|
PPO Plan Options
|
Benefit Plan
|
Deductible
|
Network Copayments*
|
Lifetime Maximum
|
|
|
In-Network
|
Out-of-Network
|
In-Network
|
Out-of-Network
|
|
|
Plan 1
|
None
|
$250/$500
|
None
|
20%
|
$5 million
|
|
Plan 2
|
$100/$200
|
$250/$500
|
10%
|
30%
|
$5 million
|
|
Plan 3
|
$250/$500
|
$500/$1,000
|
20%
|
40%
|
$5 million
|
|
Plan 4
|
$500/$1,000
|
$1,000/$2,000
|
20%
|
40%
|
$5 million
|
|
Plan 10
|
$250/$500
|
$500/$1,000
|
10%
|
40%
|
$5 million
|
|
Plan 12
|
$1,000/$2,000
|
$2,000/$4,000
|
20%
|
40%
|
$5 million
|
* Mental health, substance abuse and private duty nursing copays are 50%.
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|
