Credence PPO Plan
Credence BCBS · PPO
Medical benefits are provided through Credence BCBS, United Healthcare Surest, and Kaiser (California Employees Only).
CREDENCE PPO PLAN
Plan Details
Carrier
Credence BCBS
Plan Type
PPO
HSA Eligible
No
Healthcare FSA Eligible
Yes
Who Can Enroll
All benefits-eligible employees
Monthly Contributions
| Coverage Tier | Under $75K | $75K - <$125K | $125K+ |
|---|---|---|---|
| Employee Only | $366.36 | $442.59 | $553.81 |
| Employee + Spouse | $853.26 | $1,128.83 | $1,418.82 |
| Employee + Child(ren) | $784.35 | $1,037.66 | $1,304.23 |
| Employee + Family | $1,241.19 | $1,642.03 | $2,063.87 |
Employee Only
- Under $75K
- $366.36
- $75K - <$125K
- $442.59
- $125K+
- $553.81
Employee + Spouse
- Under $75K
- $853.26
- $75K - <$125K
- $1,128.83
- $125K+
- $1,418.82
Employee + Child(ren)
- Under $75K
- $784.35
- $75K - <$125K
- $1,037.66
- $125K+
- $1,304.23
Employee + Family
- Under $75K
- $1,241.19
- $75K - <$125K
- $1,642.03
- $125K+
- $2,063.87
Deductible, Out-of-Pocket & Coinsurance
| Feature | In-Network | Out-of-Network |
|---|---|---|
| Employee | $2,000 | $4,000 |
| Family | $4,000 | $8,000 |
| Pharmacy Deductible | $250 | N/A |
| Coinsurance | 80% | 50% |
| Annual Out-Of-Pocket Maximum - Employee | $6,250 | $12,500 |
| Annual Out-Of-Pocket Maximum - Family | $12,500 | $25,000 |
Employee
- In-Network
- $2,000
- Out-of-Network
- $4,000
Family
- In-Network
- $4,000
- Out-of-Network
- $8,000
Pharmacy Deductible
- In-Network
- $250
- Out-of-Network
- N/A
Coinsurance
- In-Network
- 80%
- Out-of-Network
- 50%
Annual Out-Of-Pocket Maximum - Employee
- In-Network
- $6,250
- Out-of-Network
- $12,500
Annual Out-Of-Pocket Maximum - Family
- In-Network
- $12,500
- Out-of-Network
- $25,000
Covered Services
| Service | In-Network | Out-of-Network |
|---|---|---|
| Preventative Care | Fully covered | 50%* |
| Primary Care | $30 copay | 50%* |
| Specialist Services | $60 copay | 50%* |
| Diagnostic Care | 80%* | 50%* |
| Mental Health - Inpatient | 80%* | 50%* |
| Mental Health- Outpatient | Office Visit: $30,Outpatient services: 80%* | 50%* |
| Urgent Care | $50 copay | 50%* |
| Emergency Room | $250 copay, then 80%* | $250 copay, then 80%* |
Preventative Care
- In-Network
- Fully covered
- Out-of-Network
- 50%*
Primary Care
- In-Network
- $30 copay
- Out-of-Network
- 50%*
Specialist Services
- In-Network
- $60 copay
- Out-of-Network
- 50%*
Diagnostic Care
- In-Network
- 80%*
- Out-of-Network
- 50%*
Mental Health - Inpatient
- In-Network
- 80%*
- Out-of-Network
- 50%*
Mental Health- Outpatient
- In-Network
- Office Visit: $30,Outpatient services: 80%*
- Out-of-Network
- 50%*
Urgent Care
- In-Network
- $50 copay
- Out-of-Network
- 50%*
Emergency Room
- In-Network
- $250 copay, then 80%*
- Out-of-Network
- $250 copay, then 80%*
- *After deductible
Pharmacy Benefits
| Tier | Cost |
|---|---|
| Retail RX - Generic | $10 copay |
| Retail RX - Preferred | 75% ($200 max)* |
| Retail RX - Non-Preferred | 50% ($200 max)* |
| Retail RX - Specialty Drugs | 70%* |
| Mail Order RX - Generic | $20 copay |
| Mail Order RX - Preferred | 75% ($200 max)* |
| Mail Order RX - Non-Preferred | 50% ($200 max)* |
| Mail Order RX - Specialty Drugs | N/A |
Retail RX - Generic
- Cost
- $10 copay
Retail RX - Preferred
- Cost
- 75% ($200 max)*
Retail RX - Non-Preferred
- Cost
- 50% ($200 max)*
Retail RX - Specialty Drugs
- Cost
- 70%*
Mail Order RX - Generic
- Cost
- $20 copay
Mail Order RX - Preferred
- Cost
- 75% ($200 max)*
Mail Order RX - Non-Preferred
- Cost
- 50% ($200 max)*
Mail Order RX - Specialty Drugs
- Cost
- N/A
- *After deductible
Plan Notes
- You'll pay more in premiums, but perhaps less at the time of service. You can choose from a network of providers who offer a fixed copay for services.
- If you or your dependent(s) expect to need more medical care this year or you have a chronic illness, the PPO may be the right choice for you to ensure your healthcare needs are covered.