PPO Plan Summaries
Base Plan (All States) Premium Plan (All States) HSA - Prudent Buyer PPO Classic - Prudent Buyer PPO In-network Coverage Shown (Out-of-Network options apply)
Plan Highlights
Annual Calendar Year Deductible Individual / Family Maximum Calendar Year Out-of-Pocket Individual / Family
$4,000 / $8,000
$1,500 / $4,500
$7,000 / $14,000
$5,000 / $10,000
Professional Services
Primary Care Physician (PCP) Office Visit
20% coinsurance after ded. 20% coinsurance after ded.
$40 copay per visit $60 copay per visit
Specialist Office Visits Preventative Care Exam
No charge No charge
No charge No charge
Well-baby Care
Diagnostic Lab and X-Ray
20% coinsurance after ded. 20% coinsurance after ded. 20% coinsurance after ded.
20% coinsurance after ded. 20% coinsurance after ded. 20% coinsurance after ded.
Complex Diagnostics (MRI / CT Scan) Rehab Services (Physical, Occupational & Speech) Office Visit Acupuncture & Chiro via ASH ( 20 combined visits/benefit period) Acupuncture & Chiro via the Medical Group ( 20 visits/benefit period)
20% coinsurance after ded.
$40 copay per visit
20% coinsurance after ded.
$40 copay per visit
Hospital Services
Inpatient Services Outpatient Surgery
20% coinsurance after ded. 20% coinsurance after ded. 20% coinsurance after ded. 20% coinsurance after ded. 20% coinsurance after ded.
20% coinsurance after ded. 20% coinsurance after ded. 20% coinsurance after ded. $150 after ded. then 20%
Ambulance
Emergency Room
Urgent care
$40 copay per visit
Maternity Care
Physician Services Hospital Services
20% coinsurance after ded. 20% coinsurance after ded.
20% coinsurance after ded. 20% coinsurance after ded.
Mental Health/Substance Abuse Services Inpatient
20% coinsurance after ded. 20% coinsurance after ded.
20% coinsurance after ded. 20% coinsurance after ded.
Outpatient Therapy
Recovery Services
Home health care - (100 visits per year)
20% coinsurance after ded. 20% coinsurance after ded. 20% coinsurance after ded.
20% coinsurance after ded. 20% coinsurance after ded. 20% coinsurance after ded.
Rehabilitation services
Skilled nursing care - (100 days per benefit period)
Prescription Drugs (30 day supply) Generic drugs - (Tier 1a / 1b) Preferred brand drugs - (Tier 2)
$5 / $15 copay after ded. $40 copay after deductible $60 copay after deductible 30% up to $250 after ded.
$5 / $20 copay
$30 copay $50 copay
Non-preferred brand drugs - (Tier 3)
Specialty drugs - (Tier 4)
30% coinsurance up to $250
10 Benefits Guide 2024-25
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