Traditional PPO

The Traditional PPO is a comprehensive medical plan that covers only both in-network and out-of-network providers. You pay co-pays, deductible and co-insurance and the insurance pays the remaining costs.

Click the Link Below to View

Plan Information

 
In-Network
Non-Network
Employer Health Savings Account (HSA) Contribution 1/1/21 Prorated for New Hires
    Single

Not Applicable

    Family

Not Applicable

DEDUCTIBLES
    Single

$2,500

    Family

$5,000

OUT-OF-POCKET MAXIMUMS (includes deductible)
    Single
$6,350 $12,700
    Family
$12,700 $25,400
PLAN CO-PAYMENTS
    Office Visit
$35 copay60% after deductible
    Specialist Office Visit
$70 copay60% after deductible
    Preventive Care
Covered at 100%60% after deductible
    Urgent Care Visit
$70 copay60% after deductible
    Emergency Room

$200 copay, plus 30% after deductible

    Hospitalization
30% after deductible60% after deductible
    Outpatient Surgery
30% after deductible60% after deductible
PRESCRIPTION DRUG COPAY
    Retail Generic
$10 copay

50% after applicable copay

    Retail Preferred Brand
$40 copay
    Retail Non-Preferred
50%
    Mail Order
102 days for 3 copays