Preferred provider organization (PPO) - The Board of Pensions of the Presbyterian Church (U.S.A.) (2024)

To better understand the coverage provided under the PPO, it’s important to know these key terms.

Deductible

The deductible is a specified annual dollar amount you must pay for covered medical services before the plan begins to pay benefits.

• PPO deductibles are based on a percentage of your effective salary, as shown on the PPO Deductibles and Medical Out-of-Pocket Maximums chart.
• If you enroll any family members, you are responsible for two medical deductibles, one for yourself and one for all your family members combined.
• You can reduce your deductible(s) by completing Call to Health, a well-being initiative that focuses on the four dimensions of wholeness: spiritual, health, financial, and vocational.

Copay

A copay is a flat dollar amount that you pay upfront for certain services when using network providers.

• Except for preventive care, you pay a copay for each network office visit (in-person or virtual): $25 for primary and behavioral health care visits, $45 for visits to a specialist or when seeking care at an urgent care center, and $10 when using the telemedicine benefit.
• Copays do not count toward the plan deductible or medical out-of-pocket maximum.
• There is a $25 copay for the vision exam benefit.
• There are separate copay amounts for prescription drugs. Read more details.

Coinsurance

Coinsurance is the percentage of the cost for covered services that you pay after you pay the deductible:

• Your coinsurance for network services is 20 percent.
• Your coinsurance is 40 percent for out-of-network care (50 percent with no deductible for doctor’s office visits).

Medical out-of-pocket maximum

The PPO includes a medical out-of-pocket maximum, which is the most you will pay in the form of coinsurance in a given year. Once you reach the medical out-of-pocket maximum, the plan pays 100 percent of allowable costs for the rest of the year. Office visit copays and deductibles do not count toward the medical out-of-pocket maximum.

• Like your deductible(s), your medical out-of-pocket maximum is based on a percentage of your effective salary, as shown on the PPO Deductibles and Medical Out-of-Pocket Maximums chart.
• Unlike deductibles, only one out-of-pocket maximum applies per family.
• A separate out-of-pocket maximum applies for prescription drugs (see the Key Provisions chart).

Total maximum out-of-pocket

The total maximum out-of-pocket is the most you will pay in a year in the form of deductibles, copays, and coinsurance. If your covered out-of-pocket expenses reach the total maximum out-of-pocket amount, the plan will pay 100 percent of allowable costs for the rest of the year.

• Expenses that count toward the PPO total maximum out-of-pocket include your network deductible(s), medical out-of-pocket maximum, prescription drug out-of-pocket maximum, office visit copays, coinsurance, and prescription drug copays (excluding non-formulary drugs and certain non-essential specialty pharmacy drugs).
• The PPO individual and family total maximum out-of-pocket amounts are shown on the Key Provisions chart.