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Permian Basin Employer Health Plan B - High 1000 |
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Prefferred Provider
(In-Network Benefits)
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Non-Prefferred Provider
(Out-of-Network Benefits) |
Deductible per Calendar Year
(Does not apply toward Out-of-Pocket Maximum) |
$1,000 per Insured
$3,000 per Family |
$3,000 per Insured
$9,000 per Family |
| Out-of-Pocket Maximum per Calendar Year |
$3,000 per Insured
$10,000 per Family |
$10,000 per Insured
$25,000 per Family |
| Preauthorization Penalty |
Failure to preauthorize reduces benefits by 50% or $500, whichever is less. |
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| Doctor Office Visits |
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Non-Specialist |
$25 per visit |
60% after Deductible |
| Specialist |
$55 per visit |
60% after Deductible |
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Hospital Services |
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Inpatient Room & Board and other Inpatient charges |
80% after Deductible |
60% after Deductible |
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Outpatient Room Surgery Facility |
80% after Deductible |
60% after Deductible |
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| Emergency Care Services |
80% Deductible Waived |
For more detailed information visit the plan documents:
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