Preferred provider organization (PPO)

When you enroll in the preferred provider organization (PPO), you have the freedom to seek care from any eligible licensed provider; however, you can save on your out-of-pocket costs for care by using the plan’s national network of physicians, hospitals, and other healthcare providers.

To better understand the coverage provided under the PPO, it’s important to know 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 Medical Out-of-Pocket 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 (in-person or virtual): $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 medical out-of-pocket maximum. 
  • There is a $25 copay for the vision exam benefit.
  • There are separate copay amounts for prescription drugs. Read more details.

Coinsurance

Coinsurance (previously referred to as a copayment) is the percentage of the cost for covered services that you pay after you pay the deductible:

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

Medical out-of-pocket maximum

The PPO includes a medical out-of-pocket maximum (previously called the copayment maximum), which is the most you will pay in the form of coinsurance (or copayments) in a given year. Once you reach the medical out-of-pocket maximum, the plan pays 100 percent of allowable costs for the rest of the year. Office visit copays and deductibles do not count toward the medical out-of-pocket maximum.

Combined maximum out-of-pocket (2020) 

The combined maximum out-of-pocket is a set annual dollar amount you pay for covered medical services and prescription drugs, after which the plan pays 100 percent of covered expenses (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
  • The combined maximum out-of-pocket applies for you and your enrolled family members combined.
  • Expenses that count toward the PPO combined maximum out-of-pocket include your deductibles, medical copayment maximum, and prescription copayment maximum.

*Total maximum out-of-pocket expenses, including office visit copays, are capped at annual limits of $7,900 per member and $15,800 per family.

Total maximum out-of-pocket (2021)

The total maximum out-of-pocket is the most you will pay in a year in the form of deductibles, copays, and coinsurance. If your covered out-of-pocket expenses reach the total maximum out-of-pocket amount, the plan will pay 100 percent of allowable costs for the rest of the year.

  • Expenses that count toward the PPO total maximum out-of-pocket include your network deductibles, medical out-of-pocket maximum, prescription drug out-of-pocket maximum, office visit copays, coinsurance, and prescription drug copays.
  • The PPO individual and family total maximum out-of-pocket amounts for 2021 are shown on the 2021 Key Provisions chart.

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