PPO Medical Comparison
| Benefits | PPO 1* | PPO 2** |
| Health Maintenance Exam (Routine AnnualPhysical) | 100% of R/C, one per calendar year, includes chest x-ray, urinalysis, EKG and select lab procedures. Only covered In-Network. | 100% of R/C, one per calendar year, includes chest x-ray, urinalysis, EKG and select lab procedures. Only covered In-Network. |
| Gynecological Exam | 100% of R/C, one per calendar year. Only covered In-Network. | 100% of R/C, one per calendar year. Only covered In-Network. |
| Pap Smear Screening - (Laboratory and pathology services) | 100% of R/C. One per calendar year. Only covered In-Network. | 100% of R/C. One per calendar year. Only covered In-Network. |
| Well Baby & Child Care | Covered-100% of R/C 6 visits, birth through 12 months 6 visits, 13 months through 23 months 6 visits, 24 months through 35 months 2 visits, 36 months through 47 months 1 visit per birth year, age 4 through 15 Only covered In-Network. |
Covered-100% of R/C 6 visits, birth through 12 months 6 visits, 13 months through 23 months 6 visits, 24 months through 35 months 2 visits, 36 months through 47 months 1 visit per birth year, age 4 through 15 Only covered In-Network |
| Immunizations | 100% of R/C, follows the Center for Disease Control (CDC) guidelines for adult and child immunizations. Only covered In-Network. | 100% of R/C, follows the Center for Disease Control (CDC) guidelines for adult and child immunizations. Only covered In-Network. |
| Fecal Occult Blood Screening | 100% of R/C. One per calendar year. Only covered In-Network. | 100% of R/C. One per calendar year. Only covered In-Network. |
| Colonoscopy | 100% of R/C. One per calendar year. Only covered In-Network. | 100% of R/C. One per calendar year. Only covered In-Network. |
| Flexible Sigmoidoscopy Exam | 100% of R/C. One per calendar year. Only covered In-Network. | 100% of R/C. One per calendar year. Only covered In-Network. |
| Prostate Specific Antigen (PSA) Screening | 100% of R/C. One per calendar year. Only covered In-Network. | 100% of R/C. One per calendar year. Only covered In-Network. |
| Mammography Screening | 100% of R/C for In-network providers; 80% of R/C after deductible for Out-of-Network providers. One per calendar year, no age restrictions. | 100% of R/C for In-Network providers; 80% of R/C after deductible for Out-of-Network providers. One per calendar year, no age restrictions. |
| Office Visits - Non Routine | $10 co-pay with In-Network providers; 80% of R/C after deductible with Out-of-Network providers must be medically necessary. | $10 co-pay with In-Network providers; 60% of R/C after deductible with Out-of-Network providers must be medically necessary. |
| Urgent Care Visits | $10 co-pay with In-Network providers; 80% of R/C after deductible with Out-of-Network providers must be medically necessary. | $10 co-pay with In-Network providers; 60% of R/C after deductible with Out-of-Network providers must be medically necessary. |
| Hospital Emergency Room | Covered - $50 copay, waived if admitted or for an accidental injury | Covered - $50 copay, waived if admitted or for an accidental injury |
| Ambulance Services - medically necessary | 100% of R/C | 80% of R/C after deductible |
| Laboratory and Pathology | 100% of R/C for In-Network services; 80% of R/C after deductible for Out-of-Network services. | 80% of R/C for In-Network services after deductible; 60% of R/C after deductible for Out-of-Network services. |
| Diagnostic Tests and X-Rays | 100% of R/C for In-Network services; 80% of R/C after deductible for Out-of-Network services. | 80% of R/C for In-Network services after deductible; 60% of R/C after deductible for Out-of-Network services. |
| Therapeutic Radiology | 100% of R/C for In-Network services; 80% of R/C after deductible for Out-of-Network services. | 80% of R/C for In-Network services after deductible; 60% of R/C after deductible for Out-of-Network services. |
| Maternity Services Provided by a Physician Delivery and Nursery Care |
100% of R/C with In-Network providers; 80% of R/C after deductible with Out-of-Network providers. Law prohibits hospital to no less than 48 hrs for a vaginal delivery and 96 hrs for a caesarian delivery, if needed. | 80% of R/C after deductible with In-Network providers; 60% of R/C after deductible with Out-of-Network providers. Law prohibits hospital to no less than 48 hrs for a vaginal delivery and 96 hrs for a caesarian delivery, if needed. |
