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Active Members Information: PPO
There are two PPO plans available – the Choice PPO and the Basic PPO.
Each plan covers the same medically-necessary services as set forth in the PEBTF Plan Document.
The difference is in the annual Deductible.
Summary
- In-network deductibles differ between the Choice PPO and the Basic PPO:
- Choice PPO – Annual in-network deductible is $400 single/$800 family
- Basic PPO – Annual in-network deductible is $1,500 single/$3,000 family
- PPO option covers medical services as set forth in the PEBTF Plan Document
- PPO option offers both an in-network and out-of-network benefit
- In order to receive the highest level of benefits, you must choose one of the in-network facilities or providers
- You may self refer for medically necessary care, as defined by the Plan
- $20 copayment for PCP office visits (for general practitioners, family practitioners, internists and pediatricians)
- $45 copayment for specialist office visit
- $50 copayment for urgent care visit
- $200 copayment for emergency room visit (waived if the visit leads to an inpatient admission to the hospital)
- Out-of-network differ between the Choice PPO and Basic PPO:
- Choice PPO – Annual deductible is $800 single/$1,600 family; plan payment 70%,
member pays 30% of the next $14,045 single/$28,090 family after which the plan pays at 100%
- Basic PPO – Annual deductible is $3,000 single/$6,000 family; plan payment 70%,
member pays 30% of the next $14,045 single/$28,090 family after which the plan pays at 100%
- Plan coverage for services rendered by out-of-network providers is based on the Usual, Customary and Reasonable (UCR) charge or plan allowance, as determined by the claims payor. Payment of amounts in excess of the UCR charge or plan allowance are your responsibility
Check with the PEBTF if you have any questions regarding the PPO Option.
For more information, refer to your Summary Plan Description or contact PEBTF.
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