Standard PPO

You meet annual deductible

• Individual
• Family maximum deductible

Network

• $250
• $500

Non-Network

• $750
• $1,500

What you pay for care received

• Doctor office visits




• Hospital stay

• $15/visit for PCP;
  $25/visit for specialists
  
  
• $250/visit then 20% of
  network allowed amount

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

• Prescription drug (prodivded by Caremark)


• generic
• preferred brand
• non-preferred brand

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

$10/retail; $20/mail order
$25/retail; $50/mail order
$40/retail; $80/mail order

Pay in full and file a claim
Pay in full and file a claim
Pay in full and file a claim

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

100% of allowed amount;
see preventive care.

40% of non-network allowed amount plus amount between charge and allowed amount; see preventive care.

Annual out-of-pocket maximum (not including deductible, copayments, cost of care not covered by plan)

• Individual coverage
• Family coverage

• $2,500 network & non-network combined
• $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