Medical Plans Highlights

 

Highlights of PPO Medical Plans

 

 Premium Plan Standard Plan Consumer Choice Plan

Pre-Existing Condition Exclusion

 None None None

Out-of-Pocket Expenses

 In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Deductible

 Individual: $450
Family: $900 		Individual: $1,000
Family: $2,000 		Individual: $2,700
Family: $5,450
(Full family deductible must be met before plan starts to pay.)

Annual Out-of-Pocket Maximum
(Includes deductible)

 Individual
$1,800
Family
$3,600		 Individual
$2,200
Family
$4,400		 Individual
$3,000
Family
$6,000		 Individual
$4,000
Family
$8,000		 Individual
$2,700
Family
$5,450		 Individual
$5,450
Family
$10,900

Benefits

 In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network

Coinsurance Paid After Deductible
(Applies to all professional services except those noted below.)

 You Pay 20% You Pay 40% You Pay 20% You Pay 40% Plan Pays 100% You Pay 40%

Office Visit Copays
(Copays do not apply to deductible or out-of-pocket maximum)

 You Pay 35% Subject to Deductible and Coinsurance You Pay 35% Subject to Deductible and Coinsurance Subject to Deductible
and Coinsurance

Lab Work/Professional Services

 Subject to Deductible
and Coinsurance		 Subject to Deductible
and Coinsurance		 Subject to Deductible
and Coinsurance, then
Plan Pays 100%

Emergency Room Visit Copayment

 Subject to Deductible
and Coinsurance		 Subject to Deductible
and Coinsurance		 Subject to Deductible
and Coinsurance, then
Plan Pays 100%

Wellness Benefit

 100% of In-Network
Eligible Charges 		100% of In-Network
Eligible Charges 		100% of In-Network
Eligible Charges

Benefit Limits

Maximum Lifetime Benefit
(Unless noted)

 Unlimited Unlimited Unlimited

Substance Abuse Treatment

 Subject to Deductible
and Coinsurance		 Subject to Deductible
and Coinsurance		 Subject to Deductible
and Coinsurance

Mental Illness

 Subject to Deductible
and Coinsurance		 Subject to Deductible
and Coinsurance		 Subject to Deductible
and Coinsurance

Chiropractic

 $2,000 annual limit for muscle manipulation expenses $2,000 annual limit for muscle manipulation expenses $2,000 annual limit for muscle manipulation expenses

Hearing Aids

 $1,500 Every 3 Years
Per Person Covered		 $1,500 Every 3 Years
Per Person Covered		 $1,500 Every 3 Years
Per Person Covered

Temporomandibular Join Dysfunction and Related Disorders

 $2,500 lifetime maximum $2,500 lifetime maximum $2,500 lifetime maximum

Physical, Occupational
and Speech Therapy

 $5,000 Per Therapy Type Per Year (Maximum does not apply to Therapy for Birth Defects or Developmental Abnormalities) $5,000 Per Therapy Type Per Year (Maximum does not apply to Therapy for Birth Defects or Developmental Abnormalities) $5,000 Per Therapy Type Per Year (Maximum does not apply to Therapy for Birth Defects or Developmental Abnormalities)

 

 

* If you see network providers, after you meet the network deductible, you pay 20% of the scheduled fee for network medical expenses (your coinsurance). If you go to an out-of-network provider, after you meet the in-network deductible, you pay the difference between the amount the out-of-network provider charges and the out-of-network eligible expense (this is the balance billing), plus 40% of the out-of-network eligible expense (your coinsurance). The balance billing does not count toward your annual out-of-pocket maximum.