PPO Plan
You pay the highest paycheck costs in exchange for the lowest deductible.
A medical plan that lets you decide where to receive care each time you need it. If you use a provider in the PPO network, you pay less for health services. If you receive care from a non-network provider, you pay a larger portion of the cost, and the cost itself is higher. Prescription drug coverage is provided through Prime Therapeutics.
PPO Plan Details
In-Network | Out-of-Network | |
|---|---|---|
Annual Deductible | $875 single $1,750 all other coverage levels | $2,625 single $5,250 all other coverage levels |
Annual Out-of-Pocket Maximum (includes deductible and copays) | $3,700 single $7,400 all other coverage levels | $11,100 single $22,200 all other coverage levels (excludes amounts above usual and customary) |
Lifetime Maximum Benefit | Unlimited | Unlimited |
General Medical Expenses | ||
Primary & Specialist Doctor Office Visit (includes maternity care) | $25 copay | 65% covered after deductible |
MDLIVE Physician1 | $25 | N/A |
Specialist Office Visit | $40 copay | 65% covered after deductible |
Inpatient Hospital Care (requires preauthorization) | ||
Hospitalization2 | 85% covered after deductible | 65% covered after deductible |
Inpatient Physician and Surgeon Services3 | 85% covered after deductible | 65% covered after deductible |
Inpatient Lab and X-ray4 | 85% covered after deductible | 65% covered after deductible |
Outpatient Care | ||
Outpatient Surgery | 85% covered after deductible If performed as a part of an office visit and billed by a physician applicable copay applies. | 65% covered after deductible |
Outpatient Lab and X-ray4 | 85% covered after deductible If performed as a part of an office visit and billed by a physician applicable copay applies. | 65% covered after deductible |
Preventative Care | ||
Annual Physical Exam & Immunizations | 100% covered | 65% covered after deductible |
Well-Baby & Well-Child Exams and Immunizations | 100% covered | 65% covered after deductible |
Well-Woman Exam | 100% covered | 65% covered after deductible |
Other Preventive Care & Cancer Screenings4 | 100% covered | 65% covered after deductible |
Maternity Care5 | ||
Office Visit: Prenatal/Postnatal | $25 copay (initial visit only) | 65% covered after deductible |
In-Hospital Delivery & Newborn Nursery Services | 85% covered after deductible | 65% covered after deductible |
Emergency Services | ||
Hospital Emergency Facility | 85% covered after deductible and after $250 copay | 85% covered after deductible and after $250 copay |
Non-Emergency Care in a Hospital Emergency Room | Not Covered | Not Covered |
Urgent Medical Care (at a non-hospital free standing facility) | 85% covered after $40 copay | 65% covered after deductible |
Non-Urgent Use of Urgent Care Provider (at a non-hospital free standing facility) | 85% covered after $40 copay | 65% covered after deductible |
Chiropractic Services | ||
Spinal Manipulation Maximum of 25 visits each calendar year (in-and out-of-network services combined) | $40 copay | 65% covered after deductible |
Short-Term Rehabilitation Therapy | ||
Outpatient Physical, Speech, Occupational Therapy 60-visit combined maximum per year | 85% covered after deductible | 65% covered after deductible |
Mental Health, Substance Abuse Care | ||
Mental Health: Rehab & Detox OUTPATIENT Coverage | $25 copay | 65% covered after deductible |
Mental Health: Rehab & Detox INPATIENT Coverage | 85% covered after deductible | 65% covered after deductible |
Residential Treatment Facility (stays in a residential treatment facility for treatment of mental disorders, alcoholism or drug abuse) | 85% covered after deductible | 65% covered after deductible |
MDLIVE® Behavioral Therapy | $25 | N/A |
Other Benefits | ||
Condition Management | BCBSTX Condition Management programs offer support for people diagnosed with chronic conditions such as asthma, diabetes, heart problems and others. | |
Prescription Drugs | Prescription Drugs are covered through Prime Therapeutics, an affiliate of BCBSTX. | |
(1) Your payments to MDLIVE count toward the in-network deductibles and out-of-pocket maximums for the HSA and PPO medical plans. (2) The plan covers bariatric surgery and some transplants if performed at a Blue Distinction Center. (3) Certain high-tech radiology tests (CT scans and MRIs) require prior authorization except during a medical emergency. Authorization is not required for low resolution diagnostic services, including mammograms, sonograms, and x-rays. (4) Other preventive exams and cancer screenings may have age and time limit restrictions. Review your medical plan details on the MyBMC Rewards website and select the Plan Documents tile. (5) Your newborn is automatically covered under the plan for the first 31 days after the date of birth. If you wish to continue coverage for the newborn beyond that date, you must add the child to your medical coverage through the MyBMC Rewards website (select the Life Changes tab) within 31 days after the newborn’s date of birth.(6) Additional plan authorization review required after 30 days. | ||