PPO Plan
Plan type: PPO · Network: BlueCross BlueShield · Administrator: BlueCross BlueShield
PPO Plan
Plan Details
HSA Eligible
No
FSA Eligible
Yes
Premiums - PPO Plan
| Coverage Tier | Bi-weekly |
|---|---|
| Employee Only | $159.98 |
| Employee + Spouse | $362.40 |
| Employee + Children | $299.78 |
| Family | $552.04 |
Employee Only
Bi-weekly$159.98
Employee + Spouse
Bi-weekly$362.40
Employee + Children
Bi-weekly$299.78
Family
Bi-weekly$552.04
Deductible, Out-of-Pocket & Coinsurance
| Feature | In-Network | Out-of-Network |
|---|---|---|
| Deductible (Individual) | $2,000 | $4,500 |
| Deductible (Family) | $6,000 | $13,500 |
| Out-of-Pocket Max (Individual) | $6,000 | $9,000 |
| Out-of-Pocket Max (Family) | $12,000 | $18,000 |
| Coinsurance | 80% after deductible (member pays 20%) | 50% after deductible (plus balance billing) |
Deductible (Individual)
In-Network$2,000
Out-of-Network$4,500
Deductible (Family)
In-Network$6,000
Out-of-Network$13,500
Out-of-Pocket Max (Individual)
In-Network$6,000
Out-of-Network$9,000
Out-of-Pocket Max (Family)
In-Network$12,000
Out-of-Network$18,000
Coinsurance
In-Network80% after deductible (member pays 20%)
Out-of-Network50% after deductible (plus balance billing)
Covered Services
| Service | You Pay |
|---|---|
| Preventive Care | 100% Covered |
| Primary Care Visit | $30 copay |
| Specialist Visit | $55 copay |
| Independent Lab | 100% Covered |
| Outpatient X-ray | 100% Covered |
| Imaging | $250 copay per scan |
| Urgent Care | $75 copay |
| Emergency Room | $500 copay |
| Convenience Clinic Visit | $30 copay |
| Teladoc Virtual Visits | No cost |
| Inpatient Hospitalization | 20% after deductible |
| Outpatient Surgery | 20% after deductible |
Preventive Care
You Pay100% Covered
Primary Care Visit
You Pay$30 copay
Specialist Visit
You Pay$55 copay
Independent Lab
You Pay100% Covered
Outpatient X-ray
You Pay100% Covered
Imaging
You Pay$250 copay per scan
Urgent Care
You Pay$75 copay
Emergency Room
You Pay$500 copay
Convenience Clinic Visit
You Pay$30 copay
Teladoc Virtual Visits
You PayNo cost
Inpatient Hospitalization
You Pay20% after deductible
Outpatient Surgery
You Pay20% after deductible
Pharmacy Benefits
| Drug Tier | Retail30-day supply | Mail order90-day supply |
|---|---|---|
| Tier one | $15 | $30 |
| Tier two | $50 | $100 |
| Tier three | $90 | $180 |
| Specialty | $150 | $300 |
Tier one
Retail30-day supply$15
Mail order90-day supply$30
Tier two
Retail30-day supply$50
Mail order90-day supply$100
Tier three
Retail30-day supply$90
Mail order90-day supply$180
Specialty
Retail30-day supply$150
Mail order90-day supply$300
Plan Notes
| Detail | Information |
|---|---|
| Pharmacy Deductible | Not applicable |
| Preventive Medication | Based on tier |
| HSA | Not eligible |
Pharmacy Deductible
InformationNot applicable
Preventive Medication
InformationBased on tier
HSA
InformationNot eligible
Blue Cross Blue Shield
Group: 71-6192N