Your Blue Selections PPO Plan provides coverage for services provided by In-Network and Out-of-Network physicians and other professional providers as listed below. Once enrolled, the Preferred Provider Plan Network is the panel of providers for which you will receive the greatest benefits.
| |
Blue Selections PPO |
Lifetime maximum benefit |
$2,000,000 per individual |
| Individual
Deductible Options per calendar year |
$1,000, $2,500, $5,000 |
| Family
deductible per calendar year |
Maximum of three family members |
| Benefit Features |
Preferred Provider Benefit |
Non-Preferred Provider Benefit |
Maximum amount of covered expenses
you pay each calendar year per person |
$4,000 |
$8,000 |
| After the maximum amount is met each calendar year, we pay |
100% |
Important note: The
deductible and covered expenses paid at 100% do
not accumulate toward the maximum amount. |
Basic Services |
Deductible Waived - We Pay |
| Immunizations all ages |
100% after $10 copayment |
| Well-baby exam to age 2 |
100% after $20 copayment |
| Annual women's exam including
Pap test and mammogram |
100% after $20 copayment |
| Office and urgent care visits for illness and injury |
100% after $20 copayment |
| Therapeutic injections and
allergy shots |
100% after $20 copayment |
| Alternative care office visits |
100% after $20 copay |
Not covered |
Other Office and Professional Services |
After Deductible We Pay |
| Surgical procedures |
80% |
60% |
| Maternity care |
80% |
60% |
| Diagnostic radiology and
lab |
80% |
60% |
| Other alternative care services |
80% |
Not covered |
Hospital Services |
After Deductible We Pay |
| Inpatient stay including maternity, rehabilitation, and mental illness |
80% |
60% |
| Visits and consultations
in hospital |
80% |
60% |
| Outpatient surgery |
80% |
60% |
| Emergency room care for medical emergency (copay waived if admitted
to hospital or other facility on an inpatient basis) |
80% after you
pay a $100 copayment |
| Emergency room care for non-emergency |
80% after you
pay a $100 copayment |
60% after you
pay a $100 copayment |
Other Services |
After Deductible We Pay |
| Ambulance |
80% |
Outpatient rehabilitation
(physical, speech, and occupational therapy) |
80% |
60% |
| Outpatient durable medical
equipment and supplies |
80% |
60% |
| Transplant |
100%
(contracted facility) |
60% (non-contracted
facility) |
Prescription and Vision Benefits |
No Deductible - We Pay |
Outpatient prescription medications
(does not apply toward your medical maximum
coinsurance) |
50% |
Vision exams
(limited to once every 24 months per enrollee) |
100% after $20
copayment |
60% |
Vision hardware
(limited to once every 24 months per enrollee) |
100%
Up to allowances |
Additional Benefits |
| BlueCard® program |
Provides savings nationwide by using Participating providers of the Blue Cross and/or Blue Shield Plan in the area where
you receive the service. Using providers outside of the Blue Cross and/or Blue Shield Plan may likely result in greater
out of pocket expenses.
Find a provider near you at www.bcbs.com. |
Asuris
NW Health
