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 $750 $1,500 |
Annual Out-of-Pocket Max - Associate - Family | Embedded $3,500 $7,000 |
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 | Yes Combined with medical |
$0 copay (no deductible) 20% (min $30, max $90) 30% (min $60, max $120) | |
Pharmacy Retail/Mail Order | 90-day supply |
$ copay (no deductible) 20% (min $90, max $270) 30% (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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