Page 45 - Down East Wood Ducks 2022 Benefits Guide

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.

Hickory & Down East Option 3
Benefit Network Out-of-Network
General Provisions
Benefit Period(1) Calendar
Deductible (per benefit period)
Individual $1,500 $3,000
Family $3,000 $6,000
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 $2,000 $4,000
Family $4,000 $8,000
Total Maximum Out-of-Pocket (includes deductible,
coinsurance, copays, prescription drug 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 $20 copayment 60% after deductible
(deductible does not apply)
Primary Care Provider Office Visits 100% after $20 copayment 60% after deductible
(deductible does not apply)
Specialist Office Visits 100% after $20 copayment 60% after deductible
(deductible does not apply)
Urgent Care Center Visits 100% after $20 copayment 60% after deductible
(deductible does not apply)
Telemedicine Services(3) 100% after $20 copayment Not Covered
(deductible does not apply)
Preventive Care
Routine Adult
Physical exams 100% (deductible does not apply) Not Covered
Adult immunizations 100% (deductible does not apply) 60% after deductible
Travel 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) 100% (deductible does not apply)
Mammograms, annual routine and medically 100% (deductible does not apply) 100% (deductible does not apply)
necessary
Diagnostic services and procedures 100% (deductible does not apply) 60% after deductible
Routine Pediatric
Physical exams 100% (deductible does not apply) 60% after deductible
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 and professional 80% after deductible 60% after deductible
services)
Medical/Surgical (except office visits) 80% after deductible 60% after deductible
Second surgical opinion 80% after deductible 60% after deductible
Emergency Services
Emergency Room Services 80% after $50 copayment (waived if admitted)
Ambulance 80% (deductible does not apply)
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PPO