MEDICAL

Your Health Matters

Independence Blue Cross Medical Plan Options

Choose from one of three medical plans to cover yourself and your dependents. All plans are through Independence Blue Cross and include prescription coverage.

Personal Choice PPO Plan

With this PPO plan, you will:

Have the freedom to visit any In-Network physician without a referral needed
Have coverage for both In and Out of Network providers
Have preventive services covered at 100%

Resources

$250 PPO
Summary of Benefits

$2800 HSA
Summary of Benefits

PPO 250	In-Network	Out-of-Network
Services
Deductible	$250 individual / $500 family	$750 individual / $1,500 family
Annual Out of Pocket Maximum	$2,500 individual / $5,000 family	$7,500 individual / $15,000 family
Inpatient Hospitalization	20% after deductible	50% after deductible
Outpatient Surgical	20% after deductible	50% after deductible
Primary Care Visits	$25 no deductible	50% after deductible
Preventive Care	No charge no deductible	50% no deductible
Specialist Visits	$50 no deductible	50% after deductible
Emergency Room	$350 no deductible, then 20%	Covered at In-Network level
Urgent Care	$75 no deductible	50% after deductible

Illustrates sample of benefits only; for full benefit overview, refer to Summary Plan Document

2800 HSA	In-Network	Out-of-Network
Services
Deductible	$2,800 individual / $5,600 family	$8,400 individual / $16,800 family
Annual Out of Pocket Maximum	$3,500 individual / $7,000 family	$10,000 individual / $20,000 family
Inpatient Hospitalization	No charge after deductible	50% after deductible
Outpatient Surgical	No charge after deductible	50% after deductible
Primary Care Visits	$35 after deductible	50% after deductible
Preventive Care	No charge no deductible	50% no deductible
Specialist Visits	$50 after deductible	50% after deductible
Emergency Room	No charge after deductible	Covered at In-Network level
Urgent Care	No charge after deductible	50% after deductible

Illustrates sample of benefits only; for full benefit overview, refer to Summary Plan Document