PMC 2024 Benefit Guide (English)

PERSONAL CHOICE PPO STANDARD PLAN $1500

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

PCP Referral Required

No

N/A

Annual Deductible

Individual: $1,500; Family: $3,000

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

Out-of-Pocket Maximum

Individual: $7,900; Family: $14,700

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

$20 copay $40 copay Covered 100% $250 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

$40 copay $40 copay $80 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 $250 copay (NOT waived if admitted) $85 copay

Covered 100% after deductible $250 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

$20 copay (first visit only) Covered 100% after deductible

Covered 50% after deductible Covered 50% after deductible

Mental Health Inpatient Outpatient

Covered 100% after deductible $40 copay

Covered 50% after deductible Covered 50% after deductible

Chiropractic Care Office visit (20 visits per calendar year)

$40 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

$40 copay

Covered 50% after deductible

$3/$20/$40/$60

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

$6/$40/$80/$120

N/A

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

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