BROUGHT TO YOU BY:
North Carolina Medical Society
Sentinel Benefits Consulting

PPO Plans

PPO stands for Preferred Provider Organization. A PPO’s premiums are usually much higher than an HDHP, but that comes with greater flexibility. PPOs allow you to get both in-network and out-of-network care — though out-of-network providers cost more. You can also see a specialist without a referral. The plans also include an out-of-pocket maximum for in-network care. If you reach your out-of-pocket maximum, your insurer covers all costs.

2024 Plan Offerings

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)

Office Visit Primary & Telemedicine

Office Visit Specialist

Hospital - Inpatient/Outpatient (Includes Maternity, Mental Health, & Substance Abuse

Mental Health & Substance Abuse Outpatient Services & Office Visit

Urgent Care/ER

Prescription Drug

PPO 1000-70

$1,000/$3,000

$3,500/$7,000

$35

$70

70% after deductible

100%

$75/$750

$10/$25/$40/$80/25% (max $100)

PPO 2000-80

$2,000/$6,000

$7,150/$14,300

$35

$70

80% after deductible

100%

$75/$500

$10/$25/$40/$80/25% (max $100)

PPO 1500-70

$1,500/$4,500

$5,000/$10,000

$35

$70

70% after deductible

100%

$75/$750

$10/$25/$40/$80/25% (max $100)

PPO 2500-80

$2,500/$7,500

$7,150/$14,300

$35

$70

80% after deductible

100%

$75/$500

$10/$25/$40/$80/25% (max $100)

PPO 2500-70

$2,500/$7,500

$8,150/$16,300

$35

$70

70% after deductible

100%

$100/$1,000

$10/$25/$40/$80/25% (max $100)

PPO 3500-80

$3,500/$10,500

$8,150/$16,300

$35

$70

80% after deductible

100%

$100/$1,000

$10/$25/$40/$80/25% (max $100)

PPO 3500-70

$3,500/$7,000

$8,150/$16,300

$35

$70

70% after deductible

100%

$100/$1,000

$20/$35/$45/$90/25% (max $100)

PPO 5000-60

$5,000/$10,000

$8,150/$16,300

$35

$70

60% after deductible

100%

$100/$1,000

$10/$25/$40/$80/25% (max $100)

PPO 2500-60

$2,500/$5,000

$8,150/$16,300

$45

60% after deductible

60% after deductible

100%

$135/60% after deductible

$10/50% (max $100)

PPO 3500-60

$3,500/$7,000

$8,150/$16,300

$45

60% after deductible

60% after deductible

100%

$135/60% after deductible

$10/50% (max $100)

PPO 4000-70

$4,000/$8,000

$8,550/$17,100

$50

60% after deductible

70% after deductible

100%

$100/$1,000

$15/$35/$45/$90/25% (min $50 / max $200)

PPO 5000-70

$5,000/$10,000

$8,550/$17,100

$40

70% after deductible

70% after deductible

100%

$120/$1,000

$15/$35/$45/$90/25% (min $50 / max $200)

PPO 7900-100

$7,900/$15,800

$7,900/$15,800

100% after deductible

100% after deductible

100% after deductible

100% after deductible

100% after deductible

 $20/$35/$45/$90/25% (max $200)

PPO 8550-100

$8,550/$17,100

$8,550/$17,100

100% after deductible

100% after deductible

100% after deductible

100% after deductible

100% after deductible

$20/$35/$45/$90/25% (max $200)

2023 Plan Offerings

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)

Office Visit Primary & Telemedicine

Office Visit Specialist

Hospital - Inpatient/Outpatient (Includes Maternity, Mental Health, & Substance Abuse

Mental Health & Substance Abuse Outpatient Services & Office Visit

Urgent Care/ER

Prescription Drug

PPO 1000-70

$1,000/$3,000

$3,500/$7,000

$35

$70

70% after deductible

100%

$75/$750

$10/$25/$40/$80/25% (max $100)

PPO 2000-80

$2,000/$6,000

$7,150/$14,300

$35

$70

80% after deductible

100%

$75/$500

$10/$25/$40/$80/25% (max $100)

PPO 1500-70

$1,500/$4,500

$5,000/$10,000

$35

$70

70% after deductible

100%

$75/$750

$10/$25/$40/$80/25% (max $100)

PPO 2500-80

$2,500/$7,500

$7,150/$14,300

$35

$70

80% after deductible

100%

$75/$500

$10/$25/$40/$80/25% (max $100)

PPO 2000-70

$2,000/$6,000

$8,150/$16,300

$35

$70

70% after deductible

100%

$75/$750

$10/$25/$40/$80/25% (max $100)

PPO 2500-70

$2,500/$7,500

$8,150/$16,300

$35

$70

70% after deductible

100%

$100/$1,000

$10/$25/$40/$80/25% (max $100)

PPO 3500-80

$3,500/$10,500

$8,150/$16,300

$35

$70

80% after deductible

100%

$100/$1,000

$10/$25/$40/$80/25% (max $100)

PPO 3500-70

$3,500/$7,000

$8,150/$16,300

$35

$70

70% after deductible

100%

$100/$1,000

$20/$35/$45/$90/25% (max $100)

PPO 5000-60

$5,000/$10,000

$8,150/$16,300

$35

$70

60% after deductible

100%

$100/$1,000

$10/$25/$40/$80/25% (max $100)

PPO 2500-60

$2,500/$5,000

$8,150/$16,300

$45

60% after deductible

60% after deductible

100%

$135/60% after deductible

$10/50% (max $100)

PPO 3500-60

$3,500/$7,000

$8,150/$16,300

$45

60% after deductible

60% after deductible

100%

$135/60% after deductible

$10/50% (max $100)

PPO 4000-70

$4,000/$8,000

$8,550/$17,100

$50

60% after deductible

70% after deductible

100%

$100/$1,000

$15/$35/$45/$90/25% (min $50 / max $200)

PPO 5000-70

$5,000/$10,000

$8,550/$17,100

$40

70% after deductible

70% after deductible

100%

$120/$1,000

$15/$35/$45/$90/25% (min $50 / max $200)

PPO 6000-60

$6,000/$12,000

$8,550/$17,100

$95

70% after deductible

60% after deductible

100%

$190/$1,500

$400 rx deductible then $15/$35/$45/$90/25% (min $50 / max $200)

PPO 7900-100

$7,900/$15,800

$7,900/$15,800

100% after deductible

100% after deductible

100% after deductible

100% after deductible

100% after deductible

 $20/$35/$45/$90/25% (max $200)

Additional Notes

The office visit primary copay is waived for the first 3 visits* if a PCP is selected on Blue Connect. Office Visit Primary and Specialist visits copays include office surgery, consultation, x-rays & labs. (*Does not apply to the PPO 7900-100).

 

For more information on assigning a PCP in Blue Connect click here.

Vision

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

Telemedicine services are provided through Teledoc. Click here for more information on Teledoc Telehealth coverage.

Pharmacy/Rx

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.