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Services

Network

Non-Network

Services

Network

Non-Network

Preventive Services

Network
MCHCP pays 100%

Non-Network
40% coinsurance

MCHCP pays 100%

40% coinsurance

Deductible
  Individual
  Family

Network
Individual: $750
Family: $1,500

Non-Network
Individual: $1,500
Family: $3,000


$750
$1,500


$1,500
$3,000

Medical OOP Maximum
  Individual
  Family

Network
Individual: $2,250
Family: $4,500

Non-Network
Individual: $4,500
Family: $9,000


$2,250
$4,500


$4,500
$9,000

Prescription OOP Maximum
  Individual
  Family

Network
Individual: $4,150
Family: $8,300

Non-Network
No Maximum


$4,150
$8,300


No Maximum

Urgent Care

Network
20% coinsurance

Non-Network
Network Benefit

20% coinsurance

Network Benefit

Emergency Room

Network
$250 copayment plus 20% coinsurance
Medicare: 20% coinsurance

Non-Network
Network Benefit

$250 copayment plus 20% coinsurance
Medicare: 20% coinsurance

Network Benefit

Inpatient

Network
$200 copayment plus 20% coinsurance

Non-Network
$200 copayment plus 40% coinsurance

$200 copayment plus 20% coinsurance

$200 copayment plus 40% coinsurance

Other Medical Services

Network
20% coinsurance

Non-Network
40% coinsurance

20% coinsurance

40% coinsurance


Copayments
Members may pay a $250 copayment for emergency room services, in addition to deductible or coinsurance. This copayment is waived if the member is admitted to the hospital or the services are considered by the medical plan to be a “true emergency.” Even if the copayment is waived, the member will still have to pay any deductible or coinsurance owed for the Emergency Room service.

Members also have a $200 copayment for inpatient services in addition to their coinsurance.

Copayments apply to the out-of-pocket maximum, but not the deductible. Medicare retirees do not have an Emergency Room copayment, they are only charged coinsurance.

How the PPO 750 Plan Works

  1. When visiting a health care provider, the member will pay for their medical expenses out of their pocket until the annual deductible is met. Members visiting an emergency room may also pay a $250 copayment (see Copayments section above).
  2. Once the deductible is met, members will pay coinsurance on covered expenses until their out-of-pocket maximum is reached. At that time, the plan will begin paying 100% of covered services (see Family Coverage section below).

Family Coverage

If two or more family members are covered in a PPO plan and one family member reaches the individual deductible or out-of-pocket maximum, the medical plan begins paying claims for the individual. If one or more additional family members meet the individual deductible or out-of-pocket maximum, the medical plan begins paying claims for the entire family.


See Prescription Drug Plans for information on the prescription drug coverage and coinsurance/copayments.


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