PPO Medical Comparison


Comparison of: PPO 1 PPO 2

Benefits
BAAG =Benefits-at-a Glance

SBC = Summary of Benefits

BCBS BAAG 2015-16
              

For FY 2015-2016=

SBC PPO 1 & PD 10/20/30

              

BCBS BAAG 2015-16
              

For FY 2015-2016=

SBC PPO 2 & PD 10/20/30

              

Deductibles In-Network:  In-Network  deductible $100 per member/$200 per family; Out-of-Network: $250 per member, $500 per family, per plan year.  Out-of-Network deductible will be $350 per member/$700 per family   Note:  Out of network deductible amounts also count toward the in network deductible. In-Network:  $250 per member/$500 per family; Out-of-Network: $500 per member, $1,000 per family, per plan year.  Note:  Out of network deductible amounts also count toward the in network deductible.

Co-insurance amount (percent copays)

Note:  Coinsurance amounts apply once the deductible has been met.

  • In-Network and Out of Network:  50% of approved amount for private duty nursing care;
  • Out-of-Network: 20% of approved amount for mental health care and substance abuse treatment.
  • Out-of-Network: 20% of approved amount for most other services.

 

  • In-Network and Out of Network:  50% of approved amount for private duty nursing care;
  • In-Network: 20% of approved amount for mental health care and substance abuse treatment
  • Out-of-Network: 40% of approved amount for mental health care and substance abuse treatment.
  • In-Network: 20% of approved amount for most other covered services.  Out-of-Network: 40% of approved amount for most other services.

 

Flat dollar Copays

$10 copay for office visits, office consultations, urgent care and chiropratic visits

$50 copay for emergency room visits

Annual out-of-pocket maximums – applies to deductibles, copays, and co-insurance amounts for all covered services.

In-network:  $600 per member

$1,200 for two or more members each plan year

Out-of-Network: $2,350 per member $4,700 for two or more members each plan year

Note:  Out-of- network cost sharing amounts also apply toward the in-network out of pocket maximum.

In-network:  $1,250 per member

$2,500 for two or more members each plan year

Out-of-Network: $3,500 per member $7,000 for two or more members each plan year

Note:  Out-of- network cost sharing amounts also apply toward the in-network out of pocket maximum.

Preventative Care Services – Only covered in-network
Health Maintenance Exam (Routine Annual Physical)100% One per calendar year, includes chest x-ray, urinalysis, EKG and select lab procedures. Only covered In-Network.
Gynecological Exam100% One per calendar year. Only covered In-Network.
Pap Smear Screening - (Lab & pathology services)100% One per calendar year. Only covered In-Network.
Well Baby & Child Care100% Covered in network 6 visits, birth through 12 months 6 visits, 13 to 23 months 6 visits, 24 to 35 months 2 visits, 36 to 47 months. Visits beyond 47 months are limited to 1 per member per calendar year – Only covered In-Network.
Adult and childhood preventative services and immunizations100% covered as recommended by the USPSTF, ACIP, HRSA or other sources as recognized by BCBSM that are in compliance with the provisions of the Patient Protection and Affordable Care Act. Only covered In-Network.
Fecal Occult Blood Screening100% covered no deductible. One per calendar year. Only covered In-Network.
Flexible sigmoidoscopy Exam100% covered no deductible. One per calendar year. Only covered In-Network.
Prostate Specific Antigen (PSA) Screening100% covered no deductible. One per calendar year. Only covered In-Network.
In-network and Out-of-Network Deductibles and/or applicable copays and coinsurance will be applied to services listed below:
Benefits PPO 1PPO 2
Voluntary Sterilizations for Males100% covered after in-network deductible; 80% out of network after deductible​80% covered after in network deductible, 60% out of network after deductible
Voluntary Sterilizations for Females100% covered in-network no deductible; 80% out of network  after deductible 100% covered in network no deductible; 60% out of network after deductible
Contraceptive injections100% covered in network no deductible; 80% covered  out of network after deductible100% covered in network no deductible; 60% out of network after deductible
Prescriptions contraceptive devices100% covered in network and out of network - no deductible100% covered in network and out of network - no deductible

Colonoscopy

Note: Subsequent colonoscopies performed during the same calendar year are subject to your deductible and co-insurance.

