10 / 32
9
Medical – PPO
Anthem Blue Cross
Choice & Select PPO
Anthem Blue Cross
PERS Care PPO
In-Network
Out-Of-Network
In-Network
Out-Of-Network
Annual Deductible
Individual
Family
$500
$1,000
$500
$1,000
$500
$1,000
$500
$1,000
Annual Out-of-Pocket
Max
(excluding pharmacy)
Individual
Family
$3,000
$6,000
None
None
$2,000
$4,000
None
None
Lifetime Max
Unlimited
Unlimited
Unlimited
Unlimited
Office Visit
Primary Provider
$20 copay
40%
$20 copay
40%
Specialist
$20 copay
40%
$20 copay
40%
Preventive Services
No Charge
40%
No Charge
40%
Acupuncture/Chiropractic
combined 20 visits per
year
$15 copay
40%
$15 copay
40%
Lab and X-ray
20%
40%
10%
40%
Inpatient Hospitalization
20%-30%
40%
10%
40%
Outpatient Surgery
20%-30%
40%
10%
40%
Urgent Care
$20 copay
40%
$20 copay
40%
Emergency Room
20%
(copay waived if
admitted)
20%
(copay waived if
admitted)
10%
(copay waived if
admitted)
10%
(copay waived if
admitted)
For 2018, the Affordable Care Act (ACA) limits out-of-pocket maximums (OOPM) amounts for health plans to $7,350 (individual) and
$14,700 (family) for both medical and pharmacy benefits combined.
Specific details and plan limitations are provided in the Summary Plan Description (SPD), which is based on the official Plan Documents that
may include policies, contracts, and plan procedures. The SPD and Plan Documents contain all the specific provisions of the plans. In the
event that the information in this summary differs from the Plan Documents, the Plan Documents will prevail.