PPO 1250 Plan

Copayments
Members will pay a copayment for office visits and urgent care. Members may pay a $250 copayment for Emergency Room services in addition to deductible and coinsurance. The Emergency Room 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 coinsurance.

Copayments apply to the out-of-pocket maximum, but not the deductible.

How the PPO 1250 Plan Works

1. When visiting a health care provider, the member will pay a copayment for each visit. The member will also pay for other medical expenses out of their pocket until the annual deductible is met (see Copayments section above).
2. The office visit copayments cover the visit only. Any lab, X-ray or other services associated with the visit will apply to the deductible and coinsurance.
3. Chiropractor copayment may be $20 or 50% of the total cost of the service, whichever is less.
4. Once the deductible is met, members will continue to pay copayments. However, members will now pay coinsurance on covered expenses until their out-of-pocket maximum is reached. At that time, the plan will begin paying 100 percent of covered services (see Family Coverage section below).
5. Active employees with a health care Flexible Spending Account (FSA) may receive reimbursement for qualified medical expenses by submitting a claim and providing necessary documentation to MoCAFE (see HSA vs FSA).

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.

Two married active state employees who cover children may combine medical deductibles by participating in a Family Roll Up.

See Prescription Drug Plans for information on the prescription drug coverage and coinsurance/copayments.