Page 10 - CPS Benefits Guide
P. 10
Schedule of Benefits
Montana, Oregon, and
Vermont Only
PPO Plan HSA Plan Out-of-Area Plan
In-Network Out-of-Network In-Network Out-of-Network In/Out-of-Network
Calendar Year Deductible
Individual $3,000 $9,000 $2,600 $7,800 $3,000
Family $6,000 $18,000 $5,200 $15,600 $6,000
Out-of-Pocket Maximum—Includes deductible and medical copays where applicable
Individual $6,850 $20,550 $6,550 $19,650 $6,850
Family $13,700 $41,100 $13,100 $39,300 $13,700
Physician Ofice Visits
Primary Care $40 copay 50% after ded . 70% after ded . 50% after ded . $40 copay
Specialist $60 copay 50% after ded . 70% after ded . 50% after ded . $60 copay
Urgent Care $100 copay 50% after ded . 70% after ded . 50% after ded . $100 copay
Wellness/Preventive
Well-Child Care and 100% no ded . 50% after ded . 100% no ded . 50% after ded . 100% no ded .
Immunizations
Adult Periodic Exams 100% no ded . 50% after ded . 100% no ded . 50% after ded . 100% no ded .
with Preventive Tests
Annual Pap or Prostate 100% no ded . 50% after ded . 100% no ded . 50% after ded . 100% no ded .
Exams
Mammograms 100% no ded . 50% after ded . 100% no ded . 50% after ded . 100% no ded .
Diagnostic X-Ray and 100% no ded . 50% after ded . 100% no ded . 50% after ded . 100% no ded .
Lab
MRIs, PET Scans, 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% no ded .
CAT Scans, and Other
Nuclear Medicine
Hospital Services
Inpatient 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Outpatient 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Emergency Room 70% after ded . 70% after ded . 70% after ded . 70% after ded . 70% after ded .
Please refer to the plan’s Summary Plan Descriptions for further detail located on the ADP portal.
10 2017 Benefits Enrollment
Montana, Oregon, and
Vermont Only
PPO Plan HSA Plan Out-of-Area Plan
In-Network Out-of-Network In-Network Out-of-Network In/Out-of-Network
Calendar Year Deductible
Individual $3,000 $9,000 $2,600 $7,800 $3,000
Family $6,000 $18,000 $5,200 $15,600 $6,000
Out-of-Pocket Maximum—Includes deductible and medical copays where applicable
Individual $6,850 $20,550 $6,550 $19,650 $6,850
Family $13,700 $41,100 $13,100 $39,300 $13,700
Physician Ofice Visits
Primary Care $40 copay 50% after ded . 70% after ded . 50% after ded . $40 copay
Specialist $60 copay 50% after ded . 70% after ded . 50% after ded . $60 copay
Urgent Care $100 copay 50% after ded . 70% after ded . 50% after ded . $100 copay
Wellness/Preventive
Well-Child Care and 100% no ded . 50% after ded . 100% no ded . 50% after ded . 100% no ded .
Immunizations
Adult Periodic Exams 100% no ded . 50% after ded . 100% no ded . 50% after ded . 100% no ded .
with Preventive Tests
Annual Pap or Prostate 100% no ded . 50% after ded . 100% no ded . 50% after ded . 100% no ded .
Exams
Mammograms 100% no ded . 50% after ded . 100% no ded . 50% after ded . 100% no ded .
Diagnostic X-Ray and 100% no ded . 50% after ded . 100% no ded . 50% after ded . 100% no ded .
Lab
MRIs, PET Scans, 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% no ded .
CAT Scans, and Other
Nuclear Medicine
Hospital Services
Inpatient 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Outpatient 70% after ded . 50% after ded . 70% after ded . 50% after ded . 70% after ded .
Emergency Room 70% after ded . 70% after ded . 70% after ded . 70% after ded . 70% after ded .
Please refer to the plan’s Summary Plan Descriptions for further detail located on the ADP portal.
10 2017 Benefits Enrollment
