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 
and Summary of Benefit Coverage (SBC) .
- Express Scripts - administered prescription plan
- Vision discount - program available through Davis Vision
- Blue Extras - offers a variety of discounts on gym memberships, alternative medicine and hearing aids
|
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 |
$1800 Member; $5400 Family |
$3,600 Member; $10,800 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 + 30% Coinsurance |
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
Exclusions
- 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
Find a Doctor
- Navigate to the Provider Finder
- Select the Group health plan and choose PPO
Monthly Premiums
|
Annual Salary |
You |
You+Spouse |
You+Child(ren) |
You+sps+child(ren) |
|
|
Full Time |
Under $42,000 |
$167 |
$365 |
$311 |
$548 |
|
$42,001- $75,000 |
$197 |
$431 |
$367 |
$647 |
|
|
$75,001- $128,000 |
$237 |
$519 |
$442 |
$781 |
|
|
$128,001- $182,000 |
$288 |
$631 |
$537 |
$948 |
|
|
$182,001 and above |
$364 |
$796 |
$678 |
$1,196 |
|
|
Part Time |
Under $42,000 |
$303 |
$663 |
$565 |
$996 |
|
$42,001- $75,000 |
$324 |
$707 |
$602 |
$1,062 |
|
|
$75,001- $128,000 |
$350 |
$766 |
$653 |
$1,152 |
|
|
$128,001- $182,000 |
$385 |
$841 |
$716 |
$1,264 |
|
|
$182,001 and above |
$435 |
$952 |
$811 |
$1,430 |