This PPO plan gives you the option to choose any provider when you need care, although as always, you will pay less out of pocket when you see a provider who is in-network. If you receive care from an out-of-network provider, you will be responsible for the difference between the covered amount and the actual charges and you may be responsible for filing claims.
| 2025 PPO Plan Rates | ||||||
|---|---|---|---|---|---|---|
| Salary <$50,000 | Salary $50,000 - $100,000 | Salary >$100,000 | ||||
| Weekly | Bi-Weekly | Weekly | Bi-Weekly | Weekly | Bi-Weekly | |
| Employee Only | $66.38 | $132.76 | $66.84 | $133.68 | $66.84 | $133.68 |
| Employee + Spouse | $168.71 | $337.43 | $208.43 | $416.85 | $212.73 | $425.45 |
| Employee + Child(ren) | $138.04 | $276.07 | $170.53 | $341.06 | $174.04 | $348.09 |
| Employee + Family | $237.73 | $475.46 | $293.69 | $587.38 | $299.75 | $599.50 |
| PPO Information | ||
|---|---|---|
| In Network | Out Of Network | |
| General Services | ||
| Annual Deductible/Individual | $1,000 | $3,000 |
| Annual Deductible/Family | $3,000 | $9,000 |
| Annual Out-of-Pocket Limit/Individual | $6,000 | $15,000 |
| Annual Out-of-Pocket Limit/Family | $12,000 | $30,000 |
| Office Services | ||
| Co-Pays |
$35 - Primary Care, Urgent Care, Chiropractic and Specialty Visit $150 - Emergency Room (waived if admitted) |
$150 - Emergency Room (waived if admitted) |
| Office Visit/Exam | 30% After Deductible | 50% After Deductible |
| Virtual Visits | $0 Copy | |
| Specialist Visit | 30% After Deductible | 50% After Deductible |
| Urgent Care | 30% After Deductible | 50% After Deductible |
| Preventative Services | 100% Covered | 50% After Deductible |
| Hospital Services | ||
| Inpatient Hospital | 30% After Deductible | 50% After Deductible |
| Outpatient Surgery | 30% After Deductible | 50% After Deductible |
| Emergency Room | 30% After Deductible | 50% After Deductible |
