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BROUGHT TO YOU BY:
North Carolina Medical Society
Sentinel Benefits Consulting
BROUGHT TO YOU BY:
North Carolina Medical Society
Sentinel Benefits Consulting
BROUGHT TO YOU BY:
North Carolina Medical Society
Sentinel Benefits Consulting
BROUGHT TO YOU BY:
North Carolina Medical Society
Sentinel Benefits Consulting
A PPO 1-2-3 Plan is similar to a standard PPO plan but with tiered benefit coverage for standard services. PPO 1-2-3 plans divide services into three benefit levels:
The values below are for in-network benefits for the 2024 Plan Year.
Plan Name (Click for Highlights) | Annual Deductible (Individual/Family) | Out-of-Pocket Maximum Individual/Family (Includes all copays, deductibles, & coins) | Level 1 Office Visit Primary & Telemedicine (Includes Mental Health & Substance Abuse) | Level 2 Inpatient Professional | Level 2 Inpatient Hospital (Includes Maternity, Mental Health, & Substance Abuse) | Level 3 Specialist Office-Based Services, Outpatient Services (Includes Mental Health & Substance Abuse), Therapies, & Scans | Urgent Care/ER | Prescription Drug |
|---|---|---|---|---|---|---|---|---|
$1,500/$3,000 | $4,500/$9,000 | $35 | 90% after deductible | $250 per admit, then 90% after deductible | 70% after deductible | 70% after deductible | $10/$25/$40/$80/25% (max $100) | |
$2,000/$4,000 | $8,150/$16,300 | $35 | 70% after deductible | $250 per admit, then 70% after deductible | 50% after deductible | 50% after deductible | $10/$25/$40/$80/25% (max $100) | |
$2,500/$5,000 | $8,150/$16,300 | $35 | 70% after deductible | $250 per admit, then 70% after deductible | 50% after deductible | 50% after deductible | $10/$25/$40/$80/25% (max $100) | |
$3,500/$7,000 | $8,150/$16,300 | $35 | 70% after deductible | $250 per admit, then 70% after deductible | 50% after deductible | 50% after deductible | $10/$25/$40/$80/25% (max $100) | |
$4,000/$8,000 | $8,150/$16,300 | $35 | 70% after deductible | $250 per admit, then 70% after deductible | 50% after deductible | 50% after deductible | $10/$25/$40/$80/25% (max $100) | |
$5,000/$10,000 | $8,150/$16,300 | $35 | 70% after deductible | $250 per admit, then 70% after deductible | 50% after deductible | 50% after deductible | $10/$25/$40/$80/25% (max $100) | |
$5,000/$10,000 | $8,150/$16,300 | $35 | 70% after deductible | $250 per admit, then 70% after deductible | 50% after deductible | 50% after deductible | $10/0% (max $100) |
The values below are for in-network benefits for the 2023 Plan Year.
Plan Name (Click for Highlights) | Annual Deductible (Individual/Family) | Out-of-Pocket Maximum Individual/Family (Includes all copays, deductibles, & coins) | Level 1 Office Visit Primary & Telemedicine (Includes Mental Health & Substance Abuse) | Level 2 Inpatient Professional | Level 2 Inpatient Hospital (Includes Maternity, Mental Health, & Substance Abuse) | Level 3 Specialist Office-Based Services, Outpatient Services (Includes Mental Health & Substance Abuse), Therapies, & Scans | Urgent Care/ER | Prescription Drug |
|---|---|---|---|---|---|---|---|---|
$1,500/$3,000 | $4,500/$9,000 | $35 | 90% after deductible | $250 per admit, then 90% after deductible | 70% after deductible | 70% after deductible | $10/$25/$40/$80/25% (max $100) | |
$2,000/$4,000 | $8,150/$16,300 | $35 | 70% after deductible | $250 per admit, then 70% after deductible | 50% after deductible | 50% after deductible | $10/$25/$40/$80/25% (max $100) | |
$2,500/$5,000 | $8,150/$16,300 | $35 | 70% after deductible | $250 per admit, then 70% after deductible | 50% after deductible | 50% after deductible | $10/$25/$40/$80/25% (max $100) | |
$3,500/$7,000 | $8,150/$16,300 | $35 | 70% after deductible | $250 per admit, then 70% after deductible | 50% after deductible | 50% after deductible | $10/$25/$40/$80/25% (max $100) | |
$4,000/$8,000 | $8,150/$16,300 | $35 | 70% after deductible | $250 per admit, then 70% after deductible | 50% after deductible | 50% after deductible | $10/$25/$40/$80/25% (max $100) | |
$5,000/$10,000 | $8,150/$16,300 | $35 | 70% after deductible | $250 per admit, then 70% after deductible | 50% after deductible | 50% after deductible | $10/$25/$40/$80/25% (max $100) | |
$5,000/$10,000 | $8,150/$16,300 | $35 | 70% after deductible | $250 per admit, then 70% after deductible | 50% after deductible | 50% after deductible | $10/0% (max $100) |
All Plans have coverage for a routine eye exam covered at 100% through an in-network provider. This is an incorporated benefit with PPO Health Plan coverage, lenses and frames are covered 100% up to $130, then 10%. This is not full “vision coverage” and requires a claim to be submitted for reimbursement.
Telemedicine services are provided through Teledoc. Click here for more information on Teledoc Telehealth coverage.
All Plans offer the same prescription formulary, referred to as Essential C Formulary. For more information around Pharmacy benefit coverage click here.
PPO Plans have a drug co-payment, as shown above. Up to a 30-day supply is one drug copayment, and a 31-60 day supply is two drug copayments. A 61-90 day supply is three drug copayments at retail pharmacies or two and a half drug copayments using mail-order service.
All plans offer mail order subscription programs through Amazon MedsYourWay. Click here for more information.