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:
- After you have paid the $350 single deductible/$700 family deductible,
- 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.
- After you have paid the annual out-of-pocket maximum ($900 single maximum/$1,800 family maximum),
- 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.
