PPO Plans

The Lovelace Individual PPO Plans are designed to offer you low out-of-pocket costs when you use providers within the Lovelace Preferred Provider network. These plans also offer you the freedom to go out-of-network with a higher deductible, coinsurance and out-of-pocket maximum. Preventive Care is covered at no cost to you. Prescription Drug coverage is included with these plans. Maternity coverage is available through our Maternity Rider.

BENEFITS	PPO 20%		PPO 30%
Annual Deductible Deductible must be met before Coinsurance applies.	$500, $750, $1,000, $2,000, $2,500, $3,500, $5,000	$1,000, $1,500, $2,000, $4,000, $5,000, $7,500, $10,000	$1,000, $2,000, $2,500, $3,500, $5,000, $7,500, $10,000	$2,000, $4,000, $5,000, $7,000, $10,000, $15,000, $20,000
Coinsurance Out-of-Pocket Maximum	$2,000, $4,000	$4,000, $8,000	$4,500	$9,000
Lifetime Maximum Benefit	Unlimited		Unlimited
Preventive Care Services	$0	40%	$0	50%
Medical Office Visits
Non-Specialist	$20	40%	$25	50%
Specialist	$40	40%	$50	50%
Emergency Care	$200		$200
Urgent Care	$40		$50
Hospital Services
Inpatient & Outpatient	20%	40%	30%	50%
Acupuncture/Chiropractic Services
$1,500 Maximum per service, per year	20%	40%	30%	50%
Prescription Drug Benefits Prescription Drugs on the HDHP Plans are subject to the plan's Annual Deductible	Must use participating pharmacy		Must use participating pharmacy
Generic	$10		$10
Brand Name Preferred	$35		$35
Brand Name Non-Preferred	$55		$55
Specialty Medications	20%		20%

This summary contains highlights only and is subject to change. The specific terms of coverage are listed in the Evidence of Coverage Handbook, including details on Limitations and Exclusions. Additionally, some services require Prior Authorization.