Individual Major Medical, Outline of Coverage
BlueCross BlueShield BlueChoice PPO Plan
Within our network of 9,300 physicians, you'll find a wide
choice of physicians and hospitals to serve you. And, depending
on the plan you choose, the cost you pay for many services
are low and fixed, making budgeting for health care expenses
easier for you. For example, with the $250, $500, $1,0001,
and $1,5001 deductible plans,
you will only pay a low copayment for office visits to in-network
providers.
$20 Office Visits* Visits to BlueChoice PPO preferred
or participating physicians cost just $20, with NO deductible.
$20 Specialist Visits* Visits to BlueChoice PPO
preferred or participating physician specialists cost just
$20, with NO deductible.
$50 Emergency Room Visits For emergency care, you'll
pay just $50 for a life-threatening emergency, and this
charge is waived if you are admitted to the hospital.
$200 Maternity Care* The cost of having a child
can truly be astronomical. But with BlueChoice PPO, the
cost is fixed—just $200 for prenatal, postnatal and
physician delivery charges. There's NO need to worry about
surprise bills. (Family Contracts Only)
Lifetime protection up to $5 million - Like a traditional
health plan, in-network hospitalization is paid at 80% after
you satisfy your annual deductible and until you reach your
annual out-of-pocket limit. Then BlueChoice PPO pays 100%
of all covered charges in-network—up to a maximum lifetime
benefit of $5,000,000. (You must obtain pre-certification
before being admitted to the hospital and for certain outpatient
procedures.) Hospitalization is always paid at 60% when you
use out-of-network providers and pre-certification is required
for both admission to the hospital and certain outpatient
procedures.
Choose any physician or hospital outside the network
- BlueChoice PPO gives you the freedom to see any physician,
specialist or hospital—anywhere! So if you need specialized
care in another part of the country, get it. You're covered.
When you receive health care services from a BlueChoice
PPO network provider, you'll never file a claim. That means
there's virtually NO paperwork. And that takes the hassle
out of health care coverage.
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This plan pays for Preventive Health Care Services!
If you select our $250 or $500 deductible plans, you'll only
pay a $20 office visit copayment, per visit, when services
are performed in a BlueChoice PPO physician's office. With
our other deductible plans, you'll only pay 20% of covered
charges, after your deductible. It's that simple! Covered
services include: routine well-baby care, immunizations, annual
gynecological exams, mammograms, Pap smears, flu shots, prostate
screening, and more.
A choice of deductibles helps you control your monthly
premiums. BlueChoice PPO lets you choose among six different
deductible options. ("Deductible" is the amount
you pay before your BlueChoice PPO benefits begin.) The higher
the deductible you choose, the lower your premiums will be.
All plans have a $2,000 out-of-pocket limit for in-network
health care. (Out-of-pocket limit is the maximum you will
have to pay each benefit period after your deductible has
been satisfied.)
Note: All health care services for which you must pay
a copayment are NOT subject to the deductible. All other benefits
are subject to the deductible, unless otherwise stated.
Choosing a higher deductible will lower your monthly plan
premium.
| |
Plan 1 |
Plan 2 |
Plan 3 |
Plan 4 |
Plan 5 |
Plan 6 |
| Deductible |
$250 |
$500 |
$1,000 |
$1,500 |
$2,500 |
$5,000 |
| Out-of-Pocket Limit |
$2,000 |
$2,000 |
$2,000 |
$2,000 |
$2,000 |
$2,000 |
The $250, $500, $1,0001
and $1,5001 deductible plans
have an in-network office copayment feature. When you visit
a network physician, you'll pay just a $20 copayment. On the
other deductible plans, office visits and all other services
are subject to the deductible and coinsurance.
You may want to consider the Consumer Choice version of
our PPO. We also offer a Consumer Choice version of our
PPO at a higher premium. Under this plan, members may nominate
an out-of-network physician or hospital to act as though they
were part of the network. Benefits for service provided by
a nominated and approved provider will be the same as for
providers inside the network.
