Page 6 - 2022 Washington Nationals Flipbook

80/60 PPO PLAN

80/60 PPO Plan

Plan Provision In-Network Out-of-Network

Annual Deductible
Individual $300 $600
Family $600 $1,200
Out-of-Pocket Maximum (Excludes Deductible)
Individual $1,500 $3,000
Family $3,000 $6,000

Lifetime Maximum Unlimited

Preventive Care 100% Not covered

Primary Physician Office Visit $15 Copay 60%*

Specialist Office Visit $15 Copay 60%*

X-Ray and Lab 80%* 60%*

Inpatient Hospital Services 80%* 60%*

Outpatient Hospital Services 80%* 60%*

Urgent Care $15 copay 60%*

Emergency Room Care $100 Copay

Click here for more detailed information on this available benefit option.

Note: This is only a brief summary of your coverage. In-network services are based on negotiated charges; out-of-network services are based on
reasonable and customary (R&C) charges.

2022 Washington Nationals Benefit Guide Page 6