Here are the five PPO plan designs offered by Priority Health for HealthbyChoice Incentives SM in 2009.
|
PPO 1 |
PPO 2 |
|
Choice Level |
Standard Level |
Choice Level |
Standard Level |
|
In-network |
Out-of-network |
In-network |
Out-of-network |
In-network |
Out-of-network |
In-network |
Out-of-network |
| Coinsurance |
100% |
80% |
90% |
70% |
90% |
70% |
80% |
60% |
Deductible, individual
|
$250 |
$500 |
$1,250 |
$2,500 |
$500 |
$1,000 |
$1,500 |
$3,000 |
Deductible, family
|
$500 |
$1,000 |
$2,500 |
$5,000 |
$1,000 |
$2,000 |
$3,000 |
$6,000 |
Out-of-pocket, individual
|
N/A
|
$2,500 |
$1,250 |
$2,500 |
$500 |
$2,500 |
$1,500 |
$2,500 |
Out-of-pocket, family
|
N/A |
$5,000 |
$2,500 |
$5,000 |
$1,000 |
$5,000 |
$3,000 |
$5,000 |
| Copayments |
|
|
|
|
|
|
|
|
| Primary Care |
$15 |
80% |
$25 |
70% |
$15 |
70% |
$25 |
60% |
| Specialist Care |
$30 |
80% |
$40 |
70% |
$30 |
70% |
$40 |
60% |
| Urgent Care |
$45 |
80% |
$55 |
70% |
$45 |
70% |
$55 |
60% |
| ER |
$100 |
$100 |
$100 |
$100 |
$100 |
$100 |
$100 |
$100 |
| Advanced Diagnostic Imaging |
$150 |
80% |
$150 |
70% |
$150 |
70% |
$150 |
60% |
Rx
Option 1
Option 2
(with or without CM)
|
$10/$40
$15/$50
|
$10/$40
$15/$50
|
$10/$40
$15/$50
|
$10/$40
$15/$50
|
$10/$40
$15/$50
|
$10/$40
$15/$50
|
$10/$40
$15/$50
|
$10/$40
$15/$50
|
|
PPO 3 |
PPO 4 |
|
Choice Level |
Standard Level |
Choice Level |
Standard Level |
|
In-network |
Out-of-network |
In-network |
Out-of-network |
In-network |
Out-of-network |
In-network |
Out-of-network |
| Coinsurance |
90% |
70% |
80% |
60% |
80% |
60% |
70% |
60% |
Deductible, individual
|
$1,000 |
$2,000 |
$2,000 |
$4,000 |
$1,500 |
$3,000 |
$25000 |
$5,000 |
Deductible, family
|
$2,000 |
$4,000 |
$4,000 |
$8,000 |
$3,000 |
$6,000 |
$5,000 |
$10,000 |
Out-of-pocket, individual
|
$1,000 |
$3,000 |
$2,000 |
$3,000 |
$1,500 |
$3,000 |
$2,500 |
$3,000 |
Out-of-pocket, family
|
$2,000 |
$6,000 |
$4,000 |
$6,000 |
$3,000 |
$6,000 |
$5,000 |
$6,000 |
| Copayments |
|
|
|
|
|
|
|
|
| Primary Care |
$15 |
70% |
$25 |
60% |
$15 |
60% |
$25 |
60% |
| Specialist Care |
$30 |
70% |
$40 |
60% |
$30 |
60% |
$40 |
60% |
| Urgent Care |
$45 |
70% |
$55 |
60% |
$45 |
60% |
$55 |
60% |
| ER |
$100 |
$100 |
$100 |
$100 |
$100 |
$100 |
$100 |
$100 |
| Advanced Diagnostic Imaging |
$150 |
70% |
$150 |
60% |
$150 |
60% |
$150 |
60% |
Rx
Option 1
Option 2
(with or without CM)
|
$10/$40
$15/$50
|
$10/$40
$15/$50
|
$10/$40
$15/$50
|
$10/$40
$15/$50
|
$10/$40
$15/$50
|
$10/$40
$15/$50
|
$10/$40
$15/$50
|
$10/$40
$15/$50
|
|
PPO 5 |
|
Choice Level |
Standard Level |
|
In-network |
Out-of-network |
In-network |
Out-of-network |
| Coinsurance |
100% |
80% |
90% |
70% |
Deductible, individual
|
N/A |
$250
|
$1,000
|
$2,000 |
Deductible, family
|
N/A |
$500 |
$1,250 |
$2,500 |
Out-of-pocket, individual
|
N/A
|
$2,500 |
$1,250 |
$2,500 |
Out-of-pocket, family
|
N/A |
$5,000 |
$2,500 |
$5,000 |
| Copayments |
|
|
|
|
| Primary Care |
$15 |
80% |
$25 |
70% |
| Specialist Care |
$30 |
80% |
$40 |
70% |
| Urgent Care |
$45 |
80% |
$55 |
70% |
| ER |
$100 |
$100 |
$100 |
$100 |
| Advanced Diagnostic Imaging |
$150 |
80% |
$150 |
70% |
Rx
Option 1
Option 2
(with or without CM)
|
$10/$40
$15/$50
|
$10/$40
$15/$50
|
$10/$40
$15/$50
|
$10/$40
$15/$50
|
Last modified
07/28/09
|
