PPO Plan Coverage

 

Premium PPO Plan

Standard PPO Plan

Consumer Choice
PPO Plan

​Benefits

​In-Network

​Out-of-Network

​​In-Network

​​Out-of-Network

​​In-Network

​​Out-of-Network

​Coinsurance Paid After Deductible
(Applies to all professional services except those noted below.)

​You Pay 20%

​You Pay 40%

​You Pay 20%

​You Pay 40%

Plan Pays 100%​

​You Pay 40%

​Office Visit Copays
(Copays do not apply to deductible or out-of-pocket maximum)

​You Pay 35%

​Subject to Deductible and Coinsurance

​You Pay 35%​

​Subject to Deductible and Coinsurance

​ ​Subject to Deductible and Coinsurance

​Lab work/Professional Services

​​Subject to Deductible

and Coinsurance

​​Subject to Deductible

and Coinsurance

​Subject to Deductible and

Coinsurance, then Plan Pays 100%

​Emergency Room Visit Copayment

​​Subject to Deductible

and Coinsurance

​​Subject to Deductible

and Coinsurance

​Subject to Deductible and

Coinsurance, then Plan Pays 100%

​Pre-Existing Condition Exclusion

​None

​None

​None

​Wellness Benefit

​100% of Eligible Charges

​100% of Eligible Charges

​100% of Eligible Charges

​Certain Periodic Preventive Services
- Routine sigmoidoscopy
- Routine colonoscopy
- Bone mineral density
- Immunizations

​100% of Eligible Charges – not subject to deductible or maximum

​100% of Eligible Charges – not subject to deductible or maximum

​100% of Eligible Charges – not subject to deductible or maximum

​Maximum Lifetime Benefit (unless noted)

​Unlimited

​Unlimited

​Unlimited

​Substance Abuse Treatment

​Subject to Deductible

and Coinsurance

​Subject to Deductible

and Coinsurance

​Subject to Deductible

and Coinsurance

​Mental Illness

​Subject to Deductible

and Coinsurance

​Subject to Deductible

and Coinsurance

​Subject to Deductible

and Coinsurance

​Chiropractic

​Subject to Deductible

and Coinsurance

​Subject to Deductible

and Coinsurance

​Subject to Deductible

and Coinsurance

​Hearing Aids

​$1,500 every three years per covered person

​$1,500 every three years per covered person

​$1,500 every three years per covered person

​Temporomandibular Joint Dysfunction & related disorders

​Subject to Deductible

and Coinsurance

​Subject to Deductible

and Coinsurance

​Subject to Deductible

and Coinsurance

​Physical, Occupational and Speech Therapy

​Subject to Deductible

and Coinsurance

​Subject to Deductible

and Coinsurance

​Subject to Deductible

and Coinsurance


 


 

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