PPO Medical Plan

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 appliesv

You pay 40%, after deductible


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 

  1. “Embedded” means if any one individual reaches the individual threshold, that individual progresses to the coinsurance or 100% benefit level regardless of coverage tier.
  2. 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.


Prescription Drugs

CVS Caremark