Skip to main content

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 Blue Cross doctor, you will be charged the in-network rates.

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

Select PPO benefits broken down by in-network, out-of-network and Northwestern Medicine network.
In-Network Out-of-Network Northwestern Medicine
Group Number 006168 006168 006168
Deductible 500 member, $1,500 family $500 member; $1,500 family $250 member, $750 family
Out-of-Pocket (OOP) Maximum $2,600 member, $7,500 family $5,300 member, $15,500 family $1,500 member, $4,500 family
Prescription OOP Maximum $1,500/year per member N/A N/A
Wellness Checkup Covered 100% according to age/sex guidelines Deductible + 40% coinsurance Covered 100% according to age/sex guidelines
Office Visit $25 physician/$35 specialist Deductible + 40% coinsurance $10 physician/$20 specialist
Emergency Room Costs $100 copay + 20% coinsurance $100 Copay + 20% coinsurance $100 copay (waived if admitted) + 20% coinsurance

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

Find a doctor

In- and out-of-network
  1. Navigate to the Provider Finder
  2. Select the group health plan and choose PPO
Northwestern Medicine participating doctors
  1. Navigate to the Northwestern Medicine Provider Finder (Be sure NOT to log in)
  2. Select the get medical care in the middle of the screen

     

Premiums are deducted from your paycheck on a pre-tax basis.  Employees who are paid bi-weekly will have half of the monthly deduction taken from the first two checks of each month.

Jump to:

Premiums for full-time employees

Select PPO monthly premiums for full-time employees by annual salary and members of family insured.
Annual Salary You You + Spouse You + Child(ren) You + Spouse + Child(ren)
Under $42,000 $44 $97 $82 $145
$42,001-$75,000 $80 $174 $148 $262
$75,001-$128,000 $129 $281 $241 $423
$128,001-$182,000 $186 $410 $349 $616
$182,001 and above $272 $593 $504 $892

 Back to top

Premiums for part-time employees

Select PPO monthly premiums for part-time employees by annual salary and family members insured.
Annual Salary You You + Spouse You + Child(ren) You + Spouse + Child(ren)
Under $42,000 $211 $461 $391 $691
$42,001-$75,000 $235 $512 $434 $770
$75,001-$128,000 $268 $584 $496 $877
$128,001-$182,000 $306 $669 $570 $1,007
$182,001 and above $363 $792 $673 $1,191

Back to top

Benefits

Prescription coverage
Discounts
  • Vision discount - program available through Davis Vision
  • Blue Discount Program - offers a variety of discounts on gym memberships, alternative medicine and hearing aids
  • Hearings aids discounts available with TruHearing at 866-687-2020
Immunizations
  • Covered under the Well Child Care provisions for children up to age 16
  • $25 office visit copay
Routine mammogram and 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 and 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