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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.
PPO 80/60 Rangers Front Office Alternate RX Plan D 016587-30, -97 Effective 1/1/23
Benefit Network Out-of-Network
General Provisions
Benefit Period(1) Calendar
Deductible (per benefit period)
Individual $300 $600
Family $600 $1,200
Plan Pays – payment based on the plan allowance 80% after deductible 60% after deductible
Out of Pocket Limit (Excludes deductible. Once met,
plan pays 100% coinsurance (excluding applicable
copays) for the rest of the benefit period)
Individual $1,500 $3,000
Family $3,000 $6,000
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 100% after $15 copayment 60% after deductible
Primary Care Provider Office Visits 100% after $15 copayment 60% after deductible
Specialist Office Visits 100% after $15 copayment 60% after deductible
Urgent Care Center Visits 100% after $15 copayment 60% after deductible
Telemedicine Services (6) 100% after $15 copayment Not Covered
Preventive Care
Routine Adult
Physical exams 100% (deductible does not apply) Not Covered
Adult immunizations 100% (deductible does not apply) 60% after deductible
Colorectal cancer screening (includes colonoscopy; 100% (deductible does not apply) 60% after deductible
sigmoidoscopy; barium enema; blood occult)
Routine gynecological exams, including a Pap Test 100% (deductible does not apply) 60% (deductible does not apply)
Mammograms, annual routine 100% (deductible does not apply) 60% after deductible
Diagnostic services and procedures 100% (deductible does not apply) 60% after deductible
Routine Pediatric
Physical exams 100% (deductible does not apply) Not Covered
Pediatric immunizations 100% (deductible does not apply) 60% (deductible does not apply)
Diagnostic services and procedures 100% (deductible does not apply) 60% after deductible
Hospital and Medical/Surgical Expenses (including maternity)
Hospital Inpatient 80% after deductible 60% after deductible
Hospital Outpatient 80% after deductible 60% after deductible
Maternity (non-preventive facility & professional 80% after deductible 60% after deductible
services)
Medical/Surgical (except office visits) 80% after deductible 60% after deductible
Emergency Services
Emergency Room Services 100% after $100 copayment (waived if admitted)
Ambulance 80% (deductible does not apply)
Therapy and Rehabilitation Services
Physical Medicine 100% after $15 copayment 60% after deductible
Limit: 70 visits per benefit period combined with Occupational and Speech
Therapy
Occupational Therapy 100% after $15 copayment 60% after deductible
Limit: 70 visits per benefit period combined with Physical Medicine and Speech
Therapy
Speech Therapy 100% after $15 copayment 60% after deductible
Limit: 70 visits per benefit period combined with Physical Medicine and
Occupational Therapy
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