Option 2: Primary Care Physician Select (PCPS. The PCPS plan is primarily a copay-based plan. If you select the PCPS you must receive your care from a specific network of doctors, hospitals, and other health care providers. Out-of- network care is not covered. Except for emergencies and services preapproved by the healthcare carrier, if you receive care from out-of-network providers, you will be responsible for the entire cost of the service. Listed below is a summary of some fees for commonly used services from network providers: Through After 12/31/22 12/31/22 • Preventive Care Office Visit $-0- $-0- • Office Visits (PCP) $25 $25 • Office Visit (Specialist) $60/30 $60/30 • Cardiac Rehabilitation $-0- $-0- • Physical Therapy Office Visit $30 $30 • Chiropractic Office Visit $30 $30 • Allergy Shots Office Visit Office Visit Office Visit • Prescription Drugs • Retail (30-day supply) • Mail Order (90-day supply) $10/40/100 $20/80/200 $10/50/110 $20/90/210 • X-rays, Labs, Diagnostics 20% Coinsurance (annual max: $475/person $950/family) 20% Coinsurance (annual max: $475/person $950/family) • Emergency Room $200 $200 • Inpatient Hospital Stay $500 $500 • Outpatient Surgery $250 $250 You will need to meet an annual deductible before the co-pays and coinsurance are applicable. Once you have met the annual deductible, you will then pay co-pays and/or coinsurance for healthcare services as outlined above. For in-network care, the annual deductible is: Year 2022 0000 0000 0000 0000 Per Person $150 $250 $250 $250 $250 Maximum Per Family $300 $500 $500 $500 $500 Your total out of pocket costs associated with all in-network, covered services shall not exceed the maximum amount allowed under Section 1302(c)(1) and (c)(2) of the Patient Protection and Affordable Care Act or related legislation (ACA). To participate in the PCPS option, the following contributions will be deducted from your weekly paycheck: PCPS 2022 2023-2026 Non-Smoker Smoker Non-Smoker Smoker Employee Only $28.14 $34.46 $29.83 $36.53 Employee & Spouse $56.25 $68.92 $59.63 $73.06 Employee & Child(ren) $56.25 $68.92 $59.63 $73.06 Employee & Family $80.16 $98.21 $84.97 $104.10
Option 2: Primary Care Physician Select (PCPS. The PCPS plan is primarily a copay-based plan. If you select the PCPS you must receive your care from a specific network of doctors, hospitals, and other health care providers. Out-of-network care is not covered. Except for emergencies and services preapproved by the insurer, if you receive care from out-of-network providers, you will be responsible for the entire cost of the service. Listed below is a summary of some fees for commonly used services from network providers: Through After 12/31/13 12/31/13 Preventive Care Office Visit $-0- $-0- Office Visits (PCP) $15 $20 Office Visit (Specialist) $30/15 $50/25 Cardiac Rehabilitation $-0- $-0- Physical Therapy Office Visit $15 $25 Chiropractic Office Visit $15 $25 Allergy Shots Office Visit $15 office visit Prescription Drugs Retail (30-day supply) $10/20/50 $10/30/70 Mail Order (90-day supply) $20/40/100 $20/60/140 X-rays, Labs, Diagnostics Covered in full 20% Coinsurance (annual max: $250/person $500/family) Emergency Room $100 $175 Inpatient Hospital Stay $300 $450 Outpatient Surgery $150 $225
