Small Group Plan Designs

PPO
Page 2
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Description of Benefits

Small Group PPO Plan Options

1500SX
  1204SX  1510SX

1501SX

1502SX

1503SX
Lifetime Maximum
(in and out-of-network combined)		 $5,000,000  $5,000,000 $5,000,000 $5,000,000 $5,000,000 $5,000,000
Calendar year Deductible
(per member-max 3 members)		  In-Network $500  $1,000 $1,000 $1,000 $1,500 $500
Out-of-Network $1,000  $2,000 $2,000 $2,000 $3,000 $1,000
Coinsurance  In-Network 80%  90% 80% 80% 80% 80%
Out-of-Network 60%  60% 60% 60% 60% 60%
Out-of-Pocket Maximum for Calendar Year - Includes Deductible
(per member-max 3 members)		  In-Network $1,500  $1,000 $1,000 $2,000 $2,500 $2,500
Out-of-Network $3,000 $4,000 $4,000 $4,000 $5,000 $5,000
Physicians Office Visit PCP/Specialist
(includes x-ray and lab work done and billed by Drs. office)		  In-Network $25/$25  $25/$25  $25/$25 $40/$40 $40/$40 $25/$25
Out-of-Network
Plan pays after deductible		 60%  60%  60% 60% 60% 60%
Outpatient Surgery Facility includes x-ray and lab
(Plan pays after deductible)		  In-Network 80%  90% 80% 80% 80% 80%
Out-of-Network 60%  60%  60% 60% 60% 60%
Physician Outpatient Services (surgeon, radiologist, anesthesiologist, etc)
(Plan pays after deductible)		  In-Network 80%  90% 80% 80% 80% 80%
Out-of-Network 60%  60%  60% 60% 60% 60%
Maternity
(physician fee only)		  In-Network
(1st visit only)		 $100  $100 $100 $100 $100 $100
Out-of-Network
Plan pays after deductible		 60%  60%  60% 60% 60% 60%
Inpatient Hospital
(Plan pays after deductible)		  In-Network 80%  90% 80% 80% 80% 80%
Out-of-Network 60%  60%  60% 70% 60% 60%
Physician Inpatient Services (surgeon, radiologist, anesthesiologist, etc)
(Plan pays after deductible)		  In-Network 80%  90% 80% 90% 80% 80%
Out-of-Network 60%  60%  60% 70% 60% 60%
Physical and Occupational Therapy,
Chiropractic, Athletic Trainers
(Plan pays after deductible)		  In-Network 80%  90% 80% 80% 80% 80%
Out-of-Network 60% 60%  60% 70% 60% 60%
Visits per year 20  20 20 20 20 20
Inpatient Behavioral Health/Substance Abuse
30 Day calendar year max
(Plan pays after deductible)		  In-Network 80%  90% 80% 80% 80% 80%
Out-of-Network 60% 60% 60% 60% 60% 60%
Outpatient Behavioral Health/Substance Abuse
20 Visit calendar year max		  In-Network $25  $25 $25 $40  $40 $25 
Out-of-Network
Plan pays after deductible		 60%  60% 60% 60%  60%  60% 

Emergency Room Copay
(waived if admitted)

 In or Out
of Network		 $100  $100 $100 $100 $100 $100
Prescription Drug
Copays

Prescription deductible per member (calendar yr)
$0
$0
$0
$0
$0
$0

Generic/Formulary

 $20 $15 $15 $20 $20 $20

Brand/Formulary

 $35 $30 $30 $35 $35 $35

Non-Formulary

 $60 $60 $60 $60 $60 $60

Mail Order

 $60 $30/$60  $30/$60 $60 $60 $60
 Note: Plan benefits listed above are intended as a summary only and do not replace benefits listed in certificate of coverage. Some specific benefits may have limitations and/or exclusions. Refer to your policy for more detail.
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