PPO Summary
Miami's PPO plan offers lower deductibles, coinsurance and set copayments.
| Service | Network Tier 1⇒ Member Pays |
Network Tier 2⇒ Member Pays | Out-of-Network Benefits Member Pays** |
|---|---|---|---|
| Calendar Year Deductible | $350 individual $700 family |
$5,000 single $10,000 family |
|
| Medical Out-of-Pocket Maximum (deductible, coinsurance, and medical copays) |
$2,350 individual $4,700 family |
$6,350 single $12,700 family |
|
| Plan Out-of-Pocket (deductible, coinsurance, medical copays and RX copays) |
$6,350 individual |
$6,350 single $12,700 family |
|
| Preventive Care (wellness exams, cancer screenings, immunizations) |
$0 | $0 | 50% after deductible |
| Office Visits (primary care physician) |
$25 copayment | $25 copayment | 50% after deductible |
| Mental/Behavioral Health | $25 copayment | $25 copayment | 50% after deductible |
| Specialist/Allergist | $35 copayment | $35 copayment | 50% after deductible |
| Physician Services (outside of office) |
10% after deductible* | 20% after deductible* | 50% after deductible |
| Diagnostic X-Rays and Lab Work | 10% after deductible* | 20% after deductible* | 50% after deductible |
| Advanced Imaging (such as MRI, CAT, PET) |
10% after deductible* | 20% after deductible* | 50% after deductible |
| Hospital Emergency Room Services (true emergency) | $100 copayment (waived if admitted) |
$100 copayment (waived if admitted) |
$100 copayment |
| Urgent Care Facility | $35 copayment | $35 copayment | $35 copayment |
| Speech Therapy (limit 30 visits per year) |
$35 copayment | $35 copayment | 50% after deductible |
| Physical and Occupational Therapy (limit 60 visits per year) |
$35 copayment | $35 copayment | 50% after deductible |
| Acupuncture (limit 20 visits per year) |
$35 copayment | $35 copayment | $35 copayment |
| Chiropractic Services (limit 20 visits per year) |
$35 copayment | $35 copayment | 50% after deductible |
| Pharmacy-Retail |
TIER 1: 10% up to maximum $40 (low-cost generic drugs) TIER 2: 20% up to maximum $50 (low-cost preferred brands and higher-priced generics) TIER 3: 20% up to maximum $75 (higher-cost, preferred brand-name drugs) |
50% after deductible | |
| Pharmacy-Specialty Drugs | TIER 4: 20% up to maximum $200 (specialty drugs) | 50% after deductible | |
When using a tier 1 or tier 2 free-standing lab or imaging center, you will pay $0.
*$0 after medical out-of-pocket maximum has been met.
**Out-of-network providers may balance bill you for charges in excess of the Usual, Customary, and Reasonable (UCR) fee. You will be responsible for charges in excess of the maximum UCR fee in addition to any applicable deductible, coinsurance or co-payment. Additionally, any amount you pay the provider in excess of the maximum UCR fee will not apply to your out-of-network deductible or out-of-pocket maximum.