Blue Cross small group plan Comparison - Dual Choice Grid Effective October 1, 2010 
Select from 27 dual-choice options for flexible plan pairings
Employers with 5 or more active enrolled employees and a table rating lower than 12 may offer dual-choice coverage. • Dual-choice options must match the grid below.
• Each benefit plan must include at least one contract.
• A maximum of two plan offerings per small group.
• Health plan(s) can only be changed at renewal.
• Only the plans listed below are available for dual choice.
Health plan name Aware Gold with copay CMM with $25 copay CMM $300 CMM $500 CMM $750 CMM $1,000 CMM $2,000 Blue Value $1,500 Blue Value $2,500 Options Blue 100 HSA $1,600/$3,200 Options Blue 100 HSA $2,100/$4,200 Options Blue 100 HSA $3,000/$6,000 Emb Ded Options Blue 80 HSA $3,000/$6,000 Emb Ded
  Plan # 4 113 118 120 121 122 123 131 132 176 178 181 175
Aware Gold with copay 4       •   •   •   •     •
CMM with $25 copay 113           •   • •   •   •
CMM $300 118             •   • • • •  
CMM $500 120 •           •     • •   •
CMM $750 121             • •   • •   •
CMM $1,000 122 • •             •   • •  
CMM $2,000 123     • • •             • •
Blue Value $1,500 131 • •     •               •
Blue Value$2,500 132   • •     •       •   •  
Options Blue 100 HSA $1,600/$3,200 176 •   • • •       •        
Options Blue 100 HSA $2,100/$4,200 178   • • • • •              
Options Blue 100 HSA $3,000/$6,000 Emb Ded 181     • •   • •   •        
Options Blue 80 HSA $3,000/$6,000 Emb Ded 175 • •     •   • •