Medical Plans
PPO Plan Highlights
|
Premium PPO Plan |
Standard PPO Plan |
Consumer Choice PPO Plan |
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| 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: $400 Family: $800 Maximum |
Individual: $1,000 Family: $2,000 Maximum |
Individual: $2,700 Family: $5,450 (Full family deductible must be met before plan starts to pay.) |
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| Annual Out-of-Pocket Maximum (Includes deductible) |
Individual $1,600 Family $3,200 |
Individual $2,000 Family $4,000 |
Individual $3,000 Family $6,000 |
Individual $4,000 Family $8,000 |
Individual $2,700 Family $5,450 |
Individual $5,400 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% |
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| Emergency Room Visit Copayment | Subject to Deductible and Coinsurance |
Subject to Deductible and Coinsurance |
Subject to Deductible and Coinsurance, then Plan Pays 100% |
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| Wellness Benefit | 100% of Eligible Charges to maximum $750 per participant annually – no deductible. Eligible Charges above $750 subject to deductible and coinsurance | 100% of Eligible Charges to maximum $750 per participant annually – no deductible. Eligible Charges above $750 subject to deductible and coinsurance | 100% of Eligible Charges to maximum $750 per participant annually – no deductible. Eligible Charges above $750 subject to deductible and coinsurance | |||
| Certain Periodic Preventive Services - Routine sigmoidoscopy - Routine colonoscopy - Bone mineral density - Immunizations |
100% of Eligible Charges – not subject to deductible or maximum | 100% of Eligible Charges – not subject to deductible or maximum | 100% of Eligible Charges – not subject to deductible or maximum | |||
| Benefit Limits | ||||||
| Maximum Lifetime Benefit (unless noted) | Unlimited | Unlimited | Unlimited | |||
| Chiropractic | $2,000 per year per covered person | $2,000 per year per covered person | $2,000 per year per covered person | |||
| Hearing Aids | $1,500 every three years per covered person | $1,500 every three years per covered person | $1,500 every three years per covered person | |||
| Temporomandibular Joint Dysfunction & related disorders | $2,500 | $2,500 | $2,500 | |||
| Physical, Occupational and Speech Therapy | $5,000 per therapy type per year (does not include therapy for birth defects or developmental abnormalities) | $5,000 per therapy type per year (does not include therapy for birth defects or developmental abnormalities) | $5,000 per therapy type per year (does not include therapy for birth defects or developmental abnormalities) | |||