Premier PPO

This plan gives you the flexibility to choose any doctor/hospital that you wish without requiring a primary care physician (PCP) or referrals. If you choose a BlueCross doctor, you will be charged the in-network rates.

Plan Benefits

This is a summary of the plan benefits. Complete benefit information is available in the BCBS PPO Premier Booklet PDF Document and Summary of Benefit Coverage (SBC) PDF Document.

In-Network

Out-of-Network

Group Number 906161/806161

Deductible

$250 Member; $750 Family

$250 Member; $750 Family

Coinsurance

10%

30%

Out-of-Pocket (OOP) Maximum

$2,200 Member; $6,600 Family

$4,400 Member; $13,200 Family

Prescription OOP Maximum

$1,500/year per member

Not Applicable

Wellness Checkup

Covered 100% according to age/sex guidelines (pdf)

Deductible + 30% Coinsurance

Office Visit

$25 physician / $35 specialist

Deductible + 30% Coinsurance

Emergency Room Costs

$100 Copay + 10% Coinsurance

$100 Copay + 10% Coinsurance

*All heallth care copays apply toward the out-of-pocket maximums.

Immunizations

  • Covered under the Well Child Care provisions for children up to age 16

Routine Mammogram & Pap Smear

  • Covered with no cost-sharing
  • Mammogram covered for women age 35+

Laboratory Tests and X-Rays

  • Coinsurance after deductible is met

Physical Therapy & Chiropractic Care

  • Coinsurance after deductible is met
  • Member's condition must show continued improvement with physical therapy

Minor Surgery in Doctor's Office or Outpatient Surgical Operations

  • Coinsurance after deductible is met

Diabetes Treatment

  • Covered at coinsurance after deductible is met
    • Glucometer
    • Self management training services rendered by a physician or licensed health care professional with expertise in diabetes management
    • Regular foot care examinations by a physician or podiatrist
  • Other supplies and equipment are covered under prescription drug program

Exclusion Examples

  • Hearings aids; discounts available with TruHearing at 866-687-2020
  • Custodial Nursing Home Care
  • Cosmetic Care except for the correction of congenital deformities or for conditions resulting from accidental injuries, tumors or disease
  • For a comprehensive list of exclusions, contact BCBS at (800) 327-8497

Find a Doctor

  1. Navigate to the Provider Finder
  2. Select the Group health plan and choose PPO

2017 Monthly Premiums

Annual Salary

You

You+Spouse

You+Child(ren)

You+sps+child(ren)

Full Time

Under $42,000

$205

$448

$382

$676

$42,001- $75,000

$243

$531

$452

$798

$75,001- $128,000

$293

$641

$545

$962

$128,001- $182,000

$355

$778

$663

$1,168

$182,001 and above

$448

$981

$835

$1,473

Part Time

Under $42,000

$374

$816

$696

$1,227

$42,001- $75,000

$397

$870

$743

$1,309

$75,001- $128,000

$432

$945

$804

$1,419

$128,001- $182,000

$473

$1,037

$884

$1,558

$182,001 and above

$536

$1,173

$999

$1,762