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RightPlan 40 PPO Benefits-at-a-glance
These amounts show your share of costs after deductible, if any.
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Plan Benefit
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In-Network
Receive negotiated savings
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Out-of-Network3
Pay higher costs
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Annual Deductible
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Single Member
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$0
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$5,000
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Family Maximum
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not applicable
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Annual
Out-of-Pocket Limit
(in addition to deductible)
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Single Member
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$3,500
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$7,000
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Family Maximum
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not applicable
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Lifetime Maximum
(combined for in-network and out-of-network)
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Health plan pays up to $5 Million per member
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Covered Services
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In-Network
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Out-of-Network 3
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Doctors’ Office Visits
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$40 copay2
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50%
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Professional Services
(X-ray, lab, anesthesia, surgeon, etc.)
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40%
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50%
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Hospital Inpatient
(overnight hospital stays)
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$500 copay
per day per admission
up to 4 days plus 40%
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$500 copay
per day per admission
up to 4 days plus 50%
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Hospital Outpatient
(if you don’t stay overnight)
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$500 copay
per surgical admission
plus 40%
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$500 copay
per surgical admission
plus 50%
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Emergency Room Services
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$100 copay (waived if admitted) plus 40%
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$100 copay (waived if admitted) plus 50%
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Maternity
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not covered
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Preventive Care
(specific routine tests based on national recommendations)
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Adult
Services
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$40 copay per office visit
plus 40% for mammogram,
Pap test, and
prostate screening
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50%
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Children’s
Services
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$40 copay per office visit
plus 40% for
age appropriate visits
and routine immunizations
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50% for age-appropriate visits
and routine immunizations
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Chiropractic Services
($200 maximum annual benefit per member)
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40%
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50%
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Prescription Drug Coverage
(see brochure for more information)
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Generic: $10 copay
Brand-name: $30 copay after annual $500 brand-name prescription drug deductible
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Generic: $10 copay plus 30%
Brand-name: $30 copay plus 30% after annual $500 brand-name prescription drug deductible
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