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Benefits-at-a-glance
for PPO Share Plans
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Plan
Benefits |
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Annual
Deductible Choices |
Individual
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$3,500/$5,000/$7,500
per member |
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Family
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Each family member
has an individual deductible.
Once 2 members each reach the
deductible, the deductible is
satisfied for the entire family.
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Annual
Out-of-Pocket Limit1
(in addition to deductible, if
any) |
Individual
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$4,000/$2,500/$0
per member |
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Family
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Each family member
has an individual deductible.
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Lifetime
Maximum |
Plan pays up
to $5 Million per member
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Covered
Services
The amounts shown are your share
of costs after any deductible
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Doctors’
Office Visits |
$40 copay (deductible
waived) |
50% of negotiated
fee plus all excess charges (deductible
waived) |
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Professional
Services
(x-ray, lab, anesthesia, surgeon,
etc.) |
30% of negotiated
fee (with $3500 and $5000 deductible
plans) or $0 (with $7500 deductible
plan) |
50% of negotiated
fee plus all excess charges (with
$3500 and $5000 deductible plans)
OR $0 (with $7500 deductible plan)
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Hospital
Inpatient
(overnight hospital stays)
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30% of negotiated
fee2 (with $3500 and
$5000 deductible plans) or $0
(with $7500 deductible plan)
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All charges except
$650 per day |
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Hospital
Outpatient
(if you don’t stay overnight)
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30% of negotiated
fee2 (with $3500 and
$5000 deductible plans) or $0
(with $7500 deductible plan)
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All charges except
$380 per day |
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Emergency
Room Services
($100 copay applies for each visit;
waived if admitted as inpatient)
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30% of negotiated
fee2 (with $3500 and
$5000 deductible plans) or $0
(with $7500 deductible plan)
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30% of customary
and reasonable fees plus all excess
charges (with $3500 and $5000
deductible plans) OR $0 (with
$7500 deductible plan) |
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Maternity
|
30% of negotiated
fee (with $3500 and $5000 deductible
plans) or $0 (with $7500 deductible
plan) |
50% of negotiated
fee plus all excess charges (with
$3500 and $5000 deductible plans)
OR $0 (with $7500 deductible plan)
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Preventive
Care
(tests ordered by physician are
covered, including appropriate
screening for breast, cervical,
ovarian, and prostate cancer)
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Adult
Services |
Annual Physical
exam(s)3: 30% of negotiated
fee (deductible waived)
OR HealthyCheckSM
Centers: $25 / $75 copay for basic/premium
screening (deductible waived)
Routine mammogram,
Pap and PSA tests: 30% of negotiated
fee (deductible waived)
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50% of negotiated
fee plus all excess charges (deductible
waived) |
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Children's
Services |
Well-Child (through
age 6): 40% of negotiated fee
(deductible waived) |
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Acupuncture
/ Acupressure |
All charges except
$30 per visit, up to 24 visits
per year (deductible waived)
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Chiropractic
Services |
30% of negotiated
fee (with $3500 and $5000 deductible
plans) or $0 (with $7500 deductible
plan) |
All charges except
$25 per visit |
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Plan covers up
to 12 visits per year |
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Prescription
Drug Coverage Options |
In-Network
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Out-of-Network
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Comprehensive
Prescription Drug Coverage
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For $5000 deductible
plan:
Generic (Tier
1): $15 copay
Brand-name (Tier
2): $35 copay after $750 annual
brand-name deducible (2 member
max)
For $3500 and
$7500 deductible plans:
Generic (Tier
1): $15 copay or 40%, whichever
is greater.
Brand-name (Tier
2): $15 copay or 40%, whichever
is greater after $750 annual brand-name
deducible (2 member max)
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50% of drug limited
fee schedule and all excess charges
plus the copay/coinsurance as
stated for in-network benefits;
subject to the $750 annual brand-name
prescription drug deductible
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Generic
Prescription Drug Coverage
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Included above
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No
Prescription Drug Coverage
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