Standard PPO

 

The Standard PPO plan offers flexibility to see any health care provider you choose. However, when you go to an in-network BlueCross BlueShield provider, you are going to receive services at a negotiated discounted fee.

Coverage at a Glance

Out-of-Pocket Expenses

In-Network

Out-of-Network

Deductible
(At least two individual deductibles must be met to satisfy family deductible)

Individual: $1,000

Family: $2,000 Maximum

Annual Out-of-Pocket Maximum
(Includes deductible)

Individual: $3,000

Family: $6,000

Individual: $4,000

Family: $8,000


 

Benefits

In-Network

Out-of-Network

Coinsurance Paid After Deductible
(Applies to all professional services except those noted below.)

You Pay 20%

You Pay 40%

Office Visit Copays
(Copays do not apply to deductible or out-of-pocket maximum)

You Pay 35%

Subject to Deductible and Coinsurance

Lab work/Professional Services

Subject to Deductible and Coinsurance

Emergency Room Visit Copayment

Subject to Deductible and Coinsurance

Wellness Benefit

100% of In-Network Eligible Charges

Periodic Preventive Services

100% of Eligible Charges – not subject to deductible or maximum

Pre-Existing Condition Exclusion

None

What is a Deductible?

The deductible is the amount you must pay for covered medical services each year before the medical plan begins to pay benefits. The deductibles under the PPO Plans start over each Jan. 1. 

Coverage for an Individual

  • If you elect coverage for yourself, the individual deductible applies to you. You must pay for covered medical services for yourself.

  • The plan will not begin to pay for benefits until you meet the individual deductible.


Coverage for an Individual and One or More Dependents

  • If you elect coverage for yourself and one or more eligible dependents, a family deductible applies to all as a single-family unit.
  • You must pay for covered medical services until any combination of two or more members of your family meet the family deductible.
  • If, however, you pay for covered medical services for any covered member of your family and meet an individual deductible, the plan will start paying for benefits for that covered family member.
  • The individual deductible helps to limit what you have to pay if one person in the family uses more health care than the rest of the family.
  • Any one or more of the other covered family members of your family can meet the rest of the family deductible.  After that, the plan will pay for benefits for the rest of the family members.


 


Benefit Limits

Maximum Lifetime Benefit (unless noted)

Unlimited

Substance Abuse Treatment

Subject to Deductible and Coinsurance

Mental Illness

Subject to Deductible and Coinsurance

Chiropractic

Subject to Deductible and Coinsurance

Hearing Aids

$1,500 every three years per covered person
Subject to Deductible and Coinsurance

Temporomandibular Joint Dysfunction & related disorders

Subject to Deductible and Coinsurance

Physical, Occupational and Speech Therapy

Subject to Deductible and Coinsurance

 

Coverage through Caremark network pharmacy or mail order only

Retail
(30-day supply)

Retail
(90-day supply)

Mail Order
(90-day supply)

Generic Copay

Preferred Brand Copay

Non-Preferred Brand Copay

$10

$35

$60

$30

$105

$180

$20

$90

$150


 

 More Information