The PPO Medical Plan covers in-network preventive care, office visits and hospital emergency room care with no deductible; you pay only a flat-dollar copay for these services—and you pay nothing for in-network preventive care. For most other in-network services, you pay 20% after meeting your annual deductible.
In-Network vs. Out-of-Network Care
In-network providers have negotiated service rates with Credence BCBS. An out-of-network provider may charge more than Credence BCBS is willing to pay. Because of this, the out-of-network deductible is higher than the in-network deductible. Before receiving treatment, check with Credence BCBS to ensure a doctor, lab, hospital, specialist or other provider is in-network, how much care will cost and to understand your health plan.
| Plan Feature | In-Network | Out-Of-Network |
|---|---|---|
|
Annual Deductible (embedded)1 |
Individual: $750 Family: $1,500 |
Individual: $1,500 Family: $3,000 |
|
Annual Out-of-Pocket Maximum (embedded)1 |
Individual: $4,250 Family: $8,500 |
Individual: $8,500 Family: $17,000 |
|
Preventive Care2 |
You pay nothing for plan-eligible preventive care; no deductible applies |
You pay 40%, after deductible |
|
Coinsurance |
You pay 20%, after deductible |
You pay 40%, after deductible |
|
Office Visit Copay |
Primary Care Physician: $30 Specialist: $60 |
You pay 40%, after deductible |
|
Hospital Emergency Room Care |
Plan pays 100% after you pay $150 copay If claim is submitted with a non-emergency diagnosis, an additional $200 will apply |
Plan pays 100% after you pay $150 copay If claim is submitted with a non-emergency diagnosis, you pay 40% after deductible |
- “Embedded” means if any one individual reaches the individual threshold, that individual progresses to the coinsurance or 100% benefit level regardless of coverage tier.
- For specific preventive services, a list of covered immunizations, visit limitations and/or pre-certification requirements, refer to the Summary Plan Descriptions at TennecoPlanDocs.com or visit CredenceBlue.com/preventiveservices.
If you’re enrolled, you and your eligible dependents also have 24/7 access to board-certified physicians from the comfort of your home, office or wherever you are through Teladoc.
