Blue Cross Small Group PPO $20 Co-Pay Plan:

The next PPO-type plan offered by Blue Cross for small group customers is similar in many ways to the previous plans. However, the co-pays are much lower and the co-insurance amounts are lower as well. The prescription coverage is slightly different from the other plans as well. As with the other PPO-type plans, there is a $5,000,000 maximum benefit amount under this plan.

Annual Deductible - This plan as a $250 annual deductible. Office visits, an annual physical exam, Healthy Check screenings and prescriptions are not subject to this deductible.

Annual Out-of-Pocket Maximum - Your employees can expect to pay $3000 out of their own pockets each year with this plan if they visit a participating provider. For visits and services with non-participating providers, the annual out-of-pocket maximum goes up to $5000 per year.

Office Visits - These visits will not be subject to the plan deductible. There are twelve allowed visits per year, with a $20 co-pay for each visit. If your employees require more than twelve office visits per year, they will then need to pay 40% of the negotiated fee for their visit. For office visits with non-participating providers, your employees will be expected to pay 40% of the customary and reasonable charges, as well as 100% of any excess charges above and beyond this coverage.

Other Professional Services - If your employees’ require maternity care, lab work, x-rays or other professional services that are not classified under an office visit, there is a 20% co-insurance fee if they receive these services from a participating provider. Otherwise, the costs go up to 40% of the customary and reasonable fee amount as well as 100% of any additional costs.

Hospital Inpatient Coverage - For inpatient care that is provided by a participating hospital, your employees’ will need to pay 20% of the negotiated fee, once they have met their annual deductible. For non-participating hospitals, these costs move up to 40% of the customary and reasonable fee and 100% of any additional fees. For professional services, such as anesthesia, lab fees or physician fees, the same pay schedule is used.

Outpatient Care - Once your employees reach their annual deductible, they will need to pay for 20% of their outpatient care with a participating provider. If they receive outpatient care from a physician or clinic that is not a participating provider, this amount goes up to 40% of the customary and reasonable charges and 100% of the additional fees, once they have met their deductible.

Prescription Drugs - Your employees will be able to purchase either a 30-day supply from a pharmacy or a 60-day supply via mail order or Internet order. There is a $15 co-pay for generic prescriptions and a $25 co-pay for brand name prescriptions. There is no brand-name deductible for these prescriptions and the medications are not subject to the annual plan deductible. The charges at a non-participating pharmacy go up to 40% of the limited fee schedule and 100% of the additional charges for prescriptions, regardless of their classification.

Physical Exam - There is a $20 co-pay for an office visit and a requirement of 20% co-insurance for a physical exam with a participating provider. There is a maximum $200 payment threshold for members that have been covered by Blue Cross for more than six months, and a $100 threshold for members that have been covered for less time. Once again, the charges for a non-participating provider move up to 40% of the customary and reasonable amount and 100% of the excess charges.

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