100% covered in-network no deductible; 80% out of network  after deductible100% covered in network no deductible; 60% out of network after deductible
Mammogram100% covered no deductible in network; 80% covered after deductible out of network.  Note:  Subsequent medically necessary mammograms performed during the same calendar year are subject to your deductible and co-insurance.100% covered no deductible in network; 60% covered after deductible out of network.  Note:  Subsequent medically necessary mammograms performed during the same calendar year are subject to your deductible and co-insurance.
Office Visits - Non Routine$10 co-pay with In-Network providers; 80% after deductible with Out-of-Network providers must be medically necessary.$10 co-pay with In-Network providers; 60% after deductible with Out-of-Network providers must be medically necessary.
Urgent Care Visits$10 co-pay with In-Network providers; 80% after deductible with Out-of-Network providers must be medically necessary.$10 co-pay with In-Network providers; 60% 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
Ambulance Services - medically necessary100% after in-network deductible80% after in-network deductible
Laboratory and Pathology100% covered after in network deductible; 80% covered after out of network deductible.80% covered after in network deductible; 60% covered after out of network deductible.
Diagnostic Tests and X-Rays100% covered after in network deductible; 80% covered after out of network deductible.80% covered after in network deductible; 60% covered after out of network deductible.
Therapeutic Radiology100% covered after in network deductible; 80% covered after out of network deductible.80% covered after in network deductible; 60% covered after out of network deductible.
Benefits PPO 1 PPO 2
Maternity Services Provided by a Physician
Delivery and Nursery Care
100% covered after in-network deductible; 80% covered after out of network deductible.80% covered after in-network deductible; 60% covered after out of network deductible.
Pre- and Post-Natal Care100% covered (no deductible or copay/coinsurance); 80% covered after out of network deductible.100% covered (no deductible or copay/coinsurance); 60% covered after out of network deductible.
Inpatient Hospital Care Semi-private room, inpatient physician care, general nursing care, hospital services and supplies.100% covered after deductible in network deductible; 80% covered after out of network deductible. Unlimited days. Note: Non-emergency care must be rendered in a participating hospital.80% covered after deductible in network deductible; 60% covered after out of network deductible. Unlimited days. Note: Non-emergency care must be rendered in a participating hospital.
Inpatient Consultations100% covered after in network deductible; 80% covered after out of network deductible.80% covered after in network deductible; 60% covered after out of network deductible.
Chemotherapy 100% covered after in network deductible; 80% covered after out of network deductible.80% covered after in network deductible; 60% covered after out of network deductible.
Skilled Nursing Care- must be in a participating skilled nursing facility100% covered after in network deductible up to 120 days per calendar year.80% covered after in network deductible up to 120 days per calendar year.
Hospice100% covered (no deductible or copay/coinsurance)100% covered (no deductible or copay/coinsurance)
Home Health Care  must be medically necessary and provided by participating  home health care agency100% after in network deductible80% after in network deductible
Infusion Therapy must be medically necessary and provided by participating Home Infusion Therapy provider or in a participating freestanding Ambulatory Infusion Center.  May use drugs that require pre- authorization – consult with your doctor.100% after in network deductible80% after in network deductible
Surgery - includes related surgical services and medically necessary facility services by a participating ambulatory surgery facility100% covered after in network deductible; 80% covered after out of network deductible 80% covered after in network deductible; 60% covered after out of network deductible
Pre-surgical consultations100% covered (no deductible or copay/coinsurance); 80% covered after out of network deductible.100% covered (no deductible or copay/coinsurance); 60% covered after out of network deductible
Human Organ Transplants

100% covered (no deductible or copay) in a designated facility only, when coordinated through BCBSM Human Organ Transplant Program - (1-800-242-3504)

