Basic PPO Plan
With this option, you have the flexibility to see providers who meet your or your family’s health care needs. “PPO” refers to “preferred provider organization” – an important feature of this type of medical plan. This option has lower levels of coverage than the Enhanced PPO and lower employee contributions. This plan might be suitable for employees who do not need expensive "first dollar" coverage but instead are looking for a lower cost plan that provides good basic coverage with catastrophic protection.
Here’s how it works:
The Basic PPO option has two level of benefits: Network and Non-network. Each time you need care you decide whether to see a network or non-network provider. You receive higher benefits when you see network providers. Network providers will also file claims for you. To see a list of network providers for your area, click on the United Health Care provider link and select the “Options PPO” provider listing or you may click on www.myuhc.com.
This option is available only to employees not covered by a collective bargaining agreement.
Summary of Benefits |
Network Provider |
Non-Network Provider |
|
Physician Services |
80% (deductible applies) |
60% of R&C * (deductible applies) |
|
Preventive Care |
Office
visits not covered; 80% for one Pap test/cal. yr 80% for mammogram
per age schedule (deductible applies) No Other Preventative Care covered |
None |
| Well Baby Care | None | None |
|
Hospital Inpatient |
80% (deductible applies) |
60% of R&C (deductible applies) |
|
Hospital Outpatient |
80% (deductible applies) |
60% of R&C (deductible applies) |
|
Emergency Room |
80% for emergencies (deductible applies)60% for non-emergencies (deductible applies) |
80% of R&C for emergencies (deductible applies) 60% of R&C for non-emergencies (deductible applies) |
|
Urgent Care Centers |
80% (deductible applies) |
60% R&C (deductible applies) |
|
Surgery |
80% (deductible applies) |
60% R&C (deductible applies) |
|
X-ray & laboratory |
80% (deductible applies) |
60% R&C (deductible applies) |
|
Prescription Drugs (one month supply) |
80%
generic (deductible and coinsurance maximum do not apply)
|
Not covered
|
|
Mail Order Prescription (3 month Supply) |
(90-day
supply) 60%
brand (deductible and coinsurance maximum do not apply)
|
Not covered |
|
Mental Health & Chemical Dependency |
Inpatient 80% Outpatient 80% (deductible and coinsurance maximum do not apply)
|
Inpatient 50% up to $400/day Outpatient 50% up to $40/visit |
|
Deductible ** |
$500/person $1000/family |
$500/person $1000/family |
|
Co-insurance maximum |
$3,500/person $7,000/ family |
$5,000/person $10,000/ family |
|
Life time maximum |
$2,000,000/person |
|
* Reasonable & Customary as determined by United Health Care
** Deductible does not apply to network providers except where noted. The deductible applies in most situation when using a non-network provider.
Employee Monthly Cost (Effective January 1, 2004)
|
Employee Only |
$ 2.31/bi-weekly |
|
Employee & Child(ren) |
$ 13.85/bi-weekly |
Employee & Spouse |
$16.15/bi-weekly |
|
Employee, Spouse & Child(ren) |
$18.46/bi-weekly |
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