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.
| PPO Information | ||
|---|---|---|
| In Network | Out Of Network | |
| General Services | ||
| Annual Deductible/Individual | $2,500 | $7,000 |
| Annual Deductible/Family | $5,000 | $15,000 |
| Annual Out-of-Pocket Limit/Individual | $7,500 | $22,500 |
| Annual Out-of-Pocket Limit/Family | $15,000 | $45,000 |
| Office Services | ||
| Primary Care Physician | $30 Copay | 50% After Deductible |
| Specialist | $60 Copay | 50% After Deductible |
| Urgent Care | $50 Copay | 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 |
Along the way, you may also be required to pay a fixed amount – or copay – each time you see a provider.
