Consumer Choice PPO Plan
Coverage at a Glance
| Out-of-Pocket Expenses | In-Network | Out-of-Network |
Deductible |
Individual: $2,700 Family: $5,450 Maximum |
|
Annual Out-of-Pocket Maximum |
Individual: $2,700 Family: $5,450 |
Individual: $5,400 Family: $10,900 |
| Benefits | In-Network | Out-of-Network |
Coinsurance Paid After Deductible |
Plan Pays 100% | You Pay 40% |
Office Visit Copays |
Subject to Deductible and Coinsurance | |
Lab work/Professional Services |
Subject to Deductible and Coinsurance, then Plan Pays 100% | |
Emergency Room Visit Copayment |
Subject to Deductible and Coinsurance | |
Wellness Benefit |
100% of In-Network Eligible Charges (up to $750 annually) Per Person |
|
Periodic Preventive Services |
100% of Eligible Charges – not subject to deductible or maximum |
|
Pre-Existing Condition Exclusion |
None | |
| Benefit Limits | ||
Maximum Lifetime Benefit (unless noted) |
Unlimited |
|
Chiropractic |
$2,000 per year per covered person |
|
Hearing Aids |
$1,500 every three years per covered person |
|
Temporomandibular Joint Dysfunction & related disorders |
$2,500 |
|
Physical, Occupational and Speech Therapy |
$5,000 per therapy type per year (does not include therapy for birth defects or developmental abnormalities) |
|
| Coverage through Caremark network pharmacy or mail order only | Retail (30-day supply) |
Retail (90-day supply) |
Mail Order (90-day supply) |
| Generic Copay Preferred Brand Copay Non-Preferred Brand Copay |
Subject to same deductible and coinsurance as other medical benefits
|
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