PPO Explained

Medical Plan Options

Preferred Provider Organization (PPO)

Under a PP0, you have coverage both in-network and out-of-network. You can see any doctor you choose, you don’t have to select a primary care physician (PCP), and you don’t need referrals to access specialists.

Under a PPO plan, you can:

  • Stay in-network and save money by using a network provider. Your out-of-pocket costs are lower because network providers typically offer their services at lower rates. In addition, you receive a higher level of benefits when you visit in-network providers.
  • Or, go out-of-network and use any doctor or hospital you’d like, but pay a greater share of the cost. You may be subject to reasonable and customary (R&C) limits.

Benefits are higher – and your costs are lower – when you seek in-network care. In addition, there are no claim forms to complete and no surprises with reasonable and customary limits when you use a network provider.

In-Network Coverage

In both PPOs, there is a $25 copayment for each office visit to a primary care physician, and a $45 copayment for each office visit to a specialist.

Under the Enhanced PPO, most other covered services are reimbursed at 90% after you meet the annual deductible. The in-network deductible is $550 per person or $1,100 for a family. If you reach the out-of-pocket limit in a calendar year, the plan will pay 100% of eligible expenses for the remainder of the year. The out-of-pocket limit is $2,000 per person and $4,000 for a family.

Under the Basic PPO, most other covered services are reimbursed at 80% after you meet the annual deductible. The in-network deductible is $750 per person or $1,500 for a family. If you reach the out-of-pocket limit in a calendar year, the plan will pay 100% of eligible expenses for the remainder of the year. The out-of-pocket limit is $2,400 per person and $4,800 for a family.

Out-of-Network Coverage

Under the Enhanced PPO, most covered services are reimbursed at 70% of the reasonable and customary costs, after you meet the annual deductible. The out-of-network deductible is $1,100 per person or $2,200 for a family. If you reach the out-of-pocket limit in a calendar year, the plan will pay 100% of eligible expenses for the remainder of the year. The annual out-of-pocket limit is $4,000 per person and $8,000 for a family. You are responsible for all out of-network charges above the reasonable and customary limits, even if you have reached the out-of-pocket maximum.

Under the Basic PPO, most covered services are reimbursed at 60% of the reasonable and customary costs, after you meet the annual deductible. The out-of-network deductible is $1,500 per person or $3,000 for a family. If you reach the out-of-pocket limit in a calendar year, the plan will pay 100% of eligible expenses for the remainder of the year. The annual out-of-pocket limit is $4,800 per person and $9,600 for a family.