PPO
Medical benefits are provided through Blue Cross Blue Shield of Texas (BCBSTX) and include PPO and HDHP with biweekly premiums, in-network and out-of-network cost.
PPO
Plan Details
Carrier
Blue Cross Blue Shield of Texas (BCBSTX)
Plan Type
PPO
Out-of-Network Coverage
Yes
HSA Eligible
No
FSA Eligible
Yes
Premiums
Employee only
- Biweekly Contribution
- $94.07
Employee + spouse
- Biweekly Contribution
- $174.80
Employee + child(ren)
- Biweekly Contribution
- $147.89
Employee + family
- Biweekly Contribution
- $248.65
Deductible, Out-of-Pocket & Coinsurance
Annual deductible - Individual
- In-network
- $1,500
- Out-of-network
- $3,000
Annual deductible - Family
- In-network
- $3,000
- Out-of-network
- $6,000
Coinsurance (you pay)
- In-network
- 20%*
- Out-of-network
- 40%*
Annual out-of-pocket maximum (maximum includes deductible) - Individual
- In-network
- $6,000
- Out-of-network
- $12,000
Annual out-of-pocket maximum (maximum includes deductible) - Family
- In-network
- $8,000
- Out-of-network
- $16,000
*After deductible
Covered Services
Preventive care
- In-network
- 100% No Deductible
- Out-of-network
- 100% No Deductible
Physician office
- In-network
- $30
- Out-of-network
- 40%*
Specialist office
- In-network
- $60
- Out-of-network
- 40%*
Urgent care
- In-network
- $80
- Out-of-network
- 40%*
Emergency room
- In-network
- Deductible + 20%
- Out-of-network
- Deductible + 20%
Telemedicine
- In-network
- $0
- Out-of-network
- N/A
X-ray/lab
- In-network
- 20%*
- Out-of-network
- 40%*
Outpatient/Inpatient**
- In-network
- 20%*
- Out-of-network
- 40%*
*After deductible
**Blue Distinction Center Providers = 10% Coinsurance after deductible
Retail RX (30-DAY SUPPLY)
Preventive - Generic
- In-network
- $10
- Out-of-network
- Copay + 40%
Preventive - Preferred brand
- In-network
- $50
- Out-of-network
- Copay + 40%
Preventive - Non-preferred brand
- In-network
- $100
- Out-of-network
- Copay + 40%
Preventive - Specialty
- In-network
- $150
- Out-of-network
- Copay + 40%
Non-preventive - Generic
- In-network
- $10
- Out-of-network
- Copay + 40%
Non-preventive - Preferred brand
- In-network
- $50
- Out-of-network
- Copay + 40%
Non-preventive - Non-preferred brand
- In-network
- $100
- Out-of-network
- Copay + 40%
Non-preventive - Specialty
- In-network
- $150
- Out-of-network
- Copay + 40%
Mail Order RX (90-DAY SUPPLY)
Preventive - Generic
- In-network
- $20
- Out-of-network
- Copay + 40%
Preventive - Preferred brand
- In-network
- $100
- Out-of-network
- Copay + 40%
Preventive - Non-preferred brand
- In-network
- $200
- Out-of-network
- Copay + 40%
Preventive - Specialty
- In-network
- $300
- Out-of-network
- Copay + 40%
Non-preventive - Generic
- In-network
- $20
- Out-of-network
- Copay + 40%
Non-preventive - Preferred brand
- In-network
- $100
- Out-of-network
- Copay + 40%
Non-preventive - Non-preferred brand
- In-network
- $200
- Out-of-network
- Copay + 40%
Non-preventive - Specialty
- In-network
- $300
- Out-of-network
- Copay + 40%
Plan Notes
- You’ll pay more in premiums, but perhaps less at the time of service.
- You can choose from a network of providers who offer a fixed copay for services.
- If you expect to need more medical care this year or you have a chronic illness, the PPO may be the right choice for you to ensure your healthcare needs are covered.
- You must call BCBS Health Advocacy Solutions to receive approval for MRI and CT Scan imaging, or you will receive a $100 penalty fee.