The PPO 750 Plan is a plan that gives access to network providers at a lower cost.
Check with your employer ot see which plans are available to you.
Preventive Services
Network
MCHCP pays 100%
Non-Network
40% coinsurance
MCHCP pays 100%
40% coinsurance
Virtual Care through Sydney Health
Network
MCHCP pays 100%
Non-Network
Network Benefit
MCHCP pays 100%
Network Benefit
Deductible
Individual
Family
Network
Individual: $750
Family: $1,500
Non-Network
Individual: $1,500
Family: $3,000
$750
$1,500
$1,500
$3,000
Medical OOP Maximum
Individual
Family
Network
Individual: $2,250
Family: $4,500
Non-Network
Individual: $4,500
Family: $9,000
$2,250
$4,500
$4,500
$9,000
Prescription OOP Maximum
Individual
Family
Network
Individual: $4,150
Family: $8,300
Non-Network
No Maximum
$4,150
$8,300
No Maximum
Urgent Care
Network
20% coinsurance
Non-Network
Network Benefit
20% coinsurance
Network Benefit
Emergency Room
Network
$250 copayment plus 20% coinsurance
Medicare: 20% coinsurance
Non-Network
Network Benefit
$250 copayment plus 20% coinsurance
Medicare: 20% coinsurance
Network Benefit
Inpatient
Network
$200 copayment plus 20% coinsurance
Non-Network
$200 copayment plus 40% coinsurance
$200 copayment plus 20% coinsurance
$200 copayment plus 40% coinsurance
Other Medical Services
Network
20% coinsurance
Non-Network
40% coinsurance
20% coinsurance
40% coinsurance
Copayments
Members may pay a $250 copayment for emergency room services, in addition to deductible or coinsurance. This copayment is waived if the member is admitted to the hospital or the services are considered by the medical plan to be a “true emergency.” Even if the copayment is waived, the member will still have to pay any deductible or coinsurance owed for the Emergency Room service.
Members also have a $200 copayment for inpatient services in addition to their coinsurance.
Copayments apply to the out-of-pocket maximum, but not the deductible. Medicare retirees do not have an Emergency Room copayment, they are only charged coinsurance.
How the PPO 750 Plan Works
Family Coverage
If two or more family members are covered in a PPO plan and one family member reaches the individual deductible or out-of-pocket maximum, the medical plan begins paying claims for the individual. If one or more additional family members meet the individual deductible or out-of-pocket maximum, the medical plan begins paying claims for the entire family.
See Prescription Drug Plans for information on the prescription drug coverage and coinsurance/copayments.
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