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
3
Made with FlippingBook Proposal Creator