$5,000 PPO Plan 2 | In-Network | Out-of-Network |
Physician Office Visit |
$35 Copayment Specialist: $70 Copayment |
$105 Copayment Specialist: $210 |
Calendar Year Deductible | $5,000 Single / $10,000 Family | $15,000 Single / $30,000 Family |
Coinsurance (Plan Pays / You Pay) | 100% / 0% | 100% / 0% |
Out-of-Pocket Maximum | $5,000 Single / $10,000 Family | $15,000 Single / $30,000 Family |
Annual Routine Physical | No cost sharing for preventive services | Coinsurance |
Emergency Room Visits | $350 Copayment | $350 Copayment |
Hospital Services | Deductible then Coinsurance | Deductible then Coinsurance |