| |
A
$300.00 annual in network deductible must be met for each
person on the plan, with a maximum of $900.00 per family.
Out of network deductible is $600.00 for each person on the
plan with a maximum of $1,800.00 per family. As our PPO health
plan is an integrated medical/dental plan, the $300.00 deductible
is for the medical portion only; an additional $50.00 will
be assigned for dental benefits.
PPO
Medical Benefits
Maximum Out of Pocket (MOOP)
| In
Network |
Employee
MOOP |
$1,500 |
| Out
of Network |
Employee
MOOP |
$3,000 |
| In
Network |
Employee
+ 1 MOOP |
$3,000 |
| Out
of Network |
Employee
+ 1 MOOP |
$6,000 |
| In
Network |
Employee
+ 2 or more MOOP |
$4,500 |
| Out
of Network |
Employee
+ 2 or more MOOP |
$9,000 |
NOTE:
Maximum Out of Pocket does not include prescription
drug co-payments or deductibles.
After
the deductible has been met, if you use the Gulf Coast
Provider Network (Sarasota, Manatee, Pasco, Pinellas and
Hillsborough counties), which includes Sarasota Memorial
Hospital, Manatee Memorial Hospital or Venice Hospital,
as well as the numerous physicians, labs and other facilities
associated with the Gulf Coast Provider Network, eligible
medical expenses are paid at 80%, and the employee is responsible
for 20%. If you do not use an in-network facility or physician,
the deductible is $600.00 per person or $1,800.00 maximum
for family. Claims are paid at 60%, with the employee assuming
the 40% balance.
Examples
of some eligible medical expenses include:
. |
Diagnostic
services |
. |
Pregnancy
expenses |
. |
Outpatient
surgery |
. |
Hospital
services and supplies |
. |
Physician
services |
. |
Well
baby care |
. |
Radiation
therapy |
. |
Wellness
Maximum $400/yr (Annual physical and routine tests) |
MEDICAL/DENTAL:
PPO, EPO1, OR EPO2
941-917-7991 (Local) or 1-877-697-2299 (Toll Free/WEBTPA) or online at www.webtpa.com for
medical
claim or eligibility questions.
DENTAL
Online
at www.hcsrq.com for
dental
claim or
eligibility questions.
A
comparison of rates for PPO, EPO1, EPO2 and Navigator
benefits can be viewed by clicking the "Schedule
of Benefits" button above.
|
