Page 1 - PPO_EPO

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Plan 1 P/E
Plan 2 P/E
Plan 3 P/E
In-Network
Out-of-Network
(PPO Only)
In-Network
Out-of-Network
(PPO Only)
In-Network
Out-of-Network
(PPO Only)
Benefit Period
Calendar year
Calendar year
Calendar year
Annual deductibles
$0 Individual
$0 Family
$500 Individual
$1,000 Family
$500 Individual
$1,000 Family
$1,000 Individual
$2,000 Family
$1,000 Individual
$2,000 Family
$3,000 Individual
$6,000 Family
Member coinsurance
None
30%
None
30%
20%
40%
Coinsurancemaximums*
$0 Individual
$0 Family
$3,000 Individual
$6,000 Family
$0 Individual
$0 Family
$6,000 Individual
$12,000 Family
$2,000 Individual
$4,000 Family
$5,000 Individual
$10,000 Family
Out of pocket maximum**
NA
NA
NA
NA
NA
NA
Preventive
Office visit (Preventive)
Periodic physical exams, well baby/child exams,
immunizations, routine eye and hearing exams
Covered
Not Covered
Covered
Not Covered
Covered
Not Covered
Immunizations, related lab tests & x-rays, pap
smears & mammograms
Covered
Not Covered
Covered
Not Covered
Covered
Not Covered
Outpatient Services
Office visit (PCP/Specialist)
$15/$30 copay
$20/$40 copay
$30/$50 copay
30% after deductible
$15/$30 copay
$20/$40 copay
$30/$50 copay
30% after deductible
$15/$30 copay
$20/$40 copay
$30/$50 copay
40% after deductible
Outpatient surgery and related services
$0 copay
$100 copay
30% after deductible
$0 copay after deductible
$100 copay after deductible
30% after deductible
20% after deductible
40% after deductible
Inpatient Services
Inpatient, Labor/Delivery, Mental Health,
Chemical Dependency
$0 copay
$500 copay
$1,000 copay
30% after deductible
$0 copay after deductible
$500 copay after deductible
$1,000 copay after deductible
30% after deductible
20% after deductible
40% after deductible
Emergency Services
Emergency care
$75 copay
$100 copay
$150 copay
$200 copay
$75 copay
$100 copay
$150 copay
$200 copay
$75 copay
$100 copay
$150 copay
$200 copay
$75 copay
$100 copay
$150 copay
$200 copay
$75 copay
$100 copay
$150 copay
$200 copay
$75 copay
$100 copay
$150 copay
$200 copay
Urgent care
$40 copay
$50 copay
$65 copay
$40 copay
$50 copay
$65 copay
$40 copay
$50 copay
$65 copay
$40 copay
$50 copay
$65 copay
$40 copay
$50 copay
$65 copay
$40 copay
$50 copay
$65 copay
Additional Benefits
Hearing Aids/Eyeglasses/Contact Lens
Optional
Not Covered
Optional
Not Covered
Optional
Not Covered
Prescription Drugs
Rx copay options
Generic/Preferred Brand/Non
Preferred Brand
$5/$30/$60
$10/$20/$40
$10/$40/$40
$10/$60/$60
$20/$40/$60
No Rx
$5/$30/$60
$10/$20/$40
$10/$40/$40
$10/$60/$60
$20/$40/$60
No Rx
$5/$30/$60
$10/$20/$40
$10/$40/$40
$10/$60/$60
$20/$40/$60
No Rx
Plan 4 P/E
Plan 5 P/E QHDHP
Plan 6 P/E QHDHP
In-Network
Out-of-Network
(PPO Only)
In-Network
Out-of-Network
(PPO Only)
In-Network
Out-of-Network
(PPO Only)
Calendar year
Calendar year
Calendar year
$2,000 Individual
$4,000 Family
$4,000 Individual
$8,000 Family
$2,000 Individual
$4,000 Family
$4,000 Individual
$8,000 Family
$3,000 Individual
$6,000 Family
$6,000 Individual
$12,000 Family
20%
40%
20%
50% after deductible
30%
50% after deductible
$5,000 Individual
$10,000 Family
$10,000 Individual
$20,000 Family
NA
NA
NA
NA
NA
NA
$5,000 Individual
$10,000 Family
$10,000 Individual
$20,000 Family
$5,000 Individual
$10,000 Family
$10,000 Individual
$20,000 Family
Preventive
Covered
Not Covered
Covered
Not Covered
Covered
Not Covered
Covered
Not Covered
Covered
Not Covered
Covered
Not Covered
Outpatient Services
$15/$30 copay
$20/$40 copay
$30/$50 copay
40% after deductible
20% after deductible
50% after deductible
30% after deductible
50% after deductible
20% after deductible
40% after deductible
20% after deductible
50% after deductible
30% after deductible
50% after deductible
Inpatient Services
20% after deductible
40% after deductible
20% after deductible
50% after deductible
30% after deductible
50% after deductible
Emergency Services
$75 copay
$100 copay
$150 copay
$200 copay
$75 copay
$100 copay
$150 copay
$200 copay
20% after deductible
50% after deductible
30% after deductible
50% after deductible
$40 copay
$50 copay
$65 copay
$40 copay
$50 copay
$65 copay
20% after deductible
50% after deductible
30% after deductible
50% after deductible
Additional Benefits
Optional
Not Covered
Not Covered
Not Covered
Not Covered
Not Covered
Prescription Drugs
$5/$30/$60
$10/$20/$40
$10/$40/$40
$10/$60/$60
$20/$40/$60
No Rx
$5/$30/$60 after deductible
$5/$30/$60 after deductible
PPO/EPO Plan Designs
* Coinsurance on certain services does
not accumulate toward the coinsurance
maximums. Please refer to individual benefit
summaries for details
** Out of Pocket Max includes deductible
and copays.
NOTE: The above comparisons are to be used
for general reference only. Please refer to
individual benefit summaries for specific
benefit levels for each service.