Medical Plan Comparison Grid

Medical Plan Comparison Grid for benefits starting January 1, 2021

Medical Plan Comparison Grid

	Presbyterian Health Plan EPO (In Network)	True Health EPO (In Network)	Cigna Healthcare Open Access Plus PPO (In Network)	Cigna Healthcare Open Access Plus PPO (Out-of-Network)	BlueCross BlueSheild PPO (In Network)	BlueCross BlueSheild PPO (Out-of-Network)
Primary Care Copay	$20	$20	$30	Deductible/ Coinsurance	$30	Deductible/ Coinsurance
Specialist Copay	$50	$50	$60	Deductible/ Coinsurance	$60	Deductible/ Coinsurance
Preventive Care Services	Plan pays 100%	Plan pays 100%	Plan pays 100%	Deductible/ Coinsurance	Plan pays 100%	Deductible/ Coinsurance
Lab / X-Rays / Ultrasound/ Other Basic Diagnostic Testing	$20 copay/day	$20 copay/day	$30 copay/day	Deductible/ Coinsurance	$30 copay/day	Deductible/ Coinsurance
Physical, Occupational and Speech Therapy (refer to complete Summary of Benefits)	$20 copay per visit up to $320 annual maximum	$20 copay per visit up to $320 annual maximum	$30 copay per visit to $480 annual maximum	Deductible/ Coinsurance	$30 copay per visit to $480 annual maximum	Deductible/ Coinsurance
Urgent Care	$50	$50	$75	$75	$75	$75
Emergency Room	$350 copay	$350 copay	$450 copay		$450 copay
Ambulance	Subject to deductible and coinsurance	Subject to deductible and coinsurance	Subject to in-network deductible and coinsurance		Subject to in-network deductible and coinsurance
Inpatient Hospitalization	Deductible and Coinsurance	Deductible and Coinsurance	Deductible and Coinsurance	Deductible and Coinsurance	Deductible and Coinsurance	Deductible and Coinsurance
Autism Spectrum Disorder Services	Deductible/ Coinsurance	Deductible/ Coinsurance	Deductible/ Coinsurance	Deductible/ Coinsurance	Based on place of treatment and type of service	Based on place of treatment and type of service
Durable Medical Equipment, Supplies, Prosthetics (refer to complete Summary of Benefits)	20% coinsurance, deductible does not apply	20% coinsurance, deductible does not apply	20% coinsurance, deductible does not apply	Deductible/ Coinsurance	20% coinsurance, deductible does not apply	Deductible/ Coinsurance

Medical Plan Deductibles and Coinsurance

	Presbyterian Health Plan EPO (In Network)	True Health EPO (In Network)	Cigna Healthcare Open Access Plus PPO (In Network)	Cigna Healthcare Open Access Plus PPO (Out-of-Network)	BlueCross BlueSheild PPO (In Network)	BlueCross BlueSheild PPO (Out-of-Network)
Single Deductible	$500	$500	$1,000	$5,000	$1,000	$5,000
Two-party Deductible	$1,000	$1,000	$2,000	$10,000	$2,000	$10,000
Family Deductible	$1,250	$1,250	$2,500	$15,000	$2,500	$15,000
Coinsurance	20%	20%	20%	50%	20%	50%
Single Out of Pocket Maximum	$4,000	$4,000	$5,000	$8,500	$5,000	$8,500
Two-party Out of Pocket Maximum	$8,000	$8,000	$10,000	$14,875	$10,000	$14,875
Family Out of Pocket Maximum	$12,000	$12,000	$12,500	$21,250	$12,500	$21,250

Maternity Services – Medical Plan Comparison Grid

	Presbyterian Health Plan EPO (In Network)	True Health EPO (In Network)	Cigna Healthcare Open Access Plus PPO (In Network)	Cigna Healthcare Open Access Plus PPO (Out-of-Network)	BlueCross BlueSheild PPO (In Network)	BlueCross BlueSheild PPO (Out-of-Network)
Prenatal, postnatal care and OB delivery charges	$50 copay - initial visit only, then plan pays 100%	$50 copay - initial visit only, then plan pays 100%	$60 copay - initial visit only, then plan pays 100%	Deductible/ Coinsurance	$60 copay - initial visit only, then plan pays 100%	Deductible/ Coinsurance
Hospital Admission	Deductible (on the mother) and Coinsurance	Deductible (on the mother) and Coinsurance	Deductible (on the mother) and Coinsurance	Deductible (on the mother) and Coinsurance	Deductible (on the mother) and Coinsurance	Deductible (on the mother) and Coinsurance

Diabetes Coverage – Medical Plan Comparison Grid

	Presbyterian Health Plan EPO (In Network)	True Health EPO (In Network)	Cigna Healthcare Open Access Plus PPO (In Network)	Cigna Healthcare Open Access Plus PPO (Out-of-Network)	BlueCross BlueSheild PPO (In Network)	BlueCross BlueSheild PPO (Out-of-Network)
Office visit and diabetes education	$10 copay/visit up to $260 annual maximum	$10 copay/visit up to $260 annual maximum	$10 copay/visit	Deductible/ Coinsurance	$10 copay/visit up to $260 annual maximum	Deductible/ Coinsurance
Diabetic medications	Refer to Prescription Drug Plan	Refer to Prescription Drug Plan	Refer to Prescription Drug Plan	Refer to Prescription Drug Plan	Refer to Prescription Drug Plan	Refer to Prescription Drug Plan
Diabetic supplies, equipment, appliances and services	Plan pays 100%	Plan pays 100%	Plan pays 100%	Deductible/ Coinsurance	Plan pays 100%	Deductible/ Coinsurance

Behavioral/Mental Health and Substance Use Disorder Services

	Presbyterian Health Plan EPO (In Network)	True Health EPO (In Network)	Cigna Healthcare Open Access Plus PPO (In Network)	Cigna Healthcare Open Access Plus PPO (Out-of-Network)	BlueCross BlueSheild PPO (In Network)	BlueCross BlueSheild PPO (Out-of-Network)
Outpatient Services	$10 copay/visit up to $260 annual maximum	$10 copay/visit up to $260 annual maximum	$10 copay/visit up to $260 annual maximum	Deductible/ Coinsurance	$10 copay/visit up to $260 annual maximum	Deductible/ Coinsurance
Inpatient Services	Deductible/ Coinsurance	Deductible/ Coinsurance	Deductible/ Coinsurance	Deductible/ Coinsurance	Deductible/ Coinsurance	Deductible/ Coinsurance