Blue Cross PPO Saver Plan:

Many times, people feel that a PPO type health insurance plan is out of their reach. However, Blue Cross has a PPO Saver plan that can give you the benefits you need from a PPO type plan without excessive fees. If you are interested in a PPO-type plan, but your budget will only allow for an HMO, you may want to take a look at what this plan has to offer. This plan features a separate hospital deductible that is much lower than the overall annual deductible.

Lifetime Maximum - Under this plan, you will receive a maximum benefit of $5,000,000 for participating and non-participating providers.

Annual Out-of-Pocket Maximum - Your annual out-of-pocket maximum with this plan is $5000, which includes your deductible. This amount is combined between participating and non-participating providers.

Annual Deductible - For services at participating providers, there is a $500 hospital deductible, and a $5000 deductible for other services covered by this plan. The deductible for non-participating providers is the same, but it is not combined. This means that your deductible could reach $10,000 per year if you see both participating and non-participating providers.

Office Visits - Well-child check-ups under this plan will cost 50% of the negotiable fee for participating and non-participating providers. You are allotted 2 adult visits and 4 child visits under this plan with a $30 co-pay for each visit for participating providers. Your deductible is waived for these visits. For office visits with non-participating providers, you will need to pay 50% of the negotiated fee. Visits to non-participating providers are subject to your deductible.

Professional Services - Professional services are defined as x-ray, lab costs, anesthesia, surgeon fees or other office visits. For participating providers, you will need to pay 20% of the negotiated fee for only services that are provided in a hospital. For out of hospital services, once you have met your out-of-pocket maximum, 100% is covered. If you need professional services from a non-participating provider, you will then need to pay 50% of the negotiated fee, as well as 100% of any excess fees.

Hospital Inpatient/Outpatient - This plan requires a 20% co-insurance fee for hospital inpatient and outpatient care received from a participating provider. If you need inpatient or outpatient care are a hospital that is not a participating provider, you will pay for all charges minus $650 per day for inpatient care and $380 per day for outpatient care.

Hospice - The lifetime maximum amount of coverage for both participating and non-participating providers under this plan is combined and will not exceed $10,000.

Emergency Services - Once you have met the $500 deductible for emergency services for participating providers, you will need to pay for 20% of the negotiated fee for these services. If you visit a non-participating provider for these services, you will have to pay 20% of the “customary and reasonable” expenses for the first 48 hours that you receive treatment, as well as 100% of any excess fees. After this time has elapsed, you will have to pay for all charges, minus $650 per day for covered services.

Maternity Coverage - This plan does not provide any maternity coverage. If this is a benefit you think you will need, please discuss your options with your insurance representative.

Preventative Care - Preventative care services at participating providers will require a co-pay of $25 or $75. This is for basic screenings, PSA and Cancer screenings, as well as routine mammograms. After this co-pay, you will have to pay 20% of the negotiated fee for these services, and your deductible is waived. If you seek preventative care from a non-participating provider, you will pay 50% of the negotiated fee as well as 100% of any excess charges.

Ambulance - There is a $750 trip maximum for participating providers and you will need to pay 20% of the negotiated fee. If your ambulance service is not a participating provider, this means that you will need to pay 50% of the “customary and reasonable” amount for these services, and 100% of any excess fees.

Physical and Occupational Therapy and Chiropractor Services - Unlike many plan, the PPO Saver plan does offer coverage for some physical therapy. You may have up to twelve visits per year, combined between participating and non-participating providers. For participating providers, you will need to pay 20% of the negotiated fee. Treatment at non-participating providers requires payment of all charges, minus $25 per visit.

Acupuncture and Acupressure Therapy - Some alternative therapies are covered by this plan. You are allowed up to 24 visits to an acupuncturist or acupressurist per year, combined between participating and non-participating providers. You will need to pay for all charges except for $25 per visit.

Prescription Benefits - This plan provides coverage for retail or mail order prescriptions, up to a 30-day supply. There is a $10 co-pay for generic prescriptions and a $30 Co-pay for brand name prescriptions. Brand prescriptions are subject to a $500 brand deductible each year. If you require self-administered injectables, minus insulin, you will need to pay 30% of the negotiated fee. Non-formulary prescriptions from a participating provider are charged in the following manner: 50% for generic drugs and 100% of the negotiated fee for brand name prescriptions.

Non-participating provider prescriptions require 50% of the cost of the prescription for generic and brand name prescriptions as well as 100% of the excess. There is also a $500 brand deductible for brand name prescriptions.

It is important to remember that charges incurred from non-participating providers that are over the negotiated fee will not be paid under this plan and further, they will not count towards your out-of-pocket maximum.

There is a $500 admission charge at participating hospitals for infusion therapy or for surgery, unless the hospital is a Preferred Participating hospital or if the admission is the result of a medical emergency or for an Ambulatory Surgical Center. In addition, if you require a visit to the emergency room, there is a $30 co-pay unless you are admitted as an inpatient.

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