What the PPO Options pay

Network providers

Network providers have agreed to offer covered services at contracted rates. This means that the dollar amount you pay for your share of covered expenses is generally lower when you use a network provider. When you see a network provider:
  • Covered office visit expenses are covered at:
    • 100% after you pay a copay, with no deductible, by the HealthPlus PPO Option.
    • 80% after the deductible by the Standard PPO Option.
  • Under both PPO Options, in-network preventive care is covered at 100% with no copay and no deductible.
  • Emergency room facility charges are paid at 100% after a copay, with no deductible, by both PPO Options. 
  • For both PPO Options, most other covered in-network services are paid at 80% of the contracted rate for other covered expenses after you meet the individual or family plan year deductible, and you pay the remaining portion of the charges (the coinsurance). 
  • Once you meet the plan year network out-of-pocket maximum, the PPO Options pay 100% of the contracted rate for covered expenses for the rest of the plan year. Note: Under the HealthPlus PPO, copays will still apply as they are not subject to the out-of-pocket maximum.

See the PPO Options (HealthPlus and Standard) summary chart for more information.

Out-of-network providers

If you see an out-of-network provider, the PPO Options generally pay 60% of recognized charges for all covered expenses (except chiropractic care and ambulance services, which are covered at 80% of recognized charges) after you meet the individual or family plan year deductible. You pay the remaining percentage (the coinsurance) and any costs above recognized charge limits. (See Recognized charge limits.) Note: Eligible claims incurred in an emergency room facility will be covered at the applicable in-network benefit level.

Once you meet the plan year out-of-network out-of-pocket maximum, the PPO Options pay 100% of recognized charges for most covered expenses for the rest of the plan year. Note: Emergency room copays will still apply as they are not subject to the out-of-pocket maximum.

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