Medical PPO Assist
Understanding the Medical PPO Assist medical plan
OhioHealth offers the OhioHealthy PPO Assist Medical Plan option to qualifying associates whose family household income meets certain criteria. The plan option provides access to the same quality healthcare and comprehensive coverage as the other OhioHealthy Medical Plan options. The Plan has lower premiums, and you’ll pay less when you seek medical care or fill a prescription. If you qualify, the PPO Assist Plan is likely the best option when choosing your medical plan.
By choosing in-network providers or specialists, you’ll keep more dollars in your pocket. Also, by using the Rightway tool you can navigate the complex healthcare journey, so you get quality care at the lowest cost.
Eligibility
You’re eligible to apply for the OhioHealthy PPO Assist if:
- You are regularly scheduled to work at least 48 hours per pay period.
- Your household income is less than or equal to the following amounts (as reported on your tax return, IRS Form 1040):
| Number of people in your household | Annual household income was less than |
|---|---|
| 1 | $43,740 |
| 2 | $59,160 |
| 3 | $74,580 |
| 4 | $90,000 |
| 5 | $105,420 |
| 6 | $120,840 |
| 7 | $136,260 |
| 8 | $151,680 |
How to apply
You need to submit an application and provide your 2023 tax return (IRS Form 1040) as proof of income in Workday by September 30, 2024 to be eligible for the benefit year that begins January 1, 2025.
Applications and proof of household income are due September 30, 2024.
Here’s how to apply:
- Login to Workday and follow these instructions. All PPO Assist applications must be completed in Workday to ensure timely processing.
- You will be required to provide your 2023 Federal IRS Form 1040 as proof of income.
Need help choosing a medical plan option?
Get help with ALEX, an interactive online tool that will walk you through your benefit options and provide personal assistance in pointing out what choices make the most sense for you. Ask ALEX here.
OhioHealthy PPO Assist coverage
| Tier 1 (In-Network Preferred) |
Tier 2 (In-Network) |
Tier 3 (Out-of-Network) |
|
|---|---|---|---|
| Deductible | What you pay before the plan pays: | ||
| Associate only | $125 | $150 | $1,800 |
| Associate + 1 dependent | $200 | $225 | $2,800 |
| Associate + 2 or more dependents | $275 | $300 | $3,600 |
| Out-of-Pocket Maximum (OOPM) | The most you’ll pay out-of-pocket in a plan year: | ||
| Associate only | $900 | $1,000 | Unlimited |
| Associate + 1 dependent | $1,400 | $1,500 | Unlimited |
| Associate + 2 or more dependents | $1,900 | $2,000 | Unlimited |
| Covered Services | What you pay for certain services: | ||
| Preventive care | 0% (plan pays 100% day one) | 0% (plan pays 100% day one) | 50% after deductible |
| Other medical | 10% after deductible | 10% after deductible | 50% after deductible |
| Primary Care Physicians | $20 copay | $20 copay | 50% after deductible |
| Specialty Care Physicians | $25 copay | $25 copay | 50% after deductible |
| Telemedicine (Teladoc) | $10 copay | $10 copay | Not covered |
| Urgent care | $20 copay | $20 copay | 50% after deductible |
| ER | $150 copay | $150 copay | $150 copay |
| Behavioral Health & Substance Use Services | 10% after deductible | 10% after deductible | 50% after deductible |
| Outpatient Surgery at Ambulatory Surgery Center | 10% after deductible | 10% after deductible | 50% after deductible |
| Outpatient Surgery at Acute Care Hospital | 10% after deductible | 10% after deductible | 50% after deductible |
| OhioHealth Pharmacies | Participating Pharmacies | Non-Participating Pharmacies | |
|---|---|---|---|
| Prescriptions (Rx) | What you pay for prescription medications: | ||
| Tier 1 | $5 copay (up to 30-day supply)
$10 copay (31 – 60-day supply) $12.50 copay (61 – 90-day supply) |
$5 copay (up to 30-day supply)
$12.50 copay (31 – 90-day supply) |
Rx Tier 1 Copayment plus the difference between the Maximum Allowable Amount and the Copayment |
| Tier 2 | 15% (but no more than $30 per 30-day supply) | 15% (but no more than $30 per 30-day supply) | Rx Tier 2 Copayment plus the difference between the Maximum Allowable Amount and the Copayment |
| Tier 3 | 25% (but no more than $60 per 30-day supply) | 25% (but no more than $60 per 30-day supply) | Rx Tier 3 Copayment plus the difference between the Maximum Allowable Amount and the Copayment |
| Specialty Rx | 20% (but no more than $500) | 20% (but no more than $500) | Not covered |
| Diabetes & Asthma Rx | 0%, if in Management Program | 15% (but no more than $30 per 30-day supply) | Rx Tier 2 Copayment plus the difference between the Maximum Allowable Amount and the Copayment |
Read more about Prescription Medications coverage.
