2027 PPO

This plan does not have any medical deductibles.

In-network: $0 copay
Out-of-network: 40% coinsurance

In-network: $45 copay
Out-of-network: 40% coinsurance

Not required

In-network: $0 copay
Out-of-network: 40% coinsurance

In-network & Out-of-network: $40 copay

The copay is not waived if you are admitted to the hospital.

In-network & Out-of-network: $115 copay
The copay is waived if you are admitted to the hospital within 24 hours for the same condition.

$115 for emergency care services and $40 copay for urgent care services. Emergency and urgent care services are covered up to a maximum of $50,000 each year.

In-network: $385/day for days 1-6; $0 copay for days 7-90

Out-of-network: 30% coinsurance per stay

In-network:
$250 copay at an Ambulatory Surgical Center
$375 copay at an Outpatient Hospital Facility
$0 copay for diagnostic colonoscopies

Out-of-network:
50% coinsurance

Medicare-covered Acupuncture:
In-network: $0 – $45 copay, based on location of service

Out-of-network: 40% coinsurance

Non-Medicare covered Acupuncture: Not Covered

Medicare-covered Chiropractic Services:
In-network: $15 copay
Out-of-network: 50% coinsurance

Non-Medicare covered Chiropractic Services: Not covered

Medicare-covered Podiatry Services:
In-network: $45 copay
Out-of-network: 50% coinsurance

Routine Foot Care: Not covered

In-network:
$50 copay for diagnostic hearing exams
$0 copay for routine hearing exams
$0 copay for fitting and evaluation for hearing aids
$699 copay per hearing aid for Advanced hearing aids OR $999 copay per aid for Premium hearing aids. Up to two TruHearing-branded hearing aids each year (one per ear per year).

Out-of-network:
50% coinsurance for diagnostic hearing exams
80% coinsurance for routine hearing exams, fitting and evaluation for hearing aids, and for hearing aids (one per ear per year).

$0 copay for participating fitness centers.

$615 (Applies to drugs in Tiers 3, 4 and 5)

$0 copay for a 30-day supply
$0 copay for a 60-day supply
$0 copay for a 100-day supply

$15 copay for a 30-day supply
$22.50 copay for a 60-day supply
$30 copay for a 100-day supply

25% co-insurance ($35 for all insulins) for a 30-day supply
25% co-insurance ($70 for all insulins) for a 60-day supply
25% co-insurance ($105 for all insulins) for a 100-day supply

25% co-insurance ($35 for all insulins) for a 30-day supply
25% co-insurance ($70 for all insulins) for a 60-day supply
25% co-insurance ($105 for all insulins) for a 100-day supply

26% co-insurance for a 30-day supply (only)

Available — Get eligible prescription medications delivered directly to your home. Mail order may be available for up to a three-month supply of many maintenance medications. Contact Member Services to learn how to get started.

In-network: $50 copay
Out-of-network: 50% coinsurance

In-network: $0 copay
Out-of-network: 50% coinsurance

One per year
In-network: $0 copay
Out-of-network: 50% coinsurance

In-network: $0 copay
Out-of-network: 50% coinsurance

In-network: Our plan pays up to $200 every year for supplemental eyewear from any in-network Superior Vision provider.
Out-of-network: 50% coinsurance, up to $200.

In-network: $0 copay
Out-of-network: 50% coinsurance

(2 cleanings per year):

In-network: $0 copay
Out-of-network: 50% coinsurance

Oral exam(s) (Frequency determined by type of oral exam):
In-network: $0 copay
Out-of-network: 50% coinsurance

Dental X-Ray(s) (Frequency determined by type of X-Ray): In-network: $0 copay
Out-of-network: 50% coinsurance

(2 fluoride treatments per year):

In-network: $0 copay
Out-of-network: 50% coinsurance

Not covered

In-network & Out-of-network:
$50 copay

In-network & Out-of-network:
$100 copay

In-network & Out-of-network:
$50 copay

In-network & Out-of-network:
$100 copay

In-network & Out-of-network:
$50 – $100 copay, depending on service

$21 monthly premium. The plan has a maximum coverage amount of $1,000 per year for in-network non-Medicare-covered comprehensive dental services. Frequency is dependent on procedure.