 $1000 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0610002 |
Precision Blue 70/50 $4550 (BR) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0610002 |
Precision Blue 70/50 $4550 (BR) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0610007 |
Precision Blue 70/50 $4550 (M) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0610007 |
Precision Blue 70/50 $4550 (M) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0610005 |
Precision Blue 80/60 $3400 (BR) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0610005 |
Precision Blue 80/60 $3400 (BR) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0610010 |
Precision Blue 80/60 $3400 (M) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0610010 |
Precision Blue 80/60 $3400 (M) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0610001 |
Precision Blue copay 70/50 $2900 (BR) |
2022 |
LAN009
|
Aug 19, 2021 |
| 19636LA0610006 |
Precision Blue copay 70/50 $2900 (M) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0610006 |
Precision Blue copay 70/50 $2900 (M) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0610003 |
Precision Blue Copay 80/60 $1000 (BR) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0610003 |
Precision Blue Copay 80/60 $1000 (BR) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0610008 |
Precision Blue Copay 80/60 $1000 (M) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0610008 |
Precision Blue Copay 80/60 $1000 (M) |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0590003 |
Signature Blue 80/60 $3400 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0590003 |
Signature Blue 80/60 $3400 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0590002 |
Signature Blue Copay 70/50 $2800 |
2022 |
LAN008
|
Aug 19, 2021 |
| 19636LA0590001 |
Signature Blue Copay 80/60 $1000 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
| 19636LA0590001 |
Signature Blue Copay 80/60 $1000 |
2022 |
NOT APPLICABLE [PCP] [Dentist]
|
Aug 19, 2021 |
