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State PPO


Life Insurance





Standard PPO

The Standard PPO gives you the flexibility to see network or non-network providers, with a lower cost to you when you use network providers. In addition:

  • Network copays make doctor visit and prescription drug costs more predictable.
  • The plan pays 100% of allowed amounts for some preventive care services.
  • You meet a deductible and pay a coinsurance percentage of most other costs.

For more information, the State Employees' PPO Plan Booklet and Benefits Document. Use the Health Plan Cost Estimator to compare your options.

Plan Highlights

Standard PPO
Covers care received in or out network

You meet annual deductible



  • Individual



  • Family maximum deductible



What you pay for care received

  • Doctor office visits

$15/visit for PCP;
$25/visit for specialists

40% of non-network
allowed amount

  • Hospital stay

$250/admission then 20% of
network allowed amount

$500/admission then 40% of
non-network allowed amount

Prescription drugs (provided by Express Scripts)

Up to 30-day retail or up to 90-day mail order prescription



  • Generic

$7/retail; $14/mail order

Pay in full and file a claim

  • Preferred brand-name

$30/retail; $60/mail order

Pay in full and file a claim

  • Nonpreferred brand-name

$50/retail; $100/mail order

Pay in full and file a claim

Preventive care: some routine physical exams, health screenings and immunizations

100% of allowed amount;
see preventive care.

100% of non-network allowed amount; you pay amount between charge and allowed amount; see preventive care.

Annual coinsurance out-of-pocket maximum (not including deductible, copayments, cost of care not covered by plan, hospital admission, charges greater than the non-network allowed amount, charges greater than plan limitations, and pre-admission certification penalties)

  • Individual coverage

$2,500 network & non-network combined

  • Family coverage

$5,000 network & non-network combined


After your out-of-pocket coinsurance costs reach these maximums, for the rest of the calendar year, the plan pays 100% for covered coinsurance in most cases, up to the allowed amount or allowance.

Lifetime benefit maximum