Three-tier provider & facility network
The three medical plan options offered by OhioHealth and administered by OhioHealthy now have a three-tier provider and facility network structure (Tier 1, Tier 2 and Tier 3). Depending on what provider and/or facility you use, your out-of-pocket costs may be different. You’ll save the most money when using Tier 1 providers and facilities.
Download the Medical Plan Tier Overview
To find what Tier your provider is in, go to OhioHealthyPlans.com or call the OhioHealthy Member Advocates at 1 (855) 571-1378.
Tier 1 Network (in-network preferred) examples include: OhioHealth Physician Group (OPG), Clinically Integrated Network (CIN), Columbus Ohio Primary Care (COPC), Nationwide Children’s Hospital, Cleveland Clinic, and emergency services at any location.
Tier 2 Network (in-network) examples include: Fairfield Medical Center, Licking Memorial Hospital, Holzer Hospital, Genesis Hospital, and out-of-area claims (PHCS Practitioner and Ancillary network and all facilities).
Tier 3 Network (out-of-network) examples include: Ohio State University (OSU), Mount Carmel Health System, Avita Health System, Adena Regional Medical Center, and Marietta Memorial.
Watch a short video on the three-tier provider & facility network structure.
How much does this benefit cost?
Full-time rates
| 2024 Associate cost per pay period | ||
|---|---|---|
| Coverage type | No discounts earned | All discounts earned |
| Associate only | $63.50 | $28.50 |
| Associate + spouse | $143 | $108 |
| Associate + child | $114.50 | $79.50 |
| Associate + children | $133.50 | $98.50 |
| Family | $162 | $127 |
Part-time rates*
| 2024 Associate cost per pay period | ||
|---|---|---|
| Coverage type | No discounts earned | All discounts earned |
| Associate only | $76.50 | $41.50 |
| Associate + spouse | $169 | $134 |
| Associate + child | $140.50 | $105.50 |
| Associate + children | $165.50 | $130.50 |
| Family | $194 | $159 |
*48-63 scheduled hours per pay period – Per-Pay Amounts
Working Spouse Surcharge
There is a premium surcharge of $70 per pay period for spouses who are working and eligible for medical coverage through a different employer. This surcharge is in addition to the premium cost for whatever plan you elect that includes a spouse: associate + spouse and family plans. This surcharge encourages those participants eligible for other group health insurance through their employer to take advantage of that coverage. Like many other employers, the working spouse premium surcharge is one way to manage ongoing healthcare costs, now and into the future.
Do you and your spouse both work for OhioHealth? If you and your spouse work for OhioHealth, then the surcharge does not apply. The surcharge is only applicable if your spouse has medical coverage options through an employer other than OhioHealth.
Watch a short video on the working spouse surcharge.
How to make the most of this benefit
- Need care? Consult your Primary Care Physician first.
- Physician not available? Call the 24/7 Nurse Advice Line at 1 (844) 834-4375 to get free private advice from a nurse.
- Can’t see your usual physician? Contact Teladoc Health for a virtual visit, where doctors can diagnose your symptoms, prescribe medications and send prescriptions to your pharmacy of choice – great if you’re away from home.
- Use urgent care instead of the emergency room for non-emergencies – but always go to the emergency room if it is an emergency and be sure to follow-up with your physician if you have questions or need further care.
- Visit ohiohealthyplans.com to find in-network providers and facilities, and estimate the costs with the treatment cost calculator.
- You’ll pay less for certain services from OhioHealth providers, including lower out-of-pocket costs for visits to one of the plan’s preferred specialists in the OhioHealth Clinically Integrated Network.
- A wide range of preventive care services are available at no cost to you, including annual physical exams, vaccines and tobacco cessation benefits – download the Preventive Care Summary.
- Combine this benefit with a Healthcare Flexible Spending Account to get eligible out-of-pocket expenses reimbursed.
- Combine this benefit with Critical Illness Insurance, Accidental Ca$hback Insurance or Hospital Indemnity Insurance to help cover out-of-pocket expenses without using your Healthcare Flexible Spending Account.
- Got an existing Health Savings Account (HSA)? You cannot contribute to an HSA while a member of the OhioHealthy PPO Assist, but you can use dollars in an existing HSA to pay eligible expenses.
- Add dependent coverage – your spouse and any children through the month they turn age 26 are eligible.
- Change your coverage at any time during the year if you have a relevant and qualified change in family status (e.g. you get married and want to add your spouse) – update your elections in Workday.