PPO Savings Plan: Overview of Coverage - Teamsters

2017 PPO Savings 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)

$1,300: Employee Only Plan
$2,600: Family Plan

$2,600: Employee Only Plan
$5,200: Family Plan
Plan Pay - payment based on the plan allowance

90% after deductible

70% after deductible
Coinsurance Maximums
(Excludes deductible; Includes prescription drug
expenses, and coinsurance. Once met, plan pays 100%
for the rest of the benefit period)

$2,100: Employee Only Plan
$4,200: Family Plan

$4,200: Employee Only Plan
$8,400: Family Plan
Office/Clinic/Urgent Care Visits
Primary Care Provider Office Visits & Virtual Visits 90% after deductible 70% after deductible
Specialist Office Visits & Virtual Visits 90% after deductible 70% after deductible
Virtual Visit Originating Site Fee 90% after deductible 70% after deductible
Urgent Care Center Visits 90% after deductible 70% after deductible
Retail Clinic Visits & Virtual Visits 90% after deductible 70% after deductible
Telemedicine Services 90% after deductible Not covered
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% after deductible
    Mammograms, routine and medically necessary Routine: 100% (deductible does not apply)
Medically Necessary: 90% after deductible
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 90% after deductible
Ambulance Emergency and Non-emergency: 90% after deductible Emergency: 90% after deductible
Non-emergency: 70% after deductible
Therapy and Rehabilitation Services
Physical Medicine 90% after deductible 70% after deductible
Limit: 24 visits/benefit period
Respiratory Therapy 90% after deductible 70% after deductible
Speech & Occupational Therapy 90% after deductible 70% after deductible
Limit: 24 visits/benefit period
Spinal Manipulations 90% after deductible 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 90% after deductible 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