Once you are familiar with each plan’s out-of-pocket expenses, you can use the graphic below to track the path of cumulative (increasing) out-of-pocket expenses until they meet the total out-of-pocket maximum and are covered 100 percent by the University. The scenarios below the graphic explain how each expense is recorded for both individual and family plans, and applied to the total out-of-pocket maximum. The graphic uses 2017 PPO Plan costs.
Scenario 1 (Based on a single individual in each plan. This is your first visit of the year.)
You are not feeling well and decide to see your Primary Care Physician. During your visit, the doctor writes you a prescription for an antibiotic and schedules blood work for a CBC (Complete Blood Count). No follow-up appointment needed.
Under the PPO Plan:
- You have a copay of $20 (the orange box)
- Your blood work fees are applied to the deductible (the green box).
- You have a prescription cost (the yellow box) that will go against your $2,000 maximum out of pocket
Scenario 2 (Based on a single individual in each plan. This is a subsequent visit to the first scenario.)
You see a specialist for your arthritis. During the visit the doctor schedules blood work, an X-ray and prescribes an anti-inflammatory prescription drug for you to take.
Under the PPO Plan:
- You pay the specialist copay $30 (the orange box)
- Your blood work and X-ray fees are applied to the deductible (the green box) and anything above the deductible is charged at 10 percent coinsurance (the blue box)
- You have a prescription cost (the yellow box) that will go against your $2,000 maximum out of pocket
Scenario 3 (Based on family coverage)
Your child was injured during soccer practice and must to be taken to the emergency room (ER) for an X-ray. The X-ray indicates a fracture of the tibia, and the leg has to be casted. He is sent home with pain relievers and crutches.
Under the PPO Plan:
- You have a $100 ER copay (applies to the orange box) (does not count toward deductible)
- You have an X-ray charge (applies toward deductible-green box)
- You have prescription drug costs (applies toward the yellow box) that will go towards his $2,000 drug out-of-pocket max
- You have a bill for the crutches (applies toward deductible-green box)
Scenario 4 (based on family coverage)
That same year, you have to have your gallbladder removed. You stay overnight in the hospital for the surgery and when you leave, you are given prescription medication for pain.
Under the PPO Plan:
- You have a hospital stay that applies to your deductible (green box). Your child met his deductible of $375 with the broken leg and now you have met the remaining $375 deductible. You will now begin paying coinsurance (blue box) for all additional expenses related to your surgery and for subsequent claims.
- You have prescription drug costs (applied toward the yellow box) that will go towards your $2,000 prescription drug deductible.