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City of La Porte Medical Plans <br />Plan FeaturePPO 500HF 1000HF 1500 <br />Deductible (Ind./Fam.)$500/$1,500$1,000/$3,000$1,500/$4,500 <br />OOP (Ind./Fam.)$3,500/$10,500$3,000/$9,000$4,500/$13,500 <br />Employee Coinsurance20%20%20% <br />Office Visits (PCP/Specialist)$25/$4020% after Ded.20% after Ded. <br />Urgent Care$4020% after Ded.20% after Ded. <br />Emergency Room$15020% after Ded.20% after Ded. <br />$150/day, max 5, <br />Hospital, Inpatient20% after Ded.20% after Ded. <br />then 100% <br />$100 copay + 20% <br />Hospital, Outpatient20% after Ded.20% after Ded. <br />after ded. <br />Lab/X-ray/Complex Imaging20% after ded.20% after Ded.20% after Ded. <br />Ambulance20% after ded.20% after Ded.20% after Ded. <br />Skilled Nursing20% after ded.20% after Ded.20% after Ded. <br />Hospice20% after ded.20% after Ded.20% after Ded. <br />$500/$1,000 <br />Fund pays employee portion of <br />Health Fund (Ind./Family)N/A <br />medical and RX expenses <br />Unused balances roll over <br />RX: (Retail/Mail Order) <br />Level 1$10/$20$10/$20$10/$20 <br />Level 2$30/$60$30/$60$30/$60 <br />Level 3$60/$120$60/$120$60/$120 <br />Benefitsingreen currently count towards the Out-of-Pocket Maximum <br />BenefitsinRedexceed the maximum allowed underPPACA <br />BenefitsinOrange could resultin member exceeding the Out-of-Pocket Maximum <br /> <br />