| Pre- and Post-Natal Care | 100% of R/C with In-Network providers 80% of R/C after deductible with Out-of-Network providers. | 100% of R/C with In-Network providers 60% of R/C after deductible with Out-of-Network providers. |
| Inpatient Hospital Care General Conditions (semi-private room, inpatient physician care, meals, special diets, general nursing care, intensive care units, drugs, equipment and supplies, etc.) | 100% of R/C with In-Network providers 80% of R/C after deductible with Out-of-Network providers. Unlimited days. Note: Nonemergency care must be rendered in a participating hospital. | 80% of R/C with after deductible In-Network providers 60% of R/C after deductible with Out-of-Network providers. Unlimited days. Note: Nonemergency care must be rendered in a participating hospital. |
| Inpatient Consultations | 100% of R/C with In-Network providers 80% of R/C after deductible with Out-of-Network providers. | 80% of R/C after deductible with In-Network providers 60% of R/C after deductible with Out-of-Network providers. |
| Chemotherapy | 100% of R/C with In-Network providers 80% of R/C after deductible with out-of-network providers. | 80% of R/C after deductible with In-Network providers 60% of R/C after deductible with Out-of-Network providers. |
| Skilled Nursing Care- non-custodial care | 100% of R/C up to 120 days per calendar year. | 80% of R/C after deductible up to 120 days per calendar year |
| Hospice | 100%, limited to dollar maximum which is adjusted periodically. | 100%, limited to dollar maximum which is adjusted periodically. |
| Home Health Care | 100% of R/C, unlimited days. | 80% of R/C after deductible, unlimited days |
| Surgery - includes related surgical services | 100% of R/C with In-Network providers 80% of R/C after deductible with Out-of-Network providers. Multiple surgeries through the same incision - they pay the amount of the highest cost surgery; but there are some surgeries that they do pay half of the other surgery. Note: if using a participating doctor, payment in full will be accepted (should be checked with customer service for more details). | 80% of R/C after deductible with In-Network providers 60% of R/C after deductible with Out-of-Network providers. Multiple surgeries through the same incision - they pay the amount of the highest cost surgery; but there are some surgeries that they do pay half of the other surgery. Note: if using a participating doctor, payment in full will be accepted (should be checked with customer service for more details). |
| Voluntary Sterilization | 100% of R/C with In-Network providers 80 of R/C after deductible with Out-of-Network providers. | 80% of R/C after deductible with In-Network providers 60% of R/C after deductible with Out-of-Network providers. |
| Human Organ Transplants Specified Organ Transplants, when coordinated through BCBSM Human Organ Transplant Program (1-800-242-3504) |
100% of R/C - approved facilities only |
100% of R/C - approved facilities only |
| Bone Marrow - when coordinated through BCBSM Human Organ Transplant Program (1-800-242-3504); specific criteria applies | 100% of R/C with In-Network providers 80% of R/C after deductible with Out-of-Network providers. | 80% of R/C after deductible with In-Network providers 60% of R/C after deductible with Out-of-Network providers. |
| Inpatient Mental Health Care (in an approved facility) | 100% of R/C with In-Network providers; 80% of R/C after deductible with Out-of-Network providers. Unlimited days. | 80% of R/C after deductible with In-Network providers; 60% of R/C after deductible with Out-of-Network providers. Unlimited days. |
| Inpatient Substance Abuse Treatment - (in an approved facility) | 100% of R/C with In-Network providers; 80% of R/C after deductible with Out-of-Network providers. | 80% of R/C after deductible with In-Network providers; 60% of R/C after deductible with Out-of-Network providers. |
| Outpatient Mental Health Care - approved facility* - physicians** charges |
Facility and Clinic: 100% of R/C |
Facility and Clinic: 100% of R/C Physician's Office: 100% of R/C** |
| *Because of the HIPAA ruling, no annual or lifetime maximums. **Needs to be seen by a fully licensed Psychologist, Psychiatrist, or Clinical Licensed Master's Social Worker within the scope of their licensure. |
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| Outpatient Substance Abuse Treatment - in an approved facility | 100% of R/C (no dollar limit) | 80% of R/C after deductible (no dollar limit) |
