Page 12 - American Advisors Group Benefit Guide 2_NonCA

EMPLOYEE BENEFITS 12

PPO MEDICAL COVERAGE

COVERAGE CIGNA PPO (OAP)
In-Network Out-of-Network

Deductible $3,000 / $6,000 $6,000 / $12,000
Maximum Out-of-Pocket $6,000 / $12,000 $12,000 / $24,000
(Single/Family)
Physician Services
PCP Office Visits $40 copay 40% after deductible
Specialists Office Visits $40 copay 40% after deductible
Lab, X-ray (Basic) 20% after deductible 40% after deductible
Complex, Lab and X-ray 20% after deductible 40% after deductible
Well Baby/Child Exam No copay 40% after deductible
Adult Physicals No copay Not covered
Hospital Services
Room and Board 20% after deductible plus $500 copay 40% after deductible plus $1,000 copay

Outpatient Surgery 20% after deductible 40% after deductible
Emergency Care
Copayment $250 copay $250 copay
(waived if admitted)
Urgent Care $125 copay 20% after deductible
Ambulance - 20% after deductible 20% after deductible
Emergency only
Durable Medical 20% after deductible 40% after deductible
Equipment
Prescription Drugs
Tier 1 - $15 copay 50% coinsurance
Generic Formulary
Tier 2 - $30 copay 50% coinsurance
Brand Name Formulary
Tier 3 - Non Formulary $45 copay 50% coinsurance
Tier 4 - $100 copay Not covered
Specialty/Injectable
Mail Order: 2x copay Not covered
Up to 90-day supply Tier 1, 2 and 3
What is a PPO?
The PPO OAP plan gives you the freedom of choice and greater flexibility.

You are not required to choose a primary care physician and do not need a referral to see a specialist.
The PPO offers a large network of contracting doctors and hospitals to choose from when care is needed.
When a contracting network provider is used, the care is considered “in-network.”