Back
PPO
Copay-based plan with the lowest deductible and broadest network flexibility.
Plan details
Availability
All eligible employees
HSA Eligible
No
FSA Eligible
Yes
Premium contributions
PPO : Full-Time
| Coverage Tier | Premium | Non-Tobacco | Tobacco |
|---|---|---|---|
| Employee Only | Bi-weekly | $89.38 | $112.45 |
| Weekly | $44.69 | $56.23 | |
| Employee + Spouse | Bi-weekly | $196.63 | $219.71 |
| Weekly | $98.32 | $109.85 | |
| Employee + Child(ren) | Bi-weekly | $165.35 | $188.42 |
| Weekly | $82.67 | $94.21 | |
| Employee + Family | Bi-weekly | $286.01 | $309.09 |
| Weekly | $143.01 | $154.54 |
PPO : Part-Time
| Coverage Tier | Premium | Non-Tobacco | Tobacco |
|---|---|---|---|
| Employee Only | Bi-weekly | $89.38 | $112.45 |
| Weekly | $44.69 | $56.23 | |
| Employee + Spouse | Bi-weekly | $338.84 | $361.92 |
| Weekly | $169.42 | $180.96 | |
| Employee + Child(ren) | Bi-weekly | $284.93 | $308.01 |
| Weekly | $142.46 | $154.00 | |
| Employee + Family | Bi-weekly | $492.86 | $515.94 |
| Weekly | $246.43 | $257.97 |
Deductible and Out-of-Pocket
| Detail | In-Network | Out-of-Network |
|---|---|---|
| Deductible (Individual) | $500 | $5,000 |
| Deductible (Family) | $1,000 | $10,000 |
| Coinsurance (plan pays) | 80% after deductible | 50% after deductible |
| Out-of-Pocket Max (Individual) | $3,500 | $10,000 |
| Out-of-Pocket Max (Family) | $7,000 | $20,000 |
What you pay per visit
| Service | In-Network | Out-of-Network |
|---|---|---|
| Preventive Care | 100% | 50% after deductible |
| Primary Care Visit | $25 copay | 50% after deductible |
| Specialist Visit | $50 copay | 50% after deductible |
| Diagnostic Care | 100% after deductible | 50% after deductible |
| Urgent Care | $75 copay | 50% after deductible |
| Emergency Room | $250 copay + 20% after deductible | $250 copay + 20% after deductible |
Pharmacy benefits
| Tier | RETAIL (30-DAY) IN-NETWORK | RETAIL (30-DAY) OUT-OF-NETWORK | Mail order (90-day) |
|---|---|---|---|
| Generic | $10 copay | $10 copay + 20% | $25 copay |
| Preferred | $30 copay | $30 copay + 20% | $75 copay |
| Non-Preferred | $60 copay | $60 copay + 20% | $150 copay |
Mail order is not available out-of-network.
PPO plan contacts
BCBS of TX
BCBS of TX (Prime Therapeutics) — Pharmacy