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

- Specified Preventive Drugs2,3

- Generic

- Brand Preferred

- Brand Non-Preferred

100% covered2,3

$10 copay

20% (min $30, max $90)

30% (min $60, max $120)

Pharmacy Retail/Mail Order

90-day supply

- Specified Preventive Drugs2,3

- Generic

- Brand Preferred

- Brand Non-Preferred

100% covered2,3

$30 copay

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.
3) As specified in essential drug list.