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Blue Cross and Blue Shield of Illinois
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Trustmark
Plans Marketed for 8/01/2007 Effective Dates and After
PPO Plans - 8/01/07
PPO Plans - 6/01/08
PPO 08 100/70
ChoicePOS 08 100/70
PPO 08 90/60
ChoicePOS 08 90/60
PPO 08 80/50
ChoicePOS 08 80/50
CoverageFirst Plans - 8/01/07
CoverageFirst Plans - 6/01/08
CoverageFirst 08 100/70
CoverageFirst 08 Choice POS 100/70
CoverageFirst 08 80/50
CoverageFirst 08 Choice POS 80/50
High Deductible Health Plans - 8/01/07
High Deductible Health Plans - 6/01/08
HDHP 08 100/70
HDHP 08 Choice POS 100/70
HDHP 08 90/60
HDHP 08 Choice POS 90/60
HDHP 08 80/50
HDHP 08 Choice POS 80/50
HMO
Vision - 6/01/08
HMO Plan 2 Option 72
Vision Optimum
HMO Plan 2 Option 80
Vision Focus
HMO Plan 75 Option 001
Vision Advantage
HMO Plan 75 Option 002
HMO Plan 75 Option 003
Dental - 6/01/08
HMO Plan 75 Option 004
Dental Traditional Preferred
HMO Plan 75 Option 005
Dental PPO
HMO Plan 75 Option 006
Drug Cards
PPO Riders
$10/$20/$40 Rx3 PPO
PPO 24 Hour Coverage
$10/$20/$40/25% Rx4 PPO
PPO 500 Supplemental Accident Rider
$10/$30/$50/25% Rx4 PPO
PPO Deductible Carry-over Rider
$10/$35/$55/25% Rx4 PPO
PPO Vision Plan 471
$30/$20/$10/$0 RxImpact
$5/$15/$35/25% HMO Drug Card
$10/$20/$40/25% HMO Drug Card
$10/$25/$45/25% HMO Drug Card
Plans Marketed Before 7/31/2007
Coverage First PPO 02 100 70
Standard Copay 100 70
Coverage First PPO 02 80 60
Standard Copay 70 50
High Deductible Health Plan 100 70
Standard Copay 80 50
High Deductible Plan 80 50
Standard Copay 90 60
High Deductible Plan 90 60
Standard Copay Value 100 70
HMO Plan 2 Opt 72
Standard Copay Value 80 50
HMO Plan 75 Opt 001
Standard Copay Value 90 60
HMO Plan 75 Opt 002
Standard PCA Coinsurance 100 70
HMO Plan 75 Opt 003
Standard PCA Coinsurance 80 50
HMO Plan 75 Opt 004
Standard PCA Coinsurance 90 60
HMO Plan 75 Opt 005
Standard PCA Coinsurance Value 100 70
HMO Plan 75 Opt 006
Standard PCA Coinsurance Value 90 60
PPO Rx 10-20-40-25
PPO Rx 10-25-45-25
PPO Rx 10-30-50-25
PPO Rx 10-35-55-25
PPO Rx 10-20-40
PPO Rx Impact Grid Sheet