RXINSIDER 2025
PPO Plan
The PPO plan gives you the freedom to seek care from the provider of your choice.
However, you will maximize your bene�ts and reduce your out-of-pocket costs if you
choose a provider participating in the (carrier name/network name) network.
The calendar year deductible must be met before certain services are covered.
Blue Cross Blue Shield (BCBS) – Side-by-Side Medical Bene�t Summary
Medical Plan
PPO 500
In-Network
PPO 1500
In-Network
Deductible
• Employee Only
• Family
$500
$1,000
$1,500
$3,000
Out-of-Pocket Limit
• Employee Only
• Family
$1,800
$3,600
$6,000
$12,000
Preventive Care
Primary Care Visit (PCMH)
Primary Care Visit (Non PCMH)
Specialist Visit
Emergency Room
Urgent Care
No Charge
$10/Copay
$20/Copay
$30/Copay
$100/Copay
$50/Copay
No Charge
$20/Copay
$30/Copay
$40/Copay
$200/Copay
$100/Copay
Prescription Drugs
Retail
• Tier 1 Lowest Cost Generic Drugs
• Tier 2 Low-Cost Generic Drugs
• Tier 3 Higher Cost Generic and Preferred Brand Name Drugs
$10/Copay
$25/Copay
$35/Copay
$10/Copay
$40/Copay
$70/Copay
Mail Order
• Tier 1 Lowest Cost Generic Drugs
• Tier 2 Low-Cost Generic Drugs
• Tier 3 Higher Cost Generic and Preferred Brand Name Drugs
$25/Copay
$62.50/Copay
$87.50/Copay
$25/Copay
$100/Copay
$175/Copay
BCBS Medical Bene�ts