Blue Cross Blue Shield PPO
A 5-minute narrated video explaining How the BCBS PPO Works
How the BU FSA Contribution Works
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.
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.
This health plan option includes a tiered network feature called Hospital Choice Cost Sharing. As a member in this plan, you will pay different levels of in-network cost share (such as copayments and/ or coinsurance) for certain services depending on the preferred general hospital you choose to furnish those covered services. For most preferred general hospitals, you will pay the lowest in-network cost sharing level. However, if you receive certain covered services from any of the preferred general hospitals, you pay the highest in-network cost sharing level. The high-cost hospital list may change from time to time.
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.
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|
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 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:
|BCBS National PPO Network|
|BMC Providers||All Other Network Providers||Out-of-Network Providers|
|Office Visit||$15||$35||n/a (deductible and coinsurance apply)|
|Prescription Drugs||See Prescription Drugs section||Not covered|
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|
|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%||12%||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:
|Prescription Drug Expenses|
|Single||$2,500||n/a (not covered)|
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||2023 FSA Contribution from BU|
|$70,000 – $100,000||$250||$500|
|> $100,000||No contribution|