PPO: deductibles, copays, copayments, and out-of-pocket maximums

​​To better understand the coverage provided under the PPO option, it’s important to understand these key terms.

Deductible

The deductible is a specified annual dollar amount you must pay for covered medical services before the plan begins to pay benefits. 

  • PPO deductibles are based on a percentage of your effective salary, as shown on the PPO Deductibles and Copayment Maximums chart.
  • If you enroll any family members, you are responsible for two medical deductibles, one for yourself and one for all your family members combined. 
  • You can reduce your deductibles by completing Call to Health, a well-being initiative that focuses on the four dimensions of wholeness: spiritual, health, financial, and vocational.

Copay 

A copay is a flat dollar amount that you pay upfront for certain services when using network providers.

  • Except for preventive care, you pay a copay for each network office visit: $25 for primary and behavioral health care visits, $45 for visits to a specialist or when seeking care at an urgent care center, and $10 when using the telemedicine benefit. 
  • Copays do not count toward the plan deductible or copayment maximum. 
  • There are separate copay amounts for the vision exam benefit and prescription drugs. See Key Provisions PPO for details.

Copayment

A copayment is the percentage of the plan allowance for covered services that you pay after meeting the deductible: 

  • Your copayment for network services is 20 percent. 
  • Your copayment is 40 percent (50 percent with no deductible for doctor’s office visits) for out-of-network care.

Copayment maximum

  • The PPO includes a copayment maximum, which is the annual maximum out-of-pocket costs you will pay in the form of copayments, after which the plan pays 100 percent of allowable costs for the rest of the year. Office visit copays and deductibles do not count toward the copayment maximum. 
  • Like your deductibles, your medical copayment maximum is based on a percentage of your effective salary, as shown on the PPO Deductibles and Copayment Maximums chart. Unlike deductibles, only one copayment maximum applies per family. 
  • A separate copayment maximum applies for prescription drugs (see Key Provisions PPO).

Combined maximum out-of-pocket 

The combined maximum out-of-pocket is a specified annual dollar amount you pay for covered medical and prescription services, after which the plan pays 100 percent of allowable costs (except for office visit copays) for the rest of the year. 

  • The PPO combined maximum out-of-pocket amounts are shown on the Key Provisions chart
  • Expenses that count toward the PPO combined maximum out-of-pocket include your deductibles, medical copayment maximum, and prescription copayment maximum.
  • The combined individual and family office visit and prescription drug copays, deductibles, and copayment maximums are capped at the Affordable Care Act annual limits of $7,900 and $15,800.