Individual PPO
Benefits In-Network Out-of-Network
Deductible - per calendar year $500 single/$1,000 family $12,000 single/$24,000 family
Out-of-Pocket Maximum (includes deductible and copays) - per calendar year $2,250 single/$4,500 family $19,800 single/$39,600 family
Office Visit Primary Care Physician, including OB/GYN $0 copay per visit 50%, after deductible
Specialist $30 copay per visit 50%, after deductible Preventative Care, including Well Baby Care $0 copay per visit 50%, after deductible Telemedicine - MeMD $0 copay per visit $0 copay per visit/MeMD In-Store Health Care Clinic $0 copay per visit 50%, after deductible
Emergency Urgent Care $30 copay per visit 50%, after deductible
Emergency Room - copay waived if admitted $250 copay per visit $250 copay per visit Ambulance - Medical Emergency $0 copay per transport $0 copay per transport
Hospital Inpatient hospital services 0%, after deductible 50%, after deductible
Outpatient hospital services 0%, after deductible 50%, after deductible
Ambulatory Surgical Center $250 copay per visit 50%, after deductible
Outpatient Laboratory/Pathology
Performed in a physician’s office or free-standing independent lab facility $25 copay per test 50%, after deductible Performed in a hospital 0%, after deductible 50%, after deductible
Outpatient Radiology - General
Performed in a physician’s office $30 copay per test 50%, after deductible Performed in an independent, non-hospital-affiliated radiology facility $50 copay per test 50%, after deductible Performed in a hospital 0%, after deductible 50%, after deductible
Outpatient Radiology/Imaging & Testing -
Including, but not limited to CT scans, MRIs, MRAs and PET/SPECT scans
Performed in a physician’s office $250 copay per scan 50%, after deductible Performed in an independent, non-hospital-affilialiated radiology facility $250 copay per scan 50%, after deductible Performed in a hospital 0%, after deductible 50%, after deductible
Maternity Prenatal and Postnatal Care $0 copay per visit 50%, after deductible
Delivery and All inpatient services for Maternity 0%, after deductible 50%, after deductible
Chiropractic Care $30 copay per visit 50%, after deductible
Short Term Physical Therapy, Occupational Therapy,
Speech Therapy - Limited to 60 visits per calendar year combined $30 copay per visit 50%, after deductible
Outpatient /Office Psychiatric and Substance Abuse Visits* $30 copay per visit 50%, after deductible
DME/Supplies/Prosthetics $50 copay per item 50%, after deductible
Vision Pediatric Only - Exam - one exam per calendar year $30 copay per visit 50%, after deductible
Pediatric Only - Glasses or Contacts - one item per calendar year $30 copay per item 50%, after deductible Naturopathy - Maximum 12 visits per calendar year $20 copay per visit Not Covered Acupuncture - Maximum 12 visits per calendar year $20 copay per visit Not Covered Theraputic Massage - Maximum 12 visits per calendar year $20 copay per visit Not Covered Gym Membership Reimbursement Up to $25 per month Up to $25 per month
Outpatient Prescription Drugs - Quantity limits may apply.
Prescription Deductible per person per calendar year $0 Not Covered
Up to a 30 Day Prescription - Retail, 90 Day Prescription-Mail Order 30 Day Retail 90 Day Mail
Generic Maintenance $0 copay $0 copay Not Covered
Meritus Choice Silver PPO Plus 4000 - CSR87
Individual PPO
Benefits In-Network Out-of-Network
Deductible - per calendar year $150 single/$300 family $12,000 single/$24,000 family
Out-of-Pocket Maximum (includes deductible and copays) - per calendar year $1,000 single/$2,000 family $19,800 single/$39,600 family
Office Visit Primary Care Physician, including OB/GYN $0 copay per visit 50%, after deductible
Specialist $10 copay per visit 50%, after deductible Preventative Care, including Well Baby Care $0 copay per visit 50%, after deductible Telemedicine - MeMD $0 copay per visit $0 copay per visit/MeMD In-Store Health Care Clinic $0 copay per visit 50%, after deductible
Emergency Urgent Care $10 copay per visit 50%, after deductible
Emergency Room - copay waived if admitted $75 copay per visit $75 copay per visit Ambulance - Medical Emergency $0 copay per transport $0 copay per transport
Hospital Inpatient hospital services 0%, after deductible 50%, after deductible
Outpatient hospital services 0%, after deductible 50%, after deductible
Ambulatory Surgical Center $75 copay per visit 50%, after deductible
Outpatient Laboratory/Pathology
Performed in a physician’s office or free-standing independent lab facility $10 copay per test 50%, after deductible Performed in a hospital 0%, after deductible 50%, after deductible
Outpatient Radiology - General
Performed in a physician’s office $20 copay per test 50%, after deductible Performed in an independent, non-hospital-affiliated radiology facility $30 copay per test 50%, after deductible Performed in a hospital 0%, after deductible 50%, after deductible
Outpatient Radiology/Imaging & Testing -
Including, but not limited to CT scans, MRIs, MRAs and PET/SPECT scans
Performed in a physician’s office $75 copay per scan 50%, after deductible Performed in an independent, non-hospital-affilialiated radiology facility $75 copay per scan 50%, after deductible Performed in a hospital 0%, after deductible 50%, after deductible
Maternity Prenatal and Postnatal Care $0 copay per visit 50%, after deductible
Delivery and All inpatient services for Maternity 0%, after deductible 50%, after deductible
Chiropractic Care $10 copay per visit 50%, after deductible
Short Term Physical Therapy, Occupational Therapy,
Speech Therapy - Limited to 60 visits per calendar year combined $10 copay per visit 50%, after deductible
Outpatient /Office Psychiatric and Substance Abuse Visits* $10 copay per visit 50%, after deductible
DME/Supplies/Prosthetics $10 copay per item 50%, after deductible
Vision Pediatric Only - Exam - one exam per calendar year $10 copay per visit 50%, after deductible
Pediatric Only - Glasses or Contacts - one item per calendar year $10 copay per item 50%, after deductible Naturopathy - Maximum 12 visits per calendar year $20 copay per visit Not Covered Acupuncture - Maximum 12 visits per calendar year $20 copay per visit Not Covered Theraputic Massage - Maximum 12 visits per calendar year $20 copay per visit Not Covered Gym Membership Reimbursement Up to $25 per month Up to $25 per month
Outpatient Prescription Drugs - Quantity limits may apply.
