Select 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 Select Booklet PDF Document and Summary of Benefit Coverage (SBC) PDF Document.

  • 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 006168

Deductible

$500 Member; $1500 Family

$500 Member; $1,500 Family

Coinsurance

20%

40%

Out-of-Pocket (OOP) Maximum

$2200 Member; $6000 Family

$4,400 Member; $12,000 Family

Prescription OOP Maximum

$1,500/year per member

Not Applicable

Wellness Checkup

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

Deductible + 40% Coinsurance

Office Visit

$25 physician / $35 specialist

Deductible + 40% Coinsurance

Emergency Room Costs

$100 Copay + 20% Coinsurance

$100 Copay + 40% Coinsurance

Immunizations

  • Covered under the Well Child Care provisions forchildren up to age 16
  • $25 office visit copay

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 underprescription drug program

Exclusions

  • Hearings aids; discounts available withTruHearing at 866-687-2020
  • Custodial Nursing Home Care
  • CosmeticCare except for the correction of congenital deformities or for conditions resulting from accidental injuries, tumors or disease

Find a Doctor

  1. Navigate to the Provider Finder
  2. 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

$34

$74

$63

$112

$42,001- $75,000

$61

$133

$113

$200

$75,001- $128,000

$99

$216

$184

$324

$128,001- $182,000

$144

$314

$267

$427

$182,001 and above

$208

$454

$387

$683

Part Time

Under $42,000

$162

$353

$300

$531

$42,001- $75,000

$180

$393

$334

$590

$75,001- $128,000

$205

$448

$382

$673

$128,001- $182,000

$236

$514

$437

$772

$182,001 and above

$278

$608

$518

$914