Blue Cross Blue Shield PPO

The BCBS PPO is a preferred provider organization (PPO) that combines the advantages of a national network with the option to use physicians and facilities outside the network, but at a higher cost.

View the PPO User Guide
View the PPO User Guide

When you join the BCBS PPO, you are not required to choose a primary care physician. There are two levels of coverage: in-network and out-of-network. The amount of coverage depends on where you receive treatment. You receive the highest level of benefits under your health care plan when you choose preferred providers. These are called your in-network benefits. You can also choose non-preferred providers, but your out-of-pocket costs are higher. These are called your out-of-network benefits.

When you participate in the BCBS PPO, you must follow a benefit management process. You need to follow some procedures when dealing with emergency care, whether within or outside the enrollment area. There are procedures to follow when making out-of-network claims and when appealing a denied claim.

Annual Deductible

For most eligible expenses, you pay the full amount until you reach the annual deductible. The deductible that applies depends on the network you choose and your coverage level:

Deductible BCBS National PPO Network Out-of-Network
Single $250 $500
Family $500 $1,000

Individual Coverage: The Plan begins to pay benefits when the individual deductible is met.
Spouse and dependent coverage: The plan begins paying benefits for a covered person when he or she meets the individual deductible amount. It then pays benefits for all covered family members when the family deductible amount is met by any combination of the remaining covered family members.

The deductible does not apply to:
• In-network preventive care
• In-network office visits
• Emergency room visits
• Prescription drugs

Copayments

Copayments or “copays” are a flat fee that applies for doctor’s office visits, emergency room visits and prescription drugs. Copays do not count toward the deductible but do count toward the out-of-pocket maximum. Copays apply to the following expenses:

Expense

Copayments

BCBS National PPO Network
BMC Providers All Other Network Providers Out-of-Network Providers
Office Visit $15 $30 n/a (deductible and coinsurance apply)
Emergency Room $100 $100 $100
Prescription Drugs See Prescription Drugs section Not covered

Coinsurance

For most eligible expenses, once you meet the annual deductible, you and the plan pay a percentage of the cost of care. The coinsurance percentage you pay depends on the type of service and the provider you choose:

Expense Coinsurance Percentage You Pay (after deductible)
BMC Provider Blue Cross Blue Shield Low and High Cost Hospital Services Out-of-Network
Low-cost High-cost
Preventive care Plan pays 100%, no deductible Plan pays 100%, no deductible 30%
Office visits n/a (copay applies) n/a (copay applies) 30%
X-rays, labs and related diagnostic tests 0% 10% 20% 30%
Outpatient care 0% 10% 20% 30%
Inpatient care 0% 10% 20% 30%

Annual Out-of-Pocket Maximum

The annual out-of-pocket maximum limits the amount you pay for the deductible, copays and coinsurance each calendar year. In the PPO Plan, separate out-of-pocket maximums apply to medical expenses and prescription drug expenses, as follows:

Expense Out-of-Pocket Maximum
In-Network Out-of-Network
Medical Expenses
Single $2,500 $5,000
Family $5,000 $10,000
Prescription Drug Expenses
Single $2,000 n/a (not covered)
Family $4,000

Contributions to the Health Care FSA

If you elect the PPO Plan, BU will contribute an amount to your Health Care FSA that can be used to pay for eligible out-of-pocket expenses, like your deductible. The amount BU contributes is based on your salary and family coverage level, as follows:

Salary Tier 2016 FSA Contribution from BU
Single Family
< $70,000 $250 $500
$70,000 – $100,000 $125 $250
> $100,000 No contribution

 

When you participate in the BCBS PPO, you must follow a benefit management process. You need to follow some procedures when dealing with emergency care, whether within or outside the enrollment area. There are procedures to follow when making out-of-network claims and when appealing a denied claim.