Prescription Deductible per person per calendar year - Does not apply to Generic Drug Tiers $0 Not Covered Up to a 30 Day Prescription - Retail, 90 Day Prescription-Mail Order 30 Day Retail 90 Day Mail
Generic Maintenance $0 copay $0 copay Not Covered
Non-maintenance Generic $5 copay $15 copay Not Covered Preferred Brand $10 copay $30 copay Not Covered Non-Preferred Brand $35 copay $105 copay Not Covered
Meritus Choice Silver PPO Plus 4000 - CSR94
Group & Individual PPO
Benefits In-Network Out-of-Network
Deductible - per calendar year $6,000 single/$12,000 family $18,000 single/$36,000 family
Out-of-Pocket Maximum (includes deductible and copays) - per calendar year $6,600 single/$13,200 family $19,800 single/$39,600 family
Office Visit Primary Care Physician, including OB/GYN $40 copay per visit 50%, after deductible
Specialist $80 copay per visit 50%, after deductible Preventative Care, including Well Baby Care $0 copay per visit 50%, after deductible Telemedicine - MeMD $0 copay per visit $0 copay per visit/MeMD In-Store Health Care Clinic $40 copay per visit 50%, after deductible
Emergency Urgent Care $80 copay per visit 50%, after deductible
Emergency Room - copay waived if admitted $500 copay per visit $500 copay per visit Ambulance - Medical Emergency 50%, after deductible 50%, after deductible
Hospital Inpatient hospital services 50%, after deductible 50%, after deductible
Outpatient hospital services 50%, after deductible 50%, after deductible
Ambulatory Surgical Center 50%, after deductible 50%, after deductible
Outpatient Laboratory/Pathology
Performed in a physician’s office or free-standing independent lab facility $25 copay per test 50%, after deductible Performed in a hospital 50%, after deductible 50%, after deductible
Outpatient Radiology - General
Performed in a physician’s office $50 copay per test 50%, after deductible Performed in an independent, non-hospital-affiliated radiology facility $150 copay per test 50%, after deductible Performed in a hospital 50%, after deductible 50%, after deductible
Outpatient Radiology/Imaging & Testing -
Including, but not limited to CT scans, MRIs, MRAs and PET/SPECT scans
Performed in a physician’s office 50%, after deductible 50%, after deductible Performed in an independent, non-hospital-affilialiated radiology facility 50%, after deductible 50%, after deductible Performed in a hospital 50%, after deductible 50%, after deductible
Maternity Prenatal and Postnatal Care $40 copay per visit 50%, after deductible
Delivery and All inpatient services for Maternity 50%, after deductible 50%, after deductible
Chiropractic Care 50%, after deductible 50%, after deductible
Short Term Physical Therapy, Occupational Therapy,
Speech Therapy - Limited to 60 visits per calendar year combined 50%, after deductible 50%, after deductible
Outpatient /Office Psychiatric and Substance Abuse Visits* $80 copay per visit 50%, after deductible
DME/Supplies/Prosthetics 50%, after deductible 50%, after deductible
Vision Pediatric Only - Exam - one exam per calendar year 50%, after deductible 50%, after deductible
Pediatric Only - Glasses or Contacts - one item per calendar year 50%, after deductible 50%, after deductible Naturopathy - Maximum 12 visits per calendar year $20 copay per visit Not Covered Acupuncture - Maximum 12 visits per calendar year $20 copay per visit Not Covered Theraputic Massage - Maximum 12 visits per calendar year $20 copay per visit Not Covered Gym Membership Reimbursement Up to $25 per month Up to $25 per month
Outpatient Prescription Drugs - Quantity limits may apply.
Prescription Deductible per person per calendar year - Does not apply to Generic Drug Tiers $300 Not Covered Up to a 30 Day Prescription - Retail, 90 Day Prescription-Mail Order 30 Day Retail 90 Day Mail
Generic Maintenance $10 copay $30 copay Not Covered