BLUECHOICE PPO
Columbus Consolidated Government
 
 

IN-NETWORK

OUT-OF-NETWORK
CHOICE OF PROVIDER Choice of any doctor and hospital in the PPO Network. Any licensed doctor or hospital.
Annual Deductible

Individual $300
Family $600

Individual $300
Family $600
Covered Percentage

80%

60%
Annual Out-of-Pocket Maximum Deductible and co-payments are excluded from out-of-pocket maximums.

Individual $2,000
Family $4,000

Individual $4,000
Family $8,000
Lifetime Maximum

$2,000,000

$2,000,000
OFFICE SERVICES    
Primary Care Physician (PCP) Office Visit

You pay a $15 co-payment per visit

You pay 40% after deductible
Specialty Care Physician (SCP) Office Visit

You pay a $25 co-payment per visit

You pay 40% after deductible
Annual Gynecological Exam by PCP
Annual Gynecological Exam by SCP

You pay a $15 co-payment per visit
You pay a $25 co-payment per visit

Not Covered
Maternity Services (Physician care per pregnancy)

You pay a $100 co-payment per pregnancy

You pay 40% after deductible
Mammograms by SCP

Included in office visit co-payment

You pay 40% after deductible
Pap Smear

Included in office visit co-payment

You pay 40% after deductible
Prostate Screening

Included in office visit co-payment

You pay 40% after deductible
Periodic Health Assessment

You pay a $15 co-payment per visit

Not Covered
Flu Shots

Included in office visit co-payment

Not Covered
Well Baby Care

You pay a $15 co-payment per visit

Not Covered
INPATIENT SERVICES    
Semi-Private Room, Board and Other Covered Services

You pay 20% after deductible

You pay 40% after deductible
EMERGENCY SERVICES (EMERGENCY ROOM)  
Medical emergencies are paid at 100% after emergency room co-payment. No benefits for non-emergency visit to the emergency room.

You pay a $50 co-payment per visit

You pay a $50 co-payment per visit
OTHER SERVICES You pay a $20 co-payment per prescription for a 30 day supply plus the difference between the brand name and the generic if brand name is chosen when generic is available
Prescription Drugs You pay a $20 co-payment for generic, $30.00 for brand name and $50.00 for non-formulary per prescription for a 30 day supply.  
Mail Order Prescription Drugs
 Long-term or maintenance medication		 You pay a $40 co-payment for generic, $60.00 for brand name and $100.00 for non-formulary  per prescription for a 90 day supply from PrecisionRX  
Physical Therapy, Occupational Therapy and Chiropractic Care (30 visits combine per calendar year)

You pay 20% after deductible

You pay 40% after deductible
MENTAL HEALTH/SUBSTANCE    
Inpatient – 30 days per year

You pay 20% after deductible

You pay 50% after deductible
Outpatient – 20 days per year

You pay 20% after deductible

You pay 50% after deductible
     
     

This outline is designed only to provide a summary of benefits.
The particulars set forth within the master contract will control

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