|
Premium PPO Plan |
Standard PPO Plan |
Consumer Choice PPO 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: $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.) |
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% |
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
(Wellness benefits are not subject to frequency or age limitations) |
|
|
|
Routine Preventive Care |
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 |
Periodic Preventive Services |
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 |
Substance Abuse Treatment |
$10,000 annual maximum
$20,000 lifetime maximum |
$10,000 annual maximum
$20,000 lifetime maximum |
$10,000 annual maximum
$20,000 lifetime maximum |
Mental Illness |
Outpatient – 45 visits per year
Inpatient – 30 days per year |
Outpatient – 45 visits per year
Inpatient – 30 days per year |
Outpatient – 45 visits per year
Inpatient – 30 days per year |
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) |
