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 |
Prescription Drugs
Administered by Express Scripts. Call Express Scripts at 1-866-563-9297.