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.
The deductible is a specified annual dollar amount you must pay for covered medical services before the plan begins to pay benefits.
A copay is a flat dollar amount that you pay upfront for certain services when using network providers.
Coinsurance (previously referred to as a copayment) is the percentage of the cost for covered services that you pay after you pay the deductible:
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.
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.
*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.
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.
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