Common use of PPO Clause in Contracts

PPO. The penalty for failure to call for preadmission approval prior to an inpatient hospital stay under the PPO is $350.00. For employees in the PPO, the following will apply: • The annual In-Network deductible will be $350.00 per individual, the annual In-Network deductible for Employee + 1 will be $700.00 and the maximum annual In-Network deductible per family will be $1,050.00. The annual Out-of- Network deductible will be $700.00 per individual, the annual Out-of-Network deductible for Employee + 1 will be $1,400.00 and the maximum annual Out- of-Network deductible per family will be $2,100.00. • Coinsurance will be 85% of eligible charges after the annual deductible has been met. • A $125.00 co-payment for the emergency room per visit will be required. The co-payment is waived if the patient is admitted from the emergency room. • A Prescription Drug Step Therapy and Prior Authorization program will be utilized. • The annual out-of-pocket expense limit is $1,500.00 per individual, $3,000.00 for Employee + 1 and a maximum of $4,000.00 per family for in-network providers. The annual out-of-pocket expense limit is $3,000.00 per individual, $6,000.00 for Employee + 1 and a maximum of $9,000.00 per family for out- of-network providers. • Coverage for outpatient surgery will be as follows: In-network (PPO) 85% Out-of-network 70% of Usual and Customary The District offers a Wellness Benefit, including Preventative Care Services to all employees and eligible dependents enrolled in the Blue Cross Blue Shield Participating Provider Organization (PPO). This benefit will encourage employees and eligible dependents to seek the preventative care and diagnostic services identified below with the goal of providing for the early diagnosis of illness which can be beneficial in controlling long term health care costs. • Routine Lab Work • Routine X-rays • Hearing Screenings • Routine Sleep Study • Routine EKG • Routine Ovarian Cancer Lab/X-ray • Routine Colorectal Lab/X-ray The Wellness Benefit will be covered at 100% of the eligible charge and the annual deductible will not apply. Covered employees and dependents must use a Participating Provider to receive the maximum benefit coverage.

PPO. The penalty for failure to call for preadmission approval prior to an inpatient hospital stay under the PPO is $350.00. For employees in the PPO, the following will apply: • The annual In-Network deductible will be $350.00 per individual, the annual In-In- Network deductible for Employee + 1 will be $700.00 and the maximum annual In-In- Network deductible per family will be $1,050.00. The annual Out-of- of-Network deductible will be $700.00 per individual, the annual Out-of-Network deductible for Employee + 1 will be $1,400.00 and the maximum annual Out- Out-of-Network deductible per family will be $2,100.00. • Coinsurance will be 85% of eligible charges after the annual deductible has been met. • A $125.00 co-payment for the emergency room per visit will be required. The co-co- payment is waived if the patient is admitted from the emergency room. • A Prescription Drug Step Therapy and Prior Authorization program will be utilized. • The annual out-of-pocket expense limit is $1,500.00 per individual, $3,000.00 for Employee + 1 and a maximum of $4,000.00 per family for in-network providers. The annual out-of-pocket expense limit is $3,000.00 per individual, $6,000.00 for Employee + 1 and a maximum of $9,000.00 per family for out- out-of-network providers. • Coverage for outpatient surgery will be as follows: In-network (PPO) 85% Out-of-network 70% of Usual and Customary The District offers a Wellness Benefit, including Preventative Care Services to all employees and eligible dependents enrolled in the Blue Cross Blue Shield Participating Provider Organization (PPO). This benefit will encourage employees and eligible dependents to seek the preventative care and diagnostic services identified below with the goal of providing for the early diagnosis of illness which can be beneficial in controlling long term health care costs. • Routine Lab Work • Routine X-rays • Hearing Screenings • Routine Sleep Study • Routine EKG • Routine Ovarian Cancer Lab/X-ray • Routine Colorectal Lab/X-ray The Wellness Benefit will be covered at 100% of the eligible charge and the annual deductible will not apply. Covered employees and dependents must use a Participating Provider to receive the maximum benefit coverage.