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PPO

On the chart below, you'll see what your plan pays for specific services. You may be responsible for a facility fee, clinic charge or similar
fee or charge (in addition to any professional fees) if your office visit or service is provided at a location that qualifies as a hospital
department or a satellite building of a hospital.
B
Texas Rangers Front Office QHDHP Value Plan 016587-20, -90 Effective 1/1/23
Benefit Network Out-of-Network
General Provisions
Benefit Period(1) Calendar
Deductible (per benefit period)
Individual $4,500 $9,000
Family $9,000 $18,000
Plan Pays – payment based on the plan allowance 70% after deductible 50% after deductible
Out of Pocket Limit (includes deductible. Once met,
plan pays 100% coinsurance (excluding applicable
copays) for the rest of the benefit period)
Individual $6,350 $12,700
Family $12,700 $25,400
Total Maximum Out-of-Pocket (includes deductible,
coinsurance, copays and other qualified medical
expenses, Network only)(2) Once met, the plan pays
100% of covered services for the rest of the benefit
period.
Individual $6,350 N/A
Family $12,700 N/A
Office/Clinic/Urgent Care Visits
Retail Clinic Visits 70% after deductible 50% after deductible
Primary Care Provider Office Visits 70% after deductible 50% after deductible
Specialist Office Visits 70% after deductible 50% after deductible
Urgent Care Center Visits 70% after deductible 50% after deductible
Telemedicine Services (6) 70% after deductible Not Covered
Preventive Care
Routine Adult
Physical exams 100% (deductible does not apply) 50% after deductible
Adult immunizations 100% (deductible does not apply) 50% after deductible
Colorectal cancer screening (includes colonoscopy; 100% (deductible does not apply) 50% after deductible
sigmoidoscopy; barium enema; blood occult)
Routine gynecological exams 100% (deductible does not apply) 50% after deductible
Routine Pap Smear 100% (deductible does not apply) 50% after deductible
Mammograms, annual routine 100% (deductible does not apply) 50% after deductible
Diagnostic services and procedures 100% (deductible does not apply) 50% after deductible
Routine Pediatric
Physical exams 100% (deductible does not apply) Not Covered
Pediatric immunizations 100% (deductible does not apply) 50% after deductible
Diagnostic services and procedures 100% (deductible does not apply) 50% after deductible
Hospital and Medical/Surgical Expenses (including maternity)
Hospital Inpatient 70% after deductible 50% after deductible
Hospital Outpatient 70% after deductible 50% after deductible
Maternity (non-preventive facility & professional 70% after deductible 50% after deductible
services)
Medical/Surgical (except office visits) 70% after deductible 50% after deductible
Emergency Services
Emergency Room Services 70% after In Network deductible
Ambulance 70% after In Network deductible
Therapy and Rehabilitation Services
Physical Medicine 70% after deductible 50% after deductible
Limit: 70 visits per benefit period combined with Occupational and Speech
Therapy
Respiratory Therapy 70% after deductible 50% after deductible
Occupational Therapy 70% after deductible 50% after deductible

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