Medical PPO
Need help choosing a medical plan option?
Our medical plan, administered by OhioHealthy, allows you to access quality healthcare and provide comprehensive coverage.
The OhioHealthy PPO has:
- Higher premiums than the OhioHealthy HDHP+HSA
- A lower deductible than the OhioHealthy HDHP+HSA (which means the plan pays benefits sooner)
- Predetermined amounts (copays) to pay for doctors’ office visits, urgent care and certain prescriptions — even if you have not met your deductible (copays do not count toward your deductible, but do count toward your out-of-pocket maximum)
By choosing in-network providers or specialists, you’ll keep more dollars in your pocket.
OhioHealthy PPO coverage
| Tier 1 (In-Network Preferred) | Tier 2 (In-Network) | Tier 3 (Out-of-Network) | |
| Tier 1 Network Examples Include: | Tier 2 Network Examples Include: | Tier 3 Network 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 | Fairfield Medical Center, Licking Memorial Hospital, Holzer Hospital, Genesis Hospital, and out-of-area claims (PHCS Practitioner and Ancillary network and all facilities) | Ohio State University (OSU), Mount Carmel Health System, Avita Health System, Adena Regional Medical Center, and Marietta Memorial | |
| Deductible | What you pay before the plan pays: | ||
|---|---|---|---|
| Associate only | $500 | $1,500 | $3,000 |
| Associate + 1 dependent | $750 | $2,250 | $4,500 |
| Associate + 2 or more dependents | $1,000 | $3,000 | $6,000 |
| Out-of-Pocket Maximum (OOPM) | The most you'll pay out-of-pocket in a plan year: | ||
| Associate only | $3,000 | $5,000 | Unlimited |
| Associate + 1 dependent | $4,500 | $7,500 | Unlimited |
| Associate + 2 or more dependents | $6,000 | $10,000 | 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 | 30% after deductible | 50% after deductible |
| Primary Care Physicians | $20 copay | $35 copay | 50% after deductible |
| Specialty Care Physicians | $30 copay | $50 copay | 50% after deductible |
| Telemedicine (Teladoc) | $10 copay | $10 copay | Not covered |
| Urgent care | $25 copay | $45 copay | 50% after deductible |
| ER | 10% + $300 copay after deductible | 10% + $300 copay after deductible | 10% + $300 copay after deductible |
| Behavioral Health & Substance Use Services | 10% after deductible | 10% after deductible | 50% after deductible |
| Outpatient Surgery at Ambulatory Surgery Center | 10% after deductible | 30% + $50 copay after deductible | 50% after deductible |
| Outpatient Surgery at Acute Care Hospital | 10% + $300 copay after deductible | 30% + $500 copay after deductible | 50% after deductible |
| OhioHealth Pharmacies | Participating Pharmacies | Non-Participating Pharmacies | |
| Prescriptions (Rx) | What you pay for prescription medications: | ||
| Tier 1* | $10 copay (30-day supply) after Rx deductible $20 copay (90-day supply) after Rx deductible | $10 copay (30-day supply) after Rx deductible $20 copay (90-day supply) after Rx deductible | Rx Tier 1 Copayment plus the difference between the Maximum Allowable Amount and the Copayment |
| Tier 2 | 20% | 20% | Rx Tier 2 Copayment plus the difference between the Maximum Allowable Amount and the Copayment |
| Tier 3 | 30% | 30% | 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; 20% if not in program | 20% | Rx Tier 2 Copayment plus the difference between the Maximum Allowable Amount and the Copayment |
Read more about Prescription Medications coverage.
* This tier has a separate deductible for Rx:
Associate only - $100
Associate + 1 dependent - $200
Associate + 2 or more dependents - $300
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.
To find what Tier your provider is in, go to OhioHealthyPlans.com or call the OhioHealthy Member Advocates at (888) 841.5670.
Watch a short video on the three-tier provider & facility network structure.
How much does this benefit cost?
| Associate cost per pay period | ||||
|---|---|---|---|---|
| Full-time rates | Part-time rates* | |||
| Coverage type | No discounts earned | All discounts earned | No discounts earned | All discounts earned |
| Associate only | $106 | $76 | $121 | $91 |
| Associate + spouse | $262 | $232 | $289 | $259 |
| Associate + child | $181 | $151 | $209 | $179 |
| Associate + children | $213 | $183 | $249 | $219 |
| Family | $293 | $263 | $327 | $297 |
*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, Accident 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, 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