Traditional PPO

The Traditional PPO medical plan has full coverage for in-network preventive care with you sharing the cost of other services through co-pays, coinsurance and your deductible. You have the same UnitedHealthcare (UHC) Choice Plus network of doctors as the HSA PPO plan. If you reside in Maine, Massachusetts or New Hampshire you have access to both the Choice Plus network and UHC’s broader Harvard Pilgrim network. You must meet your annual deductible before the plan begins to pay benefits. Co-pays for office and specialist visits, do not apply to your annual deductible, but do apply to your annual out-of-pocket maximum. Prescription drugs are part of your deductible. Visit the Pharmacy page for more information.

You are eligible to enroll in the General Purpose Flexible Spending Account (GPFSA) for your out-of-pocket expenses, when enrolled in the Traditional PPO plan.

The Traditional PPO plan gives you the option to visit any provider, allowing you to shop around when you need health care. You can visit any doctor or facility, but you will receive the best value when you go in-network. To find in-network providers, visit UHC’s website.

Traditional PPO Plan Details

	In-Network	Out-of-Network
Annual Deductible¹	Individual: $500 Family: $1,500	Individual: $500 Family: $1,500
Annual Out-of-Pocket (OOP) Maximum ²	Individual: $3,000 Family: $9,000	Individual: $6,900 Family: $20,700
Employee Coinsurance	10% after deductible	30% after deductible
Preventive (Annual Physicals, Well Care Exams)	100% covered, not subject to deductible	30% after deductible
Physician Visits	Primary Care: $30/visit Specialist: $45/visit	30% after deductible
Lab and X-Ray	10% after deductible	30% after deductible
Emergency Room³	$100/visit, then 10%	$100/visit, then 10%
Ambulance	10% after deductible	10% after deductible
Hospitalization	10% after deductible	30% after deductible
Chiropractic	$45 co-pay per visit Up to 20 visits/year	30% after deductible Up to 20 visits/year
Acupuncture	$45/visit Up to 20 visits/year	30% after deductible Up to 20 visits/year
Massage	10% after deductible Up to 20 visits/year	10% after deductible Up to 20 visits/year
Speech Therapy³	$30/visit	30% after deductible
Infertility/Fertility Preservation	10% after deductible 3 Smart Cycles per lifetime via Progyny	Not Covered

¹ Individual deductible and OOP maximum only apply to employees enrolled in Individual tier. Members in dependent tiers must satisfy an aggregate deductible – the health plan doesn’t begin paying benefits until the entire family deductible has been met. Once the entirety of the family deductible has been met, by one family member or a combination of family members, then the cost sharing begins. Paid Interns are not eligible to enroll in the Traditional PPO plan.
² OOP maximum includes Prescription Rx.
³ Available to those with conditions of medical necessity.

Employee Contributions for 2022

Per Paycheck¹

Plan	Employee Only	Employee + Spouse/Domestic Partner	Employee + Child(ren)	Employee + Family
Traditional PPO	$124.55	$280.25	$238.12	$404.80

¹ Per paycheck contributions are 24 times per year. Contributions are pre-tax (except for Domestic Partner coverage).

Dependent Eligibility

Your spouse or domestic partner. Please note: after tax contributions and imputed income may apply when covering a domestic partner. See the Domestic Partner Imputed Income Rate Table for details
Your child(ren), your spouse’s / domestic partner’s child(ren), your foster child(ren), the minor(s) you have legal guardianship of are eligible for medical coverage until age 26, regardless of marital or student status.

For more details, see the UHC Traditional PPO Summary of Benefits and Coverage (SBC). Residences of Maine, Massachusetts or New Hampshire see the UHC Traditional PPO Harvard Pilgrim Summary of Benefits and Coverage (SBC).

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Included Health is your personal healthcare assistant. Get an expert second opinion at no cost to you. You must be enrolled in a VMware medical plan to use Included Health services. For more information call 1-855-394-1635 or visit includedhealth.com/vmware.