Medical Insurance 80/60 PPO

A PPO is a Preferred Provider Organization which pays a higher benefit percentage for services from an in-network provider, and a somewhat lesser benefit percentage for services from an out-of-network provider. 

The 80/60 PPO plan has a $350 single deductible and a $700 family deductible every calendar year. The Medical Mutual SuperMed PPO utilizes the SuperMed Plus provider network.  The Anthem Blue Cross/Blue Shield PPO utilizes the Blue Access (PPO) network.

In these plans, you do not need a referral for specialist services. 

  • In-network inpatient, outpatient, and diagnostic services are covered at 80 percent after the deductible is satisfied.
  • Out-of-network coverage for these services is covered at 60 percent after the deductible has been satisfied.

Some services have a copay amount which is not subject to the deductible. For example, an office visit to an in-network Primary Care Physician simply requires a $15 copay. Several routine services such as annual well-woman exams and well-child immunizations also require only the $15 copay if an in-network provider is used. In-network coverage for routine mammograms and routine prostate specific antigen (PSA) testing is at 100 percent.

With the 90/70 and 80/60 "traditional" medical plans, you must meet the deductible before your insurance begins to pay toward your qualified medical expenses.

When will my insurance begin paying for my medical expenses?

Example 80/60 plan:

  1. After you have paid the $350 single deductible/$700 family deductible,
  2. Your insurance will begin to pay 80% toward your qualified medical expenses and you will continue to pay 20% (Co-Insurance) for your share of medical expenses.
  3. After you have paid the annual out-of-pocket maximum ($900 single maximum/$1,800 family maximum),
  4. Your insurance will begin to pay 100% of your qualified medical expenses.

NOTE:  You will continue to pay your Office Co-pays throughout the year.  Co-pays do not count toward meeting deductibles and/or annual out-of-pocket maximums.

This process is the same for the 90/70 medical plans.  The exception are the deductible, co-insurance and maximum out of pocket amounts.

90-80 Deductible Image