PPO Benefits

PPO Benefits
GENERAL CHARGES
Office Visit Copayment:	Not Applicable
Deductible:	$50 person/$150 family per year
Annual out-of-pocket limit:	$2,050 per person
Items that do not count toward the out-of-pocket limit and which are not subject to that limit, include: amounts paid for deductibles and co-payments to non-PPO Proiders; prescription co-payments; treatment of mental illness, drug addiction, and alcohol or chemical dependency; and charges in excess of the applicable contracted PPO rates.
Annual Maximum:	$750,000 (No Lifetime Maximum)
SPECIFIC CHARGES
INPATIENT BENEFITS
Alcohol and Substance Abuse	No charge (1st stay), 20% (2nd stay); limited to 2 stays per lifetime
Anesthesia	10% of PPO rate plus any charges above PPO rate
Blood	10% of PPO rate plus any charges above PPO rate
Inpatient Hospital Benefits	10% of PPO rate plus any charges above PPO rate
Inpatient Rehabilitation Care	10% of PPO rate plus any charges above PPO rate
Maternity Care (incl. delivery & C-section)	10% of PPO rate plus any charges above PPO rate
Mental and Nervous Conditions	20% of PPO rate plus any charges above PPO rate up to 30 days per stay; 2 stays per lifetime
Newborn Care	10% of PPO rate plus any charges above PPO rate, limited to pre-discharge illness, accident or congenital condition
Physician Visit	10% of PPO rate plus any charges above PPO rate
Surgeon/Assistant Surgeon	10% of PPO rate plus any charges above PPO rate
Skilled Nursing Facility	10% of PPO rate plus any charges above PPO rate, if commencing within 14 days of a hospital stay of at least 3 days
OUTPATIENT BENEFITS
Allergy Testing	10% of PPO rate plus any charges above PPO rate
Ambulance	10% of PPO rate plus any charges above PPO rate
Durable Medical Equipment	10% of PPO rate plus any charges above PPO rate
Emergency Room/Urgent Care: PPO Facility (see booklet for other rules)	10% of covered charges
Inoculations	10% of PPO rate plus any charges above PPO rate
Infertility Treatment	Not covered
Laboratory and Radiology	10% of PPO rate plus any charges above PPO rate
Maternity Care, Tests and Procedures	10% of PPO rate plus any charges above PPO rate
Mental Health Services	10% of PPO rate, if any, or 20% of UCR; limited to one visit per day and 25 visits per calendar year
Outpatient Surgery	10% of PPO rate plus any charges above PPO rate
Physician Care	10% of PPO rate plus any charges above PPO rate
Prenatal/Postnatal Office Visits	10% of PPO rate plus any charges above PPO rate
Routine Physical Exam	Every 2 years, covered up to $300
Therapy (physical, speech, rehabilitative)	10% of PPO rate plus any charges above PPO rate
Well Baby Care	10% of PPO rate plus any charges above PPO rate; for preventative care up to 5 yrs. of age or the first 60 months
Rx        Retail-Brand	10% or $5, whichever is greater, for up to a 30 day supply
Retail-Generic	10% or $5, whichever is greater, for up to a 30 day supply
Mail Order-Brand	10% or $5, whichever is greater, for up to a 90 day supply
Mail Order-Generic	10% or $5, whichever is greater, for up to a 90 day supply

See also: Prescription Drug Benefit