Microsoft Word - 2024.25 Company Benefits Summary_Dean PPO

Medical CENTURY 21 Affiliated provides group health insurance through Dean Healthcare. To provide PPO members access to physicians and facilities throughout Wisconsin and outside of Wisconsin, DHP partners with First Health. Three (3) PPO options are below with election options and premium amounts. For more information on the health insurance and in-network providers, visit www.deancare.com/find-a-doctor/ppo-providers, then select “Find a First Health Provider”.

OPTION

PPO OPTION 1

PPO OPTION 2

PPO OPTION 3

Network Name

Dean $5000 PPO

Dean $1000 PPO

Dean $500 PPO

Benefits

In-Network

Non-Network

In-Network

Non-Network

In-Network

Non-Network

Deductible Ind/Family

$5,000 / $10,000

$10,000 / $20,000

$1,000 / $3,000

$2,000 / $6,000

$500 / $1,000

$1,000 / $2,000

1 & 2 Tier is 50% coins. 3 & 4 not covered 40% coinsurance after deductible

1 & 2 Tier is 50% coins. 3 & 4 not covered 40% coinsurance after deductible

1, 2, & 4 Tier is 50% coins. 3 Tier is not covered

$10 / $50 / $80 / 25% coinsurance

$10 / $50 / $80 / /25% coinsurance

$10 / $15 / $60/ $100

RX Benefit

40% coinsurance after deductible

PCP Office Visits

$20 Copayment

$20 Copayment

$25 Copayment

Specialty Office Visits

40% coinsurance after deductible

40% coinsurance after deductible

40% coinsurance after deductible

$20 Copayment

$20 Copayment

$25 Copayment

Chiropractic Services

40% coinsurance after deductible

40% coinsurance after deductible

40% coinsurance after deductible

$20 Copayment

$20 Copayment

$25 Copayment

Preventive Exams

40% coinsurance after deductible

40% coinsurance after deductible

40% coinsurance after deductible

$0 Copayment

$0 Copayment

$0 Copayment

$80 copay and/or 20% coinsurance after deductible

$80 copay and/or 20% coinsurance after deductible

$50 copay and/or 20% coinsurance after deductible

Urgent Care

Emergency Room

$350 copay and/or 20% coinsurance after deductible

$350 copay and/or 20% coinsurance after deductible

$150 copay and/or 20% coinsurance after deductible

20% coinsurance after deductible

40% coinsurance after deductible

20% coinsurance after deductible

40% coinsurance after deductible

20% coinsurance after deductible

40% coinsurance after deductible

Hospital Services

Out-of-Pocket Maximum

$7,350 / $14,700

$2,000 / $4,000

$14,700 / $29,400

$4,000 / $12,000

$8,000 / $24,000

$1,000 / $2,000

Employee Only $109.38 Employee / Spouse $368.44 Employee / Child(ren) $351.30 Family $582.64

Employee Only $206.63 Employee / Spouse $577.52 Employee / Child(ren) $550.66 Family $913.29

Employee Only $278.67 Employee / Spouse $732.41 Employee / Child(ren) $698.34 Family $1,158.23

Employee Monthly Premiums

Out-of-Pocket Maximum includes Deductible, Rx, Office, Urgent Care & Emergency Room Copays

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