Scott & White Health plans Wisconsin
Plan Overviews
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Health Maintenance Organizations (HMO)
An HMO gives you a range of benefits for a prepaid monthly fee. The plan focuses on wellness, prevention, and treatment within a network of providers. Out-of-network providers are usually not covered, unless in an emergency.
Preferred Provider Organizations (PPO)
PPOs often have a larger network of providers. This option can offer the greatest flexibility for members seeking care in and out of network. If a member visits an in-network doctor, they’re only responsible for their annual deductible and copay. If a member gets care outside the network, benefits may be reduced and their copay may be higher. Often, annual deductibles for PPO plans are higher than deductibles for HMO plans.
| Bronze HMO 6400/50v | Bronze PPO 7150 | ||
| Benefit | HMO Plan In Network (No Out of Network) |
PPO In Network |
PPO Out of Network |
| Plan Coinsurance | 80% | 100% | 50% |
| Member Coinsurance | 20% | 0% | 50% |
| Individual Deductible 1 Family Deductible |
$6,400 $12,800 |
$7,150 $14,300 |
$14,300 $28,600 |
| Individual Max Out Of Pocket 2 Family Max Out Of Pocket |
$7,150 $14,300 |
$7,150 $14,300 |
$14,300 $28,600 |
| Primary Care Office Visit | $50 copay (first visit) | $60 copay (first 2 visits) | Deductible then 50% |
| Specialist Office Visit | Deductible then 20% | $100 copay (first 2 visits) | Deductible then 50% |
| Urgent Care | $50 copay (first visit) | Deductible then 0% | Deductible then 0% |
| Emergency Room | Deductible then 20% | Deductible then 0% | Deductible then 0% |
| Imaging (PET, CT, MRI) | Deductible then 20% | Deductible then 0% | Deductible then 50% |
| Outpatient Lab and X-Ray | Deductible then 20% | Deductible then 0% | Deductible then 50% |
| Inpatient Hospitalization | Deductible then 20% | Deductible then 0% | Deductible then 50% |
| Pharmacy Deductible | None | None | None |
| Preferred Generic Drugs | $17 copay | $40 copay | Deductible then 50% |
| Preferred Brand Drugs | Deductible then 50% | $100 copay | Deductible then 50% |
| Non-Preferred Brand | Deductible then 50% | Deductible then 50% | Deductible then 50% |
| Specialty Drugs | Deductible then 50% | Deductible then 50% | Deductible then 50% |
| (1 ) Deductibles and out-of-pocket responsibility apply per calendar year. | |||
| (2) All member responsibility for copays, deductibles, and coinsurance apply to the out-of-pocket maximum. Preventive medications are covered in full – deductible and coinsurance do not apply. | |||
| The PPO plan includes coverage when out-of-network providers are used; however, you will be responsible for any amounts above the allowed charges. These amounts can be billed to you by the provider and do not apply to your annual out-of-pocket maximum under the plan. | |||
| SCOTT AND WHITE HEALTH PLAN and the INSURANCE COMPANY OF SCOTT AND WHITE ARE QUALIFIED HEALTH PLAN ISSUERS. | |||
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