The VZW PPO Plus Plan, like all of VZW’s medical plan options, gives you and your family many choices for your health. The plan also offers free preventive care and access to providers in the CIGNA Open Access Plus/CareLink network. This national network includes doctors and hospitals that have contracted with CIGNA to provide medical care at negotiated rates. You may also choose a physician or hospital that is not part of the CIGNA network, though you will spend more for your care.
With VZW PPO Plus, you do not need to select a primary care physician (PCP). You can see any doctor, including a specialist, whenever you choose without the hassle of obtaining a referral.
|
Annual Deductible
Individual
Family
(3 or more persons)
|
$1,000
$3,000
|
$1,000
$3,000
|
|
Annual Out-of-Pocket Maximum
Individual
Family (3 or more persons)
|
$2,000
$6,000
|
$2,000
$6,000
|
| Lifetime Maximum |
Unlimited |
$1,000,000 |
| Plan Coinsurance (what the plan pays) |
Plan pays 80% after deductible |
Plan pays 60% of R&C
after deductible |
|
Physician Office Visits
-
Primary Care Office Visits
(including OB/GYN)
- Specialist Office Visits
|
-
$15 per visit copay
-
$15 per visit copay
|
Plan pays 60% of R&C
after deductible |
|
Routine Preventative Care
-
Routine Physical Exams (adult)
- Well Woman Care (including Pap Test)
-
Mammogram
-
Well Child Care
|
Plan pays 100%
|
Plan pays 100% |
| Urgent Care Facility Visit |
$200 per admission copay, waived if admitted
|
$200 per admission copay, waived if admitted
(Plan pays the in-network level if it is a true emergency; 60% after deductible if it is not a true emergency.)
|
| Emergency Room Visit |
$200 per admission copay, waived if admitted
|
$200 per admission copay, waived if admitted
(Plan pays the in-network level if it is a true emergency; 60% after deductible if it is not a true emergency.)
|
| Ambulance |
Plan pays 80% after deductible |
Plan pays 60% of R&C
after deductible |
|
Inpatient Hospital
-
Admission
- Facility Services
- Professional Services (Surgeon, Radiologist, Pathologist, Anesthesiologist)
|
Plan pays 80% after deductible |
Plan pays 60% of
R&C
after deductible |
| Outpatient Pre-admission Diagnostic
Tests |
Plan pays 100% |
Plan pays 60% of R&C
after deductible |
|
Outpatient Hospital
-
Facility Services
- Professional Services (Surgeon, Radiologist, Pathologist, Anesthesiologist)
|
Plan pays 80% after deductible |
Plan pays 60% of R&C
after deductible |
| Second Opinion (Includes all physician
billed charges) |
Plan pays 100%
|
Plan pays 60% of R&C
after deductible |
|
Rehabilitation Therapy (unlimited visits)
-
Cardiac Rehabilitation
- Cognitive Rehabilitation
- Occupational Rehabilitation
|
Plan pays 80% after deductible
|
Plan pays 60% of
R&C
after deductible |
|
Short-Term Therapy
-
Chiropractic Therapy (12 visits per year)
-
Physical Therapy (20 visits per year)
-
Occupational Therapy (20 visits per year)
-
Speech Therapy (20 visits per year)
|
$15 per visit copay
|
Plan pays 60% of
R&C
after deductible |
| Home Health Care |
Plan pays 100% |
Plan pays 60% of
R&C
after deductible |
|
Hospice Care
-
Inpatient
-
Outpatient
-
Bereavement Counseling
(up to 3 sessions per occurrence, per family)
|
Plan pays 100% |
Plan pays 60% of
R&C
after deductible |
| Skilled Nursing Facility — (up to
120 days per calendar year, no prior hospitalization required) |
Plan pays 100% |
Plan pays 60% of
R&C
after deductible |
Outpatient Private Duty Nursing
(unlimited visits)
|
Plan pays 100% |
Plan pays 60% of
R&C
after deductible |
|
Maternity Care
-
All prenatal and postnatal visits and delivery
-
Hospital Admission
-
Inpatient physician visits and Consultations
-
Birthing Centers
|
100% after $15 copay for initial visit
Plan pays 80% after deductible for all other services
|
Plan pays 60% of R&C
after deductible |
Infertility
Testing and Diagnosis
Includes testing, diagnosis, and diagnostic surgical procedures,
and determination of treatment to correct medical condition.
|
Plan pays 80% after deductible
|
Plan pays 60% of R&C
after deductible |
Durable Medical Equipment
(Based on medical necessity/ appropriateness)
|
Plan pays 80% after deductible |
Plan pays 60% of R&C
after deductible |
|
Temporomandibular Joint
Dysfunction (TMJ)
-
Office Visit
- Inpatient/Outpatient Facility
-
Physician Services
-
Appliances
-
Medically necessary surgery
|
$15 copay for office visit
Plan pays 80% after deductible for all other services
|
Plan pays 60% of R&C
after deductible |
Mental Health Treatment
Inpatient (unlimited days)
Outpatient (individual/group therapy) |
Plan pays 100%
$15 per visit copay |
Plan pays 60% of R&C
after deductible |
Substance Abuse Treatment
Inpatient (unlimited days)
Outpatient (unlimited days)
|
Plan pays 100%
$15 per visit copay |
Plan pays 60% of R&C
after deductible |
|
Enhanced CIGNA Healthy Babies Program*
-
Lactation Pumps
- Lactation Consultants
- Lamaze/Birthing classes
*Member must enroll within 1st or 2nd trimester and remain compliant throughout pregnancy
|
100%
Enrollment during 1st trimester: $250 allowance for approved items
Enrollment during 2nd trimester: $100 allowance for approved items
|
Medical Management Programs
|
Diabetes
Asthma
Cardiac
Obesity
Low Back Pain
Chronic Obstructive Pulmonary Disease (COPD)
|
WeightWatchers®
|
$100 for reaching 10% of goal weight ($100 lifetime maximum)
$100 for acheiving lifetime goal ($100 lifetime maximum) |
Nutritional Counseling
(Provided by a Registered Dietician)
|
100% ($150 lifetime maximum. Does not apply to Jenny Craig or Atkins.) |
