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PPO Plan Costs & Coverage Details

The document outlines the details of a PPO health insurance plan, including deductibles, coinsurance amounts, and costs for different services both in-network and out-of-network. In-network services have lower deductibles and coinsurance amounts than out-of-network services. Preventive care is covered at 100% in-network. Office visits, procedures, and prescriptions may require deductibles, copays, or coinsurance depending on whether they are in or out-of-network.

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75 views2 pages

PPO Plan Costs & Coverage Details

The document outlines the details of a PPO health insurance plan, including deductibles, coinsurance amounts, and costs for different services both in-network and out-of-network. In-network services have lower deductibles and coinsurance amounts than out-of-network services. Preventive care is covered at 100% in-network. Office visits, procedures, and prescriptions may require deductibles, copays, or coinsurance depending on whether they are in or out-of-network.

Uploaded by

nathan wong
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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What You Pay in the PPO Plan

PPO Plan Details In-Network Out-of-Network


Deductible* $1,500 Individual $4,500 Individual
$4,500 Family $13,500 Family

Coinsurance Plan pays 80% after deductible Plan pays 50% after deductible
You pay 20% after deductible You pay 50% after deductible

Out-of-Pocket Maximum $5,500 Individual $10,000 Individual


$11,000 Family $20,000 Family

Preventive Care Covered at 100% You meet your deductible, then pay
50% coinsurance

Telehealth $40 copay $40 copay

Primary Care Office Visit $25 copay

Specialist Office Visit You meet your deductible, then pay


You meet your deductible, then pay
20% coinsurance
50% coinsurance
Urgent Care You meet your deductible, then pay
20% coinsurance

Emergency Room You meet your deductible, then pay You meet your deductible, then pay
20% coinsurance 20% coinsurance

Hospitalization Meet your deductible, then pay 20% Meet your deductible, then pay 50%
coinsurance. coinsurance.

Lab, X-Ray, Imaging You meet your deductible, then pay You meet your deductible, then pay
20% coinsurance. MRI’s require pre- 50% coinsurance. MRI’s require pre-
notification. notification.**

Mental Health Available through Optum. See the Mental Health section for more information.

Prescription Drugs*** – You don’t have to meet your deductible before you receive a benefit for prescription
drugs, as long as you use a network pharmacy.
Pharmacy-Filled Generic $12 copay

Pharmacy-Filled formulary You pay 30% You pay 50% coinsurance ($50
($40 min / $80 max) minimum) of reasonable and
customary charges
Pharmacy-Filled Non-formulary You pay 50%
($80 min / $160 max)

Mail Ordered Generic $30 copay

Mail Ordered formulary You pay 30%


($80 min / $160 max) N/A

Mail Ordered Non-formulary You pay 50%


($180 min / $350 max)

*In-network and out-of-network deductibles are separate. Only in-network services apply toward your in-network deductible,
and only out-of-network services apply to your out-of-network deductible.

**There is a pre-call requirements for MRI and CT scans for all participants. There is Penalty of $200 if this call is not made
before imaging.
***New for 2017: If you (as a plan participant) receive a brand name drug in place of a generic in either of the situations below,
the plan will only cover the cost of the generic drug, requiring the you to pay the cost difference between the generic drug
and the brand name drug:

The doctor writes a prescription for a brand name drug and indicates the patient (plan participant) should not be switched
to the generic.
The patient (plan participant) tells the pharmacist that they are only to have the brand name drug and that they do not want
to be switched to a generic.

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