Preferred Provider Organization (PPO)
Regenexx Benefits
Under a PPO, you have coverage both in-network and out-of-network. You can see any doctor you choose, you don’t have to select a primary care physician (PCP), and you don’t need referrals to access specialists.
Under a PPO plan, you can:
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Stay in-network and save money by using a network provider. Your out-of-pocket costs are lower because network providers typically offer their services at lower rates. In addition, you receive a higher level of benefits when you visit in-network providers.
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Or, go out-of-network and use any doctor or hospital you’d like, but pay a greater share of the cost. You may be subject to reasonable and customary (R&C) limits.
Network:
Alliance Select
Group Number:
56851-0319 GreenState PPO
56851-0419 GreenState HDHP
56851-0309 Insurance PPO
56851-0409 Insurance HDHP
56851-0329 Trust PPO
56851-0429 Trust HDHP
Website:
Support:
1.800.524.9242
Claim Submission Address:
Wellmark BC/BS of IA
Station 39
636 Grand Avenue
Des Moines, IA 50309-2565
(Plan pre-fix: LDS)
BENEFITS
PPO
HDHP
Deductible
$1,500 Single
$3,000 Family
$3,200 Single
$6,400 Family
Coinsurance
80/20%
0%
Out of Pocket
Maximum
$3,000 Single
$6,000 Family
$3,200 Single
$6,400 Family
Office Visits
PCP: $20 copay
Specialist: $40 copay
Doctor on Demand: $40 Copay
PCP: Deductible applies
Specialist: Deductible applies
Doctor on Demand: $49 Copay
Preventative Services
Covered at 100%
Covered at 100%
Emergency Room
20% after deductible
Deductible applies
Urgent Care
$20 copay
Deductible applies
Inpatient Hospital
20% after deductible
Deductible applies
Outpatient Hospital
20% after deductible
Deductible applies
Prescription Drug
Walgreens is no longer a covered pharmacy effective 01/01/2024
$100/$200 deductible
(waived for Tier 1)
Non-preferred Pharmacy Copay
(CVS)
$20 / $45 / $60 / $200
All Other Pharmacies Copay
$4 / $25 / $40 / $200
Deductible applies
Prescription Drug Out of Pocket Maximum
$3,000 Single
$6,000 Family
All prescription expenses apply to the Medical OPM.
There is no separate OPM.
In-Network Coverage
Most covered services are reimbursed at 80% after you meet the annual deductible.
Under the GreenState Traditional PPO, there is a $20 copayment for each office visit to a primary care physician, chiropractor, occupational therapist, physical therapist, speech pathologist, