Page 10 - 2022 Penn Engineering Guide

Your Health Coverage

Here’s a partial listing of covered expenses under the PPO Option. Refer to your Summary Plan Description for a complete
listing of covered expenses.

Preferred Provider Organization (PPO) Summary of Covered Expenses
Covered Expense In-Network Provider Out-of-Network Provider
80% after $30 co-payment;
Allergy Treatments 70% of covered charges after deductible
No deductible
Ambulance Service 100% when medically necessary; otherwise not covered
80%; after deductible
Blood Donation
(when donating for self or immediate family member)
Chiropractic Care 80% of covered charges after deductible 70% of covered charges after deductible
Diagnostic X-ray and Lab 80%; after $30 co-pay;
70% of covered charges after deductible
Services No deductible
80% after $50 co-payment
Emergency Room Visits
($150 co-payment if determined non-emergency); no deductible
70% of covered charges after deductible;
Home Health Care 80%; after deductible; requires pre-certification
requires pre-certification

Hospice Care 80%; after deductible 70% of covered charges after deductible.
70% of covered charges after deductible;
Inpatient Hospital 80%; after deductible; requires pre-certification
requires pre-certification
100% for one routine mammogram per year; no
100% for one routine mammogram per year; no
deductible;
Mammography deductible; additional Mammograms covered
$30 co-payment for any additional at 70% after deductible
Mammograms covered at 80%
Mental Health/Substance
Abuse Inpatient 80%; after deductible 70% after deductible

Outpatient 80%; after $50 co-payment per visit 70% after deductible
80%; after deductible; for accident or 70% of covered charges after deductible; for
Oral Surgery
impactions only accident or impactions only
Organ Transplant (Donor 80%; after deductible 70% of covered charges after deductible
also covered)
80% after $30 co-payment / $50 specialist co-
Physician Office Visits 70% of covered charges after deductible
payment; no deductible

Routine Physical Exam 80% after $30 co-payment; no deductible 70% of covered charges; after $30
limited to one exam per year co-payment; no deductible; limited to one exam
per year
Skilled Nursing Facility 80%; after deductible; requires pre-certification 70% of covered charges after deductible;
requires pre-certification
Surgery 80%; after deductible; requires pre-certification 70% of covered charges after deductible;
requires pre-certification
Vision Care Separate Plan through Vision Benefits of America; Employee covered at no charge; Employee
can add dependents for a minimal weekly premium.
Benefit Form required for your office visit. See rates on page 19.
Well Baby Care 80% after $30 co-payment; no deductible; 70% of covered charges after deductible;
includes immunizations includes immunizations

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