With the PPO Plan , you can see both in-network and out-of-network providers without a referral, but keep in mind staying in-network for care will almost always be less expensive.
PPO Plan | |||||||||||||||||||||||||||||||||||
Where Available | Nationwide | ||||||||||||||||||||||||||||||||||
Annual Deductible - Associate - Family | Embedded $900 $1,800 Annual Out-of-Pocket Max - Associate - Family Embedded $3,750 $7,500 IN-NETWORK - YOU PAY Preventive Care $02 Teladoc Telemedicine Visit - Medical - Mental Health $20 per visit $20 per visit Office Visit - PCP - Specialist 20%1 20%1 Urgent Care 20%1 Emergency Room 20%1 Diagnostic Testing 20%1 Outpatient X-Ray and Lab 20%1 Hospitalization - Inpatient Semi-Private Room - Inpatient Physician 20%1 20%1 Outpatient Treatment (Physical, Occupational & Speech Therapy) 20%1 Mental Health/Substance Abuse - Inpatient - Outpatient 20%1 20%1 Pharmacy Retail 30-day supply - Annual Deductible Applies - Pharmacy Out-of-Pocket Max No Combined with medical $0 copay (no deductible) $10 copay 20%2 (min $30, max $90) 30%2 (min $60, max $120) Pharmacy Retail/Mail Order 90-day supply $0 copay (no deductible) $30 copay 20%2 (min $90, max $270) 30%2 (min $180, max $360) | ||||||||||||||||||||||||||||||||||
1) Coinsurance you pay after you meet the annual deductible unless otherwise noted.
2) Annual deductible waived.
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