Blue cross blue shield ppo specialist copay

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.

Annual Deductible

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:

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

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:

Copayments

Coinsurance

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:

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:

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:

Plans that give you flexibility to see doctors and specialists outside the network

Our BlueMedicare PPO Plans

• Primary care doctor and telehealth visits
• No referrals to see in-network doctors
• Dental, vision, hearing and OTC
• The Blue Medicare Sapphire card is an annual debit card to help reduce out-of-pocket covered dental, vision or hearing expenses

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FeaturesCoverageBlueMedicare
Saver Choice (PPO)BlueMedicare
Value Choice (PPO)BlueMedicare
Premier Choice (PPO)BlueMedicare
Freedom Giveback (PPO)Premium$0$29$49$0Part B GivebackNoNoNo$50 per monthMaximum Out-of-Pocket$5,000$6,000$5,700$4,500PCP Copay$0$0$0$0Specialist Copay$30$40$35$35Prescription DrugsYesYesYesNoDental, Vision & Hearing CoverageYesYesYesYesFitness ProgramYesYesYesYesTelehealthYesYesYesYes

• Prescription drugs
• Dental
• Vision
• Hearing
• Fitness
  Program
• Telehealth
• Meals
• Sapphire
  Card

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Last updated 10/01/2022

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