PMC 2024 Benefit Guide (English)

PERSONAL CHOICE PPO BASE PLAN $3000

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

PCP Referral Required

No

N/A

Annual Deductible

Individual: $3,000; Family: $6,000

Individual: $5,000; Family: $10,000

Out-of-Pocket Maximum

Individual: $7,900; Family: $15,800

Individual: $10,000; Family: $20,000

Lifetime Maximum

Unlimited

Preventive Care Adult Preventive Care Adult Annual Physical Exam Well-Child Care

Covered 100% Covered 100% Covered 100%

Covered 50% No deductible Covered 50% No deductible Covered 50% No deductible

Outpatient Care Primary care physician office visits Specialist office visits Telemedicine Virtual Visit at designated IBC provider Outpatient facility surgery

$30 copay $60 copay Covered 100% $300 copay after deductible

Covered 50% after deductible Covered 50% after deductible Not covered Covered 50% after deductible

Outpatient Lab & X-Ray* Outpatient Lab Diagnostic X-Ray/Radiology Complex Imaging

$60 copay $60 copay $200 copay (pre-authorization required)

Covered 50% after deductible Covered 50% after deductible Covered 50% after deductible

Emergency Care Ambulance when medically necessary At hospital emergency room Urgent Care

Covered 100% after deductible $300 copay (NOT waived if admitted) $100 copay

Covered 100% after deductible $300 copay (NOT waived if admitted) Covered 50% after deductible

Hospital Services Inpatient Care

Covered 100% after deductible

Covered 50% after deductible

Maternity Care Prenatal and Post-natal care Hospital services for mother and child

$30 copay (first visit only) Covered 100% after deductible

Covered 50% after deductible Covered 50% after deductible

Mental Health Inpatient Outpatient

Covered 100% after deductible $60 copay

Covered 50% after deductible Covered 50% after deductible

Chiropractic Care Office visit (20 visits per calendar year)

$60 copay

Covered 50% after deductible

Physical/Occupational & Speech Therapy 30 visits/calendar year combined for PT and OT; 20 visits/calendar year for Speech Therapy Prescription Drugs Retail Pharmacy (30 day supply) Low-Cost Generic/Generic/Preferred Brand/Non Preferred Brand Mail Order (90 day supply) Generic/Preferred Brand/Non-Preferred Brand

$60 copay

Covered 50% after deductible

$3/$20/$40/$60

30% reimbursement of drug’s retail cost for the total amount dispensed

N/A

$6/$40/$80/$120

*For outpatient laboratory and radiology services, make sure to check that the facility being used is a participating provider with IBC in order to avoid any additional out of pocket charges.

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