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: $2,350
Family: $7,050
Individual: $6,250
Family: $18,750
Employee Coinsurance 10% after deductible 30% of UCR3, after deductible
Preventive (Annual Physicals, Well Care Exams) 100% covered, not subject to deductible 30% of UCR3, after deductible
Physician Visits Primary Care: $20/visit
Specialist: $30/visit
30% of UCR3, after deductible
Lab and X-Ray 10% after deductible 30% of UCR3, after deductible
Emergency Room4 $100/visit, then 10% $100/visit, then 10%
Ambulance 10% after deductible 10% after deductible
Hospitalization 10% after deductible 30% of UCR3, after deductible
Chiropractic $30 co-pay per visit
Up to 20 visits/year
30% after deductible
Up to 20 visits/year
Acupuncture $30/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 Therapy4 $30/visit 30% after deductible
Infertility/Fertility Preservation 10% after deductible
2 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 Usual, customary, and reasonable charges.
4 Available to those with conditions of medical necessity.

Employee Contributions for 2019

Per Paycheck1

Plan Employee Only Employee +
Spouse/Domestic Partner
Employee + Child(ren) Employee + Family
Traditional PPO $110.69 $249.04 $211.60 $359.73

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).

Contact Us

HR Source
ASK HR [VMware network access required]
Phone: 1-888-VMWARE8, option ‘US Benefits’
Internal Phone: ext. 29200


UnitedHealthcare
Phone: 1-844-562-6290
Visit pre-member website
Visit website

Resources

Benefit Byte Video: Benefits for Living


Benefit Byte Video: Health FSA Plans


Benefits Contact Quick Reference Guide


Domestic Partner Imputed Income Rate Table


Key Benefit Terms


Palo Alto Medical Foundation Mobile Clinic


UHC Behavioral Health TOC
Letter


UHC Gender Dysphoria Hair Removal & Voice Therapy Claim Form


UHC Harvard Pilgrim Passport Connect FAQ


UHC Health4Me Mobile App


UHC HealthSafe ID (HSID) Step by Step Registration


UHC Health Insurance Claim
Form


UHC Massage Therapy Claim
Form


UHC Preventive Care Guidelines


UHC Preventive Care Services with Codes


UHC Rally Health Mobile App


UHC Rally Health Mobile App Webinar


UHC Traditional PPO Benefit Summary


UHC Traditional PPO Harvard Pilgrim Summary of Benefits and Coverage (SBC)


UHC Traditional PPO Summary of Benefits and Coverage (SBC)


UHC Traditional PPO Summary Plan Description (SPD)


UHC Transtion of Care


UHC Virtual Visits FAQ


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