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sample plans
2022 exhibit
PPO HIGH-DEDUCTIBLE
National PPO Network
$6,000 Med/Rx Deductible
$6,500 Annual Maximum
40% Primary / 40% Specialist
40% Labs / 40% X-Rays
40% Complex Imaging
40% Urgent / 40% ER
40% Ambulance
40% Surgery – ASC
40% Outpatient Hospital
40% Inpatient Hospital
$6,000 Med/Rx Deductible
40% Generic / 40% Brand
40% Non-Pref / 40% Special
$ ___ / EMPLOYEE (EE)
$ ___ / EE + SPOUSE
$ ___ / EE + CHILD(REN)
$ ___ / EE + FAMILY
PPO SPLIT-DEDUCTIBLE
National PPO Network
$2,500 Medical Deductible
$6,500 Annual Maximum
$45 Primary / $70 Specialist
30% Labs / 30% X-Rays
30% Complex Imaging
$90 Urgent / $250+30% ER
30% Ambulance
30% Surgery – ASC
30% Outpatient Hospital
30% Inpatient Hospital
$250 Rx Deductible
$15 Generic / $30 Brand
$75 Non-Pref / 30% Special
$ ___ / EMPLOYEE (EE)
$ ___ / EE + SPOUSE
$ ___ / EE + CHILD(REN)
$ ___ / EE + FAMILY
PPO ZERO-DEDUCTIBLE
National PPO Network
$0 Deductible
$4,000 Annual Maximum
$20 Primary / $40 Specialist
10% Labs / $40 X-Rays
$250 Complex Imaging
$20 Urgent / $100 ER
$250 Ambulance
$500 Surgery – ASC
$500 Outpatient Hospital
$500/ Day Inpatient Hospital
$100 Rx Deductible
$10 Generic / $30 Brand
$50 Non-Pref / 30% Special
$ ___ / EMPLOYEE (EE)
$ ___ / EE + SPOUSE
$ ___ / EE + CHILD(REN)
$ ___ / EE + FAMILY
benefitCOMPARE footnotes
* benefitCOMPARE on-demand illustrates in-network benefit highlights. Text contained within the illustration is sourced from various plan documents including the plan Certificate of Coverage/Evidence of Coverage, Summary of Benefits & Coverage, Summary of Plan Description, and Benefit Summary. While every effort was taken to accurately display the highlighted benefits, discrepancies or errors are always possible. In case of discrepancy between the illustration and the actual plan documents; the actual plan documents will prevail. For questions regarding benefit citations or clarification, please contact us at 949-402-2690.
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