PPO
View 2021 Enable Midstream Benefit Rates
With the PPO Plan, you pay copays for prescription drugs and visits to in-network doctor's offices, urgent care clinics and emergency rooms. For other care, you meet a deductible and then pay coinsurance until you meet your out-of-pocket maximum. Keep in mind your co-pays on the PPO plan do not count towards the deductible, but they do count towards the out-of-pocket maximum.
2021 Summary of Benefits & Coverage
2020 Summary of Benefits & Coverage
| Service | In-Network* | Out-of-Network* |
|---|---|---|
| Deductible |
$750 Individual $1,500 Family** |
$1,500 Individual 3,000 Family** |
|
Enable Contribution HSA or FSA |
N/A | |
| Coinsurance |
Plan pays 80% You pay 20% |
Plan pays 55% You pay 45% |
| Out-of-Pocket Maximum |
$3,000 Individual $7,500 Family** |
$7,500 Individual $18,750 Family** |
| Preventive Care | Covered at 100% | 45% after deductible |
| Primary Care Office Visit | $25 copay |
45% after deductible |
|
Specialist Office Visit |
$40 copay |
45% after deductible |
|
Urgent Care |
$75 copay |
45% after deductible |
|
Emergency Room |
20% after deductible plus a $250 copay. If you are admitted to the hospital, the $250 copay is waived |
45% after deductible plus a $250 copay. If you are admitted to the hospital, you receive in-network benefits (you meet your in-network deductible and pay 20% coinsurance). |
|
Hospitalization |
20% after deductible |
45% after deductible |
|
MDLIVE |
$10 copay |
N/A |
|
MDLIVE - Behavioral Health |
$10 copay |
N/A |
|
Prescription Drugs |
You receive pharmacy benefits whether or not you've met your deductible. | |
|
Pharmacy-filled Generic |
$10 copay |
45% after deductible |
|
Pharmacy-filled Preferred |
$35 copay |
45% after deductible |
| Pharmacy-filled Non-Preferred (34-day supply) |
$60 copay |
45% after deductible |
| Mail-ordered/Smart90 Generic (90-day supply) |
$20 copay |
N/A |
|
Mail-ordered/Smart90 Preferred |
$70 copay | N/A |
| Mail-ordered/Smart90 Non-Preferred (90-day supply) |
$120 copay | N/A |
*In-network and out-of-network deductibles are separate. Only in-network services apply toward your in-network deductible, and only out-of-network services apply to your out-of-network deductible.
** Family coverage includes employee + spouse, employee + child(ren), and employee + family
HDHP and PPO Plan Comparison
| Plan Detail | HDHP | PPO |
|---|---|---|
|
|
In-Network |
In-Network |
|
Deductible* |
$1,500 Employee only $3,000 Family** |
$750 Individual $1,500 Family** |
|
Enable Contribution HSA or FSA |
$500 Employee Only $1,000 Family** |
N/A |
|
Coinsurance (after deductible) |
Plan pays 90% You pay 10% |
Plan pays 80% Plan pays 20% |
|
Out-of-Pocket Maximum |
$4,000 Individual $8,000 Family** |
$3,000 Individual $7,500 Family** |
|
Preventive Care |
Covered at 100% |
Covered at 100% |
|
Primary Care Office Visit |
10% after deductible |
$25 copay |
|
Specialist office visit |
10% after deductible |
$40 copay |
|
Urgent Care |
10% after deductible |
$75 copay |
|
Emergency Room |
10% after deductible |
20% after deductible plus a $250 copay. If admitted to the hospital, the $250 copay is waived |
|
Hospitalization |
10% after deductible |
20% after deductible |
|
MDLIVE |
$44 per visit until you meet your deductible, then 10% |
$10 copay |
|
MDLIVE - Behavioral health |
$85-$175 per visit depending on the services received until you meet your deductible, then 10% |
$10 copay |
|
Pharmacy-filled Generic (34-day supply) |
$10 copay after deductible |
$10 copay |
|
Pharmacy-filled Preferred/Formulary (34-day supply) |
$25 copay after deductible |
$35 copay |
|
Pharmacy-filled Non-Preferred/Formulary (34-day supply) |
$45 copay after deductible |
$60 copay |
|
Mail-ordered/Smart90 Generic (90-day supply) |
20% after deductible |
$20 copay |
|
Mail-ordered/Smart90 Preferred/Formulary (90-day supply) |
20% after deductible |
$70 copay |
|
Mail-ordered/Smart90 Non-Preffered/Non-Formulary (90-day supply) |
20% after deductible |
$120 copay |
*In-network and out-of-network deductibles are seperate. Only in-network services apply toward your in-network deductible, and only out-of-network servcies apply to your out-of-network deductible
** Family coverage includes employee + spouse, employee + child(ren), and employee + family
For detailed plan information, visit the Plan Documents page on the HUB. You may also request a copy of the plan document by contacting the HR Service Center at 844-687-4748 (844-OUR-HR4U) or HR@enablemidstream.com.