Advantage PPO Health Plan

Benefits

Basic Definition

Higher payroll deduction; generally copay and out-of-pocket expenses are lower

Calendar Year Deductible

In Network / Out of Network
$1,000 per person each calendar year; $3,000 family maximum

Prescription deductible: $150 individual/$450 family

Calendar Year Out-of-pocket Maximum
(This is the amount you would pay before benefits would be paid at 100%.)

In Network / Out of Network
Separate medical: $2,000 individual; $6,000 family (Includes $1,000 individual; $3,000 family medical deductible). Separate prescription drugs: $3,300 individual; $6,600 family (Includes $150 individual; $450 family prescription drug deductible)

In Network
Deductibles, copays and coinsurance apply to the out-of-pocket maximum

Out of Network
Coinsurance applies to the out-of-pocket maximum

Pre-certification is required for many services, including but not limited to: hospital admissions, PET scans, CT scans, MRIs, MRAs, physician-administered drugs, inpatient rehab, home health care, etc. Generally, if pre-certification is not obtained, no benefits are available. See Contact Your Benefits Providers page for contact numbers.

Preventive Care

(See the Preventive Services Listing for details.)

In Network
100% coverage for all listed services

Out of Network
Not covered

Office Visit

In Network
100% coverage after $35 primary care physician copay (OB/GYN included); 100% coverage after $60 specialist copay

Out of Network
70% coverage maximum allowable charge (MAC) after annual deductible

Hospital Visit

In Network
90% coverage after $300 per-admission copay

Out of Network
70% MAC coverage after $300 per-admission copay

Emergency Services

In Network
90% coverage after calendar year deductible

Out of Network
90% MAC coverage after calendar year deductible

Chiropractic Care

In Network / Out of Network
90% coverage after calendar year deductible; limit of 30 total visits per person per calendar year

Speech, Physical and Occupational (Hand) Therapy

In Network / Out of Network
90% coverage subject to calendar year deductible; limit of 40 habilitative and 40 rehabilitative visits per person per calendar year. Medical necessity review required for visits 20-40

PET Scans, CT Scans, MRIs and MRAs

In Network / Out of Network
Pre-certification required for these screenings. No coverage for noncertified procedures

In Network
Covered at 90% of the allowance with no deductible or copay

Out of Network
Covered at 70% of the allowance, subject to the calendar year deductible

*Pre-certification is required for these screenings. No coverage for noncertified procedures

See the Medical Page for links to detailed documents about the Advantage PPO Plan.