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| Benefits
at a Glance: |
| BlueChoice PPO Plan |
250 |
500 |
1000 |
1500 |
2500 |
5000 |
| |
| Lifetime Maximum |
$5,000,000 |
| |
| Deductible |
$250 |
$500 |
$1,000 |
$1,500 |
$2,500 |
$5,000 |
| |
| Coinsurance |
| In-Network |
Plan
pays 80% |
| Out-of-Network |
Plan
pays 60% |
| |
| Out-of-pocket
Limit |
| In-Network |
$2,000 |
| Out-of-Network |
No
out-of-pocket maximum |
| |
| Office
Visits |
| In-Network |
$20
office visit copay |
$20
copay; after 4 copays, plan pays 80% |
Plan
pays 80% |
| Out-of-Network |
Plan
pays 60% |
| |
| Preventive care through
age 5 |
$20
office visit copay |
Plan
pays 80% of covered charges, deductible waived |
| |
| Preventive care for
adults |
$20
office visit copay |
Plan
pays 80% of covered charges |
| |
| Lab/X-ray |
| In-Network |
Plan
pays 80% |
| Out-of-Network |
Plan
pays 80% |
| |
| Hospital-Based Physicians |
Plan
pays 80% in network; 60% out-of-network |
| |
| Maternity2
Family Contracts Only |
| In-Network |
Physician: $200 copay
Hospital: plan pays 80% |
Plan pays 80% |
Not covered |
| Out-of-Network |
Plan pays 60% |
Not covered |
| |
| Outpatient Facility |
| In-Network |
Plan pays 80% |
| Out-of-Network |
Plan pays 60% |
| |
| Physical/ Occupational/ Chiropractic
Therapy |
Plan pays 80% in-network;
60% out-of-network; 30 visits per year |
| |
| Mental Health |
| Inpatient |
$100 per day up to
$3,000 per year; $10,000 lifetime maximum |
| Outpatient |
Not covered |
| |
| Inpatient Hospital |
| In-Network |
80% |
| Out-of-Network |
60% |
| |
| Retail Rx |
$150 annual Rx deductible
per member |
| Generic/Formulary |
$15 copay, after deductible
is met |
| Brand/Formulary |
$25 copay, after deductible
is met |
| Non-Formulary |
$40 copay, after deductible
is met |
|
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BlueChoice PPO Q&A
Can I pay the $20 copayment for a physician visit right
away, or do I have to satisfy my deductible first? By
choosing the $250, $500, $1,0001
and $1,5001 deductible
plans, you can visit a network physician or specialist for
just $20 right from the start! The annual deductible
you select does not apply to in-network physician visits.
On all other plans, these services are subject to the deductible
and coinsurance.
What if I want to use a physician or hospital outside
the network? You have freedom of choice! Although you'll
save money when you use a BlueChoice PPO network provider,
you're free to use physicians or hospitals outside the network.
The chart above shows your in-network and out-of-network
benefits. Keep in mind, you have a wide choice of physicians
and hospitals within the BlueChoice PPO network and your
physician may already participate.
Can I cover just my kids if I want to? Yes. We realize
no two families' insurance needs are exactly alike. If you
need child-only coverage, it's available in the same benefit
amount as adults. By the same token, you can also get coverage
for just yourself, your spouse, your dependents, any children
for whom you assume legal guardianship such as foster children,
or any combination of the above.
What if I have an emergency when traveling? Don't
worry. You'll receive your in-network benefits for emergency
care and accidental injuries throughout the country.
How much does BlueChoice PPO cost? It's quite affordable.
Prices vary depending on your coverage selections. Please
note: You can never be singled out for a rate increase—or
have your coverage canceled—due to your age, health,
or the number, type, or size of the claims you may have.
Rates can only be adjusted if they are adjusted for all
BlueChoice PPO members.
Who should I contact if I have a question or to sign
up? For further information about BlueChoice PPO, please
contact Kayda Insurance Services via one of the methods
listed on our contact page.
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