Benefits PPO 1 PPO 2
Bone Marrow – must be coordinated through BCBSM Human Organ Transplant Program (1-800-242-3504)100% covered after in network deductible; 80% covered after out of network deductible.80% covered after in network deductible; 60% covered after out of network deductible.
Specified oncology clinical trials Note:  BCBSM covers clinical trials in compliance with PPACA.100% covered after in network deductible; 80% covered after out of network deductible.80% covered after in network deductible; 60% covered after out of network deductible.
Kidney, cornea and skin transplants100% covered after in network deductible; 80% covered after out of network deductible.80% covered after in network deductible; 60% covered after out of network deductible.
Inpatient Mental Health Care (in an approved facility)100% covered after in network deductible; 80% covered after out of network deductible. Unlimited days.80% covered after in network deductible; 60% covered after out of network deductible. Unlimited days.
Inpatient Substance Abuse Treatment - (in an approved facility)100% covered after in network deductible; 80% covered after out of network deductible. Unlimited days.80% covered after in network deductible; 60% covered after out of network deductible. Unlimited days.
Outpatient Mental Health Care* Facility and Clinic: 100% covered after in network deductible in participating facilities only.
Physician's Office: 100% covered after in network deductible; 80% covered after out of network deductible.
Facility and Clinic: 80% covered after in network deductible in participating facilities only.
Physician's Office: 80% covered after in network deductible; 60% covered after out of network deductible.
Outpatient Substance Abuse* Treatment - in an approved facility
100% covered after in network deductible; 80% covered after out of network deductible (in-network cost-sharing will apply if there is no PPO network)
80% covered after in network deductible; 60% covered after out of network deductible (in-network cost-sharing will apply if there is no PPO network)
*Some mental health and substance abuse services are considered by BCBSM to be comparable to an office visit.  When a mental health and substance abuse service is considered by BCBSM to be comparable to an office visit, you pay only for an office visit.
Autism Spectrum Disorders, diagnoses and treatment100% covered after deductible for both in network and out of  network providers80% covered after deductible for both in network and out of  network providers
Autism Spectrum Disorders – Outpatient Physical/Speech/ Occupational Therapy, and nutritional counseling  100% covered after in network deductible; 80% covered after out of network deductible.80% covered after in network deductible; 60% covered after out of network deductible.
Autism Spectrum Disorders – Other covered services including mental health services100% covered after in network deductible; 80% covered after out of network deductible80% covered after in network deductible; 60% covered after out of network deductible
Outpatient Diabetes Management Program100% covered after in network deductible for diabetes medical supplies; 100% covered in network (no deductible or copay/coinsurance) for diabetes self-management training; 80% covered after out of network deductible.80% covered after in network deductible for diabetes medical supplies; 100% covered in network (no deductible or copay/coinsurance) for diabetes self-management training; 60% covered after out of network deductible.
Allergy Testing/Therapy100% covered (no deductible or copay/coinsurance); 80% covered after out of network deductible.100% covered (no deductible or copay/coinsurance); 60% covered after out of network deductible.
Benefits PPO 1 PPO 2
Chiropractic care Chiropractic manipulation & Osteopathic manipulation therapy$10 office visit with in-network providers; 80% covered after out of network deductible.  Up to 24 visits per calendar year.$10 office visit with in-network providers; 60% covered after out of network deductible.  Up to 24 visits per calendar year.
Outpatient Physical, Speech & Occupational Therapy – provided for rehabilitation100% covered after in network deductible; 80% covered after out of network deductible. Note: Services at non-participating outpatient physical therapy facilities are not covered. Limited to a combined 60 maximum visits per member per calendar year.80% covered after in network deductible; 60% covered after out of network deductible. Note: Services at non-participating outpatient physical therapy facilities are not covered. Limited to a combined 60 maximum visits per member per calendar year.

Durable Medical Equipment

Note: For a list of covered DME items required under the PPACA call BCBSM.

100% covered after in network deductible80% covered after in network deductible
Prosthetic and Orthotic Appliance 100% covered after in network deductible80% covered after in network deductible
Private Duty Nursing50% covered after in network deductible
Hearing Evaluation/  Hearing Aids100% coverage includes hearing evaluation, hearing aids every 36 months up to plan limit of $1,800 for one aid or $3,600 binaural. Adults must get referral form from in-network physician and children 18 and younger must be referred by Ear Nose Throat (ENT) doctor.  No coverage for non- participating providers.100% coverage includes hearing evaluation, hearing aids every 36 months up to plan limit of $1,800 for one aid or $3,600 binaural.  Adults must get referral from from in-network physician and children 18 and younger must be referred by Ear Nose Throat (ENT) doctor.  No coverage for non-participating providers.
Prescription DrugsCovered under a separate provider, CVS/CaremarkCovered under a separate provider, CVS/Caremark


 

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