PPO Blue Plan: Overview of Coverage - Teamsters

2017 PPO Blue Overview of Coverage for Teamsters
Benefit In-Network Out-of-Network
Benefit Period

Twelve months beginning on the contract date

Deductible per benefit period
(applies to medical and prescription drug benefits)

$250: Employee Only Plan
$250/$375: Parent/Child(ren) Plan
$250/$500: Husband/Wife, Employee/Partner, Family Plan

$500: Employee Only Plan
$1,000: Family Aggregate

Plan Pay - payment based on the plan allowance

90% after deductible

70% after deductible
Coinsurance Maximums
(Excludes deductible; Employee pays 10% of plan allowance)

$1,000: Employee Only Plan
$1,000/$1,500: Parent/Child(ren) Plan
$1,000/$2,000: Husband/Wife, Employee/Partner, Family Plan

$2,000: Employee Only Plan
$4,000: Family Aggregate
Office/Clinic/Urgent Care Visits
Primary Care Provider Office Visits & Virtual Visits 100% after $10 copayment 70% after deductible
Specialist Office Visits & Virtual Visits 100% after $20 copayment 70% after deductible
Virtual Visit Originating Site Fee 90% after deductible 70% after deductible
Urgent Care Center Visits 100% after $20 copayment 70% after deductible
Retail Clinic Visits & Virtual Visits 100% after $20 copayment 70% after deductible
Telemedicine Services 100% after $10 copayment Not Applicable
Preventive Care
Routine Adult:    
    Physical exams 100% (deductible does not apply) 70% after deductible
    Adult immunizations 100% (deductible does not apply) 70% after deductible
    Colorectal cancer screening 100% (deductible does not apply) 70% after deductible
    Routine gynecological exams, including a Pap Test 100% (deductible does not apply) 70% (deductible does not apply)
    Mammograms, routine and medically necessary 100% (deductible does not apply) 70% after deductible
    Diagnostic services and procedures 100% (deductible does not apply) 70% after deductible
Routine Pediatric:    
    Physical exams 100% (deductible does not apply) 70% after deductible
    Pediatric immunizations 100% (deductible does not apply) 70% (deductible does not apply)
    Diagnostic services and procedures 100% (deductible does not apply) 70% after deductible
Hospital and Medical/Surgical Expenses (including maternity)
Hospital Inpatient 90% after deductible 70% after deductible
Hospital Outpatient
Maternity (non-preventive facility & professional services)
Medical/Surgical
Emergency Services
Emergency Room Services 100% after $100 copayment (waived if admitted)
Ambulance Emergency and Non-emergency: 90% after deductible Emergency: 90% after deductible
Non-emergency: 70% after deductible
Therapy and Rehabilitation Services
Physical Medicine 100% after $20 copayment 70% after deductible
Limit: 24 visits/benefit period
Respiratory Therapy 90% after deductible 70% after deductible
Speech & Occupational Therapy 100% after $20 copayment 70% after deductible
Limit: 24 visits/benefit period
Spinal Manipulations 100% after $20 copayment 70% after deductible
Limit: 24 visits/benefit period
Other Therapy Services (Cardiac Rehab, Infusion Therapy, Chemotherapy, Radiation Therapy, and Dialysis) 90% after deductible 70% after deductible
Mental Health/Substance Abuse
Inpatient 90% after deductible 70% after deductible
Inpatient Detoxification/Rehabilitation
Outpatient 100% after $10 copayment 70% after deductible
Other Services
Allergy Extracts and Injections 90% after deductible 70% after deductible
Applied Behavior Analysis for Autism Spectrum Disorder 90% after deductible 70% after deductible
Assisted Fertilization Procedures (Artificial Insemination only) 90% after deductible 70% after deductible
Dental Services Related to Accidental Injury 90% after deductible 70% after deductible
Diagnostic Services (Advanced imaging; MRI, CAT, PET scan, etc.) 90% after deductible 70% after deductible
Basic Diagnostic Services (standard imaging, diagnostic medical, lab/pathology, allergy testing) 90% after deductible 70% after deductible
Durable Medical Equipment, Orthotics and Prosthetics 90% after deductible 70% after deductible
Gastric Bypass/Bariatric Surgery 90% after deductible Not Covered
Gender Reassignment Surgery/Transgender Services 90% after deductible 70% after deductible
Home Health Care 90% after deductible 70% after deductible
Limit: 120 visits/benefit period
Hearing Care Services 90% after deductible
Limit: $700 per 36 months for the purchase of a hearing aid device and audio metric testing
Hospice 90% after deductible 70% after deductible
Infertility Counseling, Testing and Treatment 90% after deductible 70% after deductible
Private Duty Nursing 90% after deductible

70% after deductible

Limit: 240 hours/benefit period
Skilled Nursing Facility Care 90% after deductible 70% after deductible
Limit: 100 days/benefit period
Transplant Services 90% after deductible Not Covered
Wigs (Cancer diagnosis only) 90% after deductible
Limit: $300 maximum/lifetime
Precertification Requirements Yes

Note: Total Maximum Out-of-Pocket Maximum (TMOOP) is mandated by the federal government effective with plan years beginning on or after January 1, 2014. TMOOP must include deductible, coinsurance, copays, prescription drug cost share and any qualified medical expense. With plan years beginning on or after January 1, 2017, TMOOP cannot be more than $7,150 for an individual and $14,300 for plans with two or more persons. This plan satisfies this requirement.