PPO Tiered Network Commercial PPO Tiered Network Plans

PPO Tiered Network plans are available for large group (51+) customers. The plans give customers another way to lower costs while providing their employees with access to high-quality, affordable care.

The PPO Tiered Network is a broad access PPO network with no participating PPO providers excluded. All network PPO hospitals and ambulatory surgical centers (ASCs) were evaluated and assigned to one of two in-network benefit tiers based on cost and minimum quality standards:

  • Tier 1 — Members pay the lowest cost-sharing for hospital and outpatient surgery services.
  • Tier 2 — Members pay a higher cost-sharing for hospital and outpatient surgery services when compared to Tier 1.

The following provider types and services are subject to tiering:

  • Outpatient surgery at ASCs
  • Inpatient hospital admissions for medical and maternity care
  • Hospital-based outpatient radiology centers*
  • Hospital-based outpatient labs*

* Benefit tier placements for hospital-based outpatient radiology centers and labs follow their affiliated hospital. These hospital-based outpatient facilities were not evaluated separately from their affiliated acute care hospital.

Frequently Asked Questions

What are the criteria used for determining benefit tier placement?

Are all providers in the PPO Tiered Network assigned a benefit tier?

How do I know what cost-sharing amount to collect from a member enrolled in a PPO Tiered Network plan?

How do I know which benefit tier applies to the hospitals and ASCs to which I direct my patients?

How will I know if a member is covered through a PPO Tiered Network plan?

How can members enrolled in a PPO Tiered Network plan identify Tier 1 providers?

Which provider types and services are not subject to tiering?

How often will Independence update provider benefit tiers?

How do tiered network products impact my reimbursement rates?

Where can I find more information about the PPO Tiered Network?

What are the criteria used for determining benefit tier placement?
All in-network PPO hospitals and ASCs were evaluated and assigned to one of two in-network benefit tiers based on cost and minimum quality standards. Please also note the following:

  • Only hospitals within the Independence Blue Cross (Independence) five-county service area (i.e., Philadelphia, Delaware, Montgomery, Bucks, and Chester counties) were assigned benefit tier placements.
  • Hospitals within a health system were assigned the same benefit tier to keep member costs the same and reduce confusion.
  • Hospital-based outpatient radiology centers and labs are assigned the benefit tier of their affiliated hospital.

Are all providers in the PPO Tiered Network assigned a benefit tier?
While all Personal Choice® PPO providers are included in the tiered network, only facility providers (hospitals, ASCs, hospital-based labs/radiology) are included in tiering.

How do I know what cost-sharing amount to collect from a member enrolled in a PPO Tiered Network plan?
As you do today, continue to use the Eligibility and Benefits Inquiry transaction on the NaviNet® web portal to verify your patients’ cost-sharing amount for eligible services. The transaction will display the appropriate cost-sharing amounts for each in-network tier. Therefore, to determine the appropriate amount of cost-sharing, you will need to know the benefit tier placement for the hospitals and ASCs to which you direct your patients for care.

How do I know which benefit tier applies to the hospitals and ASCs to which I direct my patients?
Review the link below for a listing of our Tier 1 and Tier 2 hospitals arranged by county. Note: This document is current as of the revision date listed. For the most up-to-date information, use the Find a Doctor tool.

How will I know if a member is covered through a PPO Tiered Network plan?
In addition to using NaviNet to verify coverage, a unique ID card is issued to members enrolled in PPO Tiered Network plans to assist providers and members in recognizing the cost-sharing differences between in-network tiered services. ID cards display “PPO Tiered Network” (in the lower left corner) and member cost-sharing for primary care physician (PCP) office visit, specialist office visit (SPEC), emergency room (ER) visit, deductible (DED), and hospitalization (HOSP).

IBX member card

How can members enrolled in a PPO Tiered Network plan identify Tier 1 providers?
Members can use the Find a Doctor tool on ibx.com or log in to ibxpress.com to look for Tier 1 providers. “Personal Choice Tiered” has been added to the Select a Plan drop-down menu. Hospitals and ASCs display with a Tier 1 or Tier 2 indicator, and additional information is provided for members regarding the lower out-of-pocket cost when using a Tier 1 provider.

Which provider types and services are not subject to tiering?
The following provider types and services are not subject to tiering; therefore, member cost-sharing is the same across all in-network providers:

  • Primary care and specialist office visits
  • Emergency room
  • Urgent care centers
  • Non-hospital-based outpatient labs (LabCorp, independent labs)
  • Ambulance providers for emergency and non-emergency ambulance services
  • Physical, occupational, and speech therapists
  • Injectable medications (included allergy injections)
  • Chemotherapy/dialysis
  • Skilled nursing facilities for skilled nursing care
  • Hospice
  • Home health care
  • Durable medical equipment
  • Mental health and substance abuse services

How often will Independence update provider benefit tiers?
Independence will re-evaluate the benefit tier placements annually and will provide network providers with advance written notice of any changes to their benefit tier placement that will become effective on January 1 of the following year.

How do tiered network products impact my reimbursement rates?
You will be reimbursed in accordance with your applicable payment rates for commercial products.

Where can I find more information about the PPO Tiered Network?
Go to ibx.com/employers/large_business/medical to learn more about the Personal Choice PPO Tiered Network and the full large group product portfolio.

Contact Us

If you have questions about the PPO Tiered Network or your benefit tier placement, please send an email to the appropriate address based on your provider type: