PMC 2024 Benefit Guide (English)

PERSONAL CHOICE PPO BUY-UP PLAN

BENEFIT

IN-NETWORK

OUT-OF-NETWORK

PCP Referral Required

No

N/A

Annual Deductible

Individual: None; Family: None

Individual: $2,500; Family: $5,000

Out-of-Pocket Maximum

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

Individual: $10,000; Family: $30,000

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

$15 copay $35 copay Covered 100% $150 copay

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

Covered 100% $35 copay $70 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

$35 copay $200 copay (NOT waived if admitted) $70 copay

Covered 100% $200 copay (NOT waived if admitted) Covered 50% after deductible

Hospital Services Inpatient Care

$150 copay/day (max 5 copays/admission)

Covered 50% after deductible

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

$15 copay (first visit only) $150 copay/day (max 5 copays/admission)

Covered 50% after deductible Covered 50% after deductible

Mental Health Inpatient Outpatient

$150 copay/day (max 5 copays/admission) $35 copay

Covered 50% after deductible Covered 50% after deductible

Chiropractic Care Office visit (20 visits per calendar year)

$35 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

$35 copay

Covered 50% after deductible

$3/$20/$40/$60

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

N/A

$5/$40/$80/$120

*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.

5