What You Pay in the PPO Plan

In-Network Out-of-Network
Deductible* $1,500 Individual
$4,500 Family
$4,500 Individual
$13,500 Family
Coinsurance Plan pays 80% after deductible
You pay 20% after deductible
Plan pays 50% after deductible
You pay 50% after deductible
Out-of-Pocket Maximum $5,500 Individual
$11,000 Family
$10,000 Individual
$20,000 Family
Preventive Care Covered at 100% You meet your deductible, then pay 50% coinsurance.
Telehealth $4 copay after deductible, up to a maximum $44 allowance 35% coinsurance after deductible
Primary Care Office Visit $25 copay You meet your deductible, then pay 50% coinsurance.
Specialist Office Visit You meet your deductible, then pay 20% coinsurance.
Urgent Care You meet your deductible, then pay 20% coinsurance.
Emergency Room You meet your deductible, then pay 20% coinsurance. You meet your deductible, then pay 20% coinsurance.
Hospitalization You meet your deductible, then pay 20% coinsurance. You meet your deductible, then pay 50% coinsurance.
Lab, X-Ray, Imaging You meet your deductible, then pay 20% coinsurance. You meet your deductible, then pay 50% coinsurance.
Mental Health Available through Optum. See the Mental Health section for more information.
Prescription Drugs** – You don’t have to meet your deductible before you receive a benefit for prescription drugs, as long as you use a network pharmacy.
Pharmacy-Filled Generic
(30-day supply)
$12 copay You pay 50% coinsurance ($50 minimum) of reasonable and customary charges.
Pharmacy-Filled Formulary
(30-day supply)
You pay 30%
($40 min. / $80 max.)
Pharmacy-Filled Non-formulary
(30-day supply)
You pay 50%
($80 min. / $160 max.)
Mail Ordered Generic
(90-day supply)
$30 copay N/A
Mail Ordered Formulary
(90-day supply)
You pay 30%
($80 min. / $160 max.)
Mail Ordered Non-formulary
(90-day supply)
You pay 50%
($180 min. / $350 max.)