Page 7 - Guide

2017 BENEFITS ENROLLMENT

Medical Benefit Summary PPO Plan

2017 Medical Plan Comparison

PPO Plan
Regional One Health Baptist/Regional One BCBS
Provider Network Provider Network— Health Network Network S Out-of-Network
Partnership
Annual Deductible Embedded Embedded Embedded
Employee Only $0 $500 $750 $1,500
(individual)
Employee + Spouse $0 $1,000 $1,500 $3,000
Employee + Child(ren) $0 $1,300 $1,950 $3,900
Family $0 $1,300 $1,950 $3,900
Annual Out-of-Pocket Includes Deductible Includes Deductible Includes Deductible
Maximum
Employee Only $0 $2,000 $3,000 $6,000
(individual)
Employee + Spouse $0 $4,000 $6,000 $12,000
Employee + Child(ren) $0 $4,000 $6,000 $12,000
Family $0 $4,000 $6,000 $12,000
Preventive Care Covered 100% Covered 100% Covered 100% Deductible plus 50%
Physician Ofice Visit
Primary Care $0 $20 $30 Deductible plus 50%
Specialist $0 $50 $60 Deductible plus 50%
Hospital Services
Inpatient $0 Deductible plus 20% Deductible plus 20% Deductible plus 50%
Emergency $250 $250 $250 $250
Maternity $0 Deductible plus 20% Deductible plus 20% Deductible plus 50%
Advanced Diagnostic $0 Deductible plus 20% Deductible plus 20% Deductible plus 50%
Imaging
Lab/X-Ray $0 Deductible plus 20% Deductible plus 20% Deductible plus 50%

Visit Regional One for care and services with no deductible, coinsurance, or copay charges to you (emergency
room copay is a $250 copay). Visit Baptist or Network S for care and services and receive the corresponding
charges above.

REGIONAL ONE HEALTH 7