PPO medical plan
PPO
Medical benefits are provided through Blue Cross Blue Shield of Texas (BCBSTX).
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 – Health Care FSA
| Coverage Tier | Biweekly Contribution |
|---|---|
| Employee only | $94.07 |
| Employee + spouse | $174.80 |
| Employee + child(ren) | $147.89 |
| Employee + family | $248.65 |
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
| Feature | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Annual deductible - Individual | $1,500 | $3,000 |
| Annual deductible - Family | $3,000 | $6,000 |
| Coinsurance (you pay) | 20%* | 40%* |
| Annual out-of-pocket maximum (maximum includes deductible) - Individual | $6,000 | $12,000 |
| Annual out-of-pocket maximum (maximum includes deductible) - Family | $8,000 | $16,000 |
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
| Service | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Preventive care | 100% No Deductible | 100% No Deductible |
| Physician office | $30 | 40%* |
| Specialist office | $60 | 40%* |
| Urgent care | $80 | 40%* |
| Emergency room | Deductible + 20% | Deductible + 20% |
| Telemedicine | $0 | N/A |
| X-ray/lab | 20%* | 40%* |
| Outpatient/inpatient** | 20%* | 40%* |
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
| Drug Tier | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Preventive drugs - Generic | $10 | Copay + 40% |
| Preventive drugs - Preferred brand | $50 | Copay + 40% |
| Preventive drugs - Non-preferred brand | $100 | Copay + 40% |
| Preventive drugs - Specialty | $150 | Copay + 40% |
| Non-preventive drugs - Generic | $10 | Copay + 40% |
| Non-preventive drugs - Preferred brand | $50 | Copay + 40% |
| Non-preventive drugs - Non-preferred brand | $100 | Copay + 40% |
| Non-preventive drugs - Specialty | $150 | Copay + 40% |
Preventive drugs - Generic
- IN-NETWORK
- $10
- OUT-OF-NETWORK
- Copay + 40%
Preventive drugs - Preferred brand
- IN-NETWORK
- $50
- OUT-OF-NETWORK
- Copay + 40%
Preventive drugs - Non-preferred brand
- IN-NETWORK
- $100
- OUT-OF-NETWORK
- Copay + 40%
Preventive drugs - Specialty
- IN-NETWORK
- $150
- OUT-OF-NETWORK
- Copay + 40%
Non-preventive drugs - Generic
- IN-NETWORK
- $10
- OUT-OF-NETWORK
- Copay + 40%
Non-preventive drugs - Preferred brand
- IN-NETWORK
- $50
- OUT-OF-NETWORK
- Copay + 40%
Non-preventive drugs - Non-preferred brand
- IN-NETWORK
- $100
- OUT-OF-NETWORK
- Copay + 40%
Non-preventive drugs - Specialty
- IN-NETWORK
- $150
- OUT-OF-NETWORK
- Copay + 40%
| Drug Tier | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Preventive drugs - Generic | $20 | Copay + 40% |
| Preventive drugs - Preferred brand | $100 | Copay + 40% |
| Preventive drugs - Non-preferred brand | $200 | Copay + 40% |
| Preventive drugs - Specialty | $300 | Copay + 40% |
| Non-preventive drugs - Generic | $20 | Copay + 40% |
| Non-preventive drugs - Preferred brand | $100 | Copay + 40% |
| Non-preventive drugs - Non-preferred brand | $200 | Copay + 40% |
| Non-preventive drugs - Specialty | $300 | Copay + 40% |
Preventive drugs - Generic
- IN-NETWORK
- $20
- OUT-OF-NETWORK
- Copay + 40%
Preventive drugs - Preferred brand
- IN-NETWORK
- $100
- OUT-OF-NETWORK
- Copay + 40%
Preventive drugs - Non-preferred brand
- IN-NETWORK
- $200
- OUT-OF-NETWORK
- Copay + 40%
Preventive drugs - Specialty
- IN-NETWORK
- $300
- OUT-OF-NETWORK
- Copay + 40%
Non-preventive drugs - Generic
- IN-NETWORK
- $20
- OUT-OF-NETWORK
- Copay + 40%
Non-preventive drugs - Preferred brand
- IN-NETWORK
- $100
- OUT-OF-NETWORK
- Copay + 40%
Non-preventive drugs - Non-preferred brand
- IN-NETWORK
- $200
- OUT-OF-NETWORK
- Copay + 40%
Non-preventive drugs - 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.