PSM of TN – PPO and RBP – Plan Comparison

PPO PLANS

• PPO $500 Titanium

• PPO $1,000 Diamond

• PPO $1,500 Platinum

• PPO $2,500 Gold

• PPO $3,500 Silver

• PPO $5,000 Bronze

• PPO $7,350 Copper

• PPO $2,500 HDHP (HSA)

RBP PLANS

• RBP $500 Titanium

• RBP $1,000 Diamond

• RBP $1,500 Platinum

• RBP $2,500 Gold

• RBP $3,500 Silver

• RBP $5,000 Bronze

• RBP $7,350 Copper

• RBP $2,500 HDHP (HSA)

• RBP $3,500 HDHP (HSA)

• RBP $5,000 HDHP (HSA)

Group Name: Population Science Management of Tennessee

Subject to plan allowable. The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to www.detegohealth.com or call 1-866-815-6001. For general denitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.dol.gov/ebsa/healthreform.com or www.cciio.cms.gov   

Services may require Preauthorization. Failure to obtain Preauthorization will result in the denial of benefits. 

Precertication 

 Precertication is required for all in-hospital admissions, imaging (CT/PET/MRI/MRA), home health, skilled nursing, hospice, DME (over $500), chemotherapy/radiation, sleep studies, prosthetics/orthotics, therapies (chiropractic, cardiac, PT/OT/ST), and outpatient surgery. Please refer to the plan document for a complete list of all services that require precertication under your plan. A 50% (up to $2,500) penalty will apply for not obtaining precertication.

In-network and Out-of-network Deductible and Out-of-pocket Limits are separate and do not cross accumulate. All other limits (days, visits, sessions, dollar amounts, etc.) do cross accumulate between In-network and Out-of-network, unless noted differently. Day, session or visit limits for certain services shown on this summary are not applicable to Mental Health and/or Substance Use Disorders. Once the annual Out-of-pocket Limit is reached, most Covered Services are payable by the plan at 100% for the rest of the benet period. 

PPO Plans: PPO $500, PPO $1,000, PPO $1,500, PPO $2,500, PPO $3,500, PPO $5,000, and PPO $7,350

RBP Plans: RBP $500, RBP $1,000, RBP $1,500, RBP $2,500, RBP $3,500, RBP $5,000, and RBP $7,350 

 Copayment(s) (copay(s) apply to: 

• Physician Office

• Specialist Office

• Urgent Care Facility 

• Physical, Occupational, and Speech Therapy Services

• Cardiac Rehabilitation

• Manipulations

• Routine Vision Exam

• Prenatal/Postnatal Office

• Mental Health/Substance Abuse/Autism Outpatient & Office

• Prescription Drugs

 PPO Plan: PPO $2,500 HDHP (HSA)

Copayment(s) (copay(s) apply to:

• This plan has no medical or prescription copays 

RBP Plans:

RBP $2,500 HDHP (HSA), RBP $3,500 HDHP (HSA), RBP $5,000 HDHP (HSA)

Copayment(s) (copay(s)) apply to:

• Prescription Drugs

• This plan has no medical copays

 The Copay amount varies by the type of Covered Services. Refer to the appropriate category for benet information.      

Group Name:

Population Science Management of Tennessee  

Deductible (the amount the Covered Person pays each Calendar Year for Covered Services before the Coinsurance is payable) 

Coinsurance:

(The percentage amount the Covered Person must pay for most Covered Services after the Deductible has been met) 

Out-of-Pocket Limit:

(includes Deductible, Coinsurance and Copays) 

Info is shown in diagrams below...