Annual Medical 100% except as After 100% except as After COINSURANCE described below DEDUCTIBLE: described below DEDUCTIBLE: for: DURABLE 90%/10% applies for: DURABLE 90%/10% applies MEDICAL to medical MEDICAL to medical EQUIPMENT, services except EQUIPMENT, services except cochlear implants for office visits, cochlear implants for office visits, and hearing aids. and as described and hearing aids. and as described Then, 80% to below. Then, 80% to below. COINSURANCE OOPL. COINSURANCE (OOPL). applies to applies to (OOPL) except as (OOPL) except as described below. described below. Benefit: WPE eligible WPE eligible WPE eligible High Participating PARTICIPANTS PARTICIPANTS PARTICIPANTS DEDUCTIBLE Wisconsin Public in (Program in PO 6 who are in PO 4 including Health Plan WPE Option PO 2 and not eligible for MEDICARE eligible (PO 7) Employer’s (WPE) MEDICARE nor enrolled in eligible and PARTICIPANTS 3 eligible and MEDICARE as enrolled enrolled in PO 6 the primary and PO 7) payor3 Annual Medical None except as $1,250 After $500 per After OOPL (OOPL) described below individual DEDUCTIBLE: for: DURABLE aggregate $1,000 aggregate $2,500 per MEDICAL family limit except per family individual plan EQUIPMENT, as described DEDUCTIBLE, $5,000 per family cochlear implants below.1 none except as plan except as and hearing aids. described below described below. Then, 80% to for: DURABLE OOPL. 1 MEDICAL EQUIPMENT, cochlear implants and hearing aids. Then, 80% to OOPL. 1 Routine, 100% 100% 100% 100% preventive services as required by federal law Primary Care No medical $15, No medical After Office Visit COPAYMENTs DEDUCTIBLE COPAYMENTs DEDUCTIBLE: COPAYMENT need not be met $15 applies to: first
Annual Medical COINSURANCE 100% except as described below for: DURABLE MEDICAL EQUIPMENT, cochlear implants and hearing aids. Then, 80% to (OOPL). After DEDUCTIBLE: 90%/10% applies to medical services except for office visits, and as described below. COINSURANCE applies to (OOPL) except as described below. 100% except as described below for: DURABLE MEDICAL EQUIPMENT, cochlear implants and hearing aids. Then, 80% to OOPL. After DEDUCTIBLE: 90%/10% applies to medical services except for office visits, and as described below. COINSURANCE applies to (OOPL) except as described below. Benefit: Participating Wisconsin Public Employer’s (WPE) WPE eligible PARTICIPANTS in (Program Option PO 2 and MEDICARE eligible and enrolled in PO 6 and PO 7) WPE eligible PARTICIPANTS in PO 6 who are not eligible for nor enrolled in MEDICARE as the primary payor3 WPE eligible PARTICIPANTS in PO 4 including MEDICARE eligible and enrolled High DEDUCTIBLE Health Plan WPE eligible (PO 7) PARTICIPANTS 3 Annual Medical OOPL (OOPL) None except as described below for: DURABLE MEDICAL EQUIPMENT, cochlear implants and hearing aids. Then, 80% to OOPL. 1 $1,250 aggregate family limit except as described below.1 After $500 per individual $1,000 aggregate per family DEDUCTIBLE, none except as described below for: DURABLE MEDICAL EQUIPMENT, cochlear implants and hearing aids. Then, 80% to OOPL. 1 After DEDUCTIBLE: $2,500 per individual plan $5,000 per family plan except as described below. Routine, preventive services as required by federal law 100% 100% 100% 100% Primary Care Office Visit COPAYMENT applies to: No medical COPAYMENTs $15, DEDUCTIBLE need not be met first No medical COPAYMENTs After DEDUCTIBLE: $15
Exhibit1-PBP_Agreement_Rev01-04-2017_clean.docx