| Allergy Testing/Therapy | 100% of R/C with In-Network providers 80% of R/C after deductible with Out-of-Network providers. | 100% of R/C with In-Network providers 60% of R/C after deductible with Out-of-Network providers. |
| Chiropractic care | Chiropractic manipulation: covered at 100% of R/C with In-Network providers 80% of R/C after deductible with Out-of-Network providers. Up to 24 visits per calendar year. | Chiropractic manipulation: 100% of R/C with In-Network providers 60% of R/C after deductible with Out-of-Network providers. Up to 24 visits per calendar year. |
| Physical Therapy Facility And Clinic |
100% of R/C with In-Network providers 100% of R/C with Out-of-Network providers. Limited to a combined 60 visits per calendar year for physical therapy in the outpatient department of a hospital as well as in the physician's office. | 80% of R/C after deductible with In-Network providers 80% of R/C after deductible with Out-of-Network providers. Limited to a combined 60 visits per calendar year for physical therapy in the outpatient department of a hospital as well as in the physician's office. |
| Physical Therapy Physician's Office |
100% of R/C with In-Network providers 80% of R/C after deductible with Out-of-Network providers. Limited to a combined 60 visits per calendar year for physical therapy in the outpatient department of a hospital as well as in the physician's office. | 80% of R/C with In-Network providers 60% of R/C after deductible with Out-of-Network providers. Limited to a combined 60 visits per calendar year for physical therapy in the outpatient department of a hospital as well as in the physician's office. |
| Durable Medical Equipment | 100% of R/C | 80% of R/C after deductible |
| Prosthetic and Orthotic Appliance (accredited provider required for custom made appliances) | 100% of R/C | 80% of R/C after deductible |
| Private Duty Nursing | 50% of R/C | 50% of R/C after deductible |
| Cardiac Rehabilitation | 100% Coverage in Phase I & II (within 90 days of event);80% coverage with Out-of-Network providers after $250 per person/$500 per family deductible. | 80% Coverage in Phase I & II (within 90 days of event) after $250 per person/$500 per family deductible; 60% coverage with Out-of-Network providers after $500 per person/$1000 per family deductible. |
| Prescription Drugs | Covered under a separate provider, CVS/Caremark | Covered under a separate provider, CVS Caremark |
| Vision Therapy | Not covered | Not covered |
| Payment of Benefits | Participating Hospitals: 100% of covered benefits Preventative Services: Only a benefit In-Network Non-PPO Providers: Without a referral will require you to pay a 20% copay. Care with a referral may result in you being billed the difference between our approved amount and the provider's charge. | Participating Hospitals: 80% of covered benefits Preventative Services: Only a benefit In-Network Non-PPO Providers: Without a referral will require you to pay a 40% copay. Care with a referral may result in you being billed the difference between our approved amount and the provider's charge. |
| Deductibles, Co-pays and Benefit Maximums | Deductible: In-Network: None Out-of-Network: $250 per member, $500n per family, per calendar year. Co-payments: Fixed: $10 office visits, $50 Emergency Room Percent In-Network:None for general services, 50% co-pay for private duty nursing. Percent Out-of-Network: 20% for general services up to annual out-of-pocket maximum, 50% private duty nursing. (Services without a network are covered at in-network level.) Annual out-of-pocket Maximums: In-Network:None Out-of-Network: $2,000 per member, $4,000 per family, excludes private duty nursing. | Deductible: In-Network: $250 per member, $500 per family, per calendar year. Out-of-Network:$500 per member, $1,000 per family, per calendar year. Co-payments: Fixed: $10 office visits, $50 Emergency Room Percent In-Network:20% copay for general services, 20% copay for mental health and substance abuse care, 50% copay for private duty nursing. Percent Out-of-Network:40% for general services up to annual out-of-pocket maximum, 50% private duty nursing. (Services without a network are covered at in-network level.) Annual out-of-pocket Maximums: In-Network:$1,000 per member, $2,000 per family per calendar year Out-of-Network:$3,000 per member, $6,000 per family per family per calendar year, excludes private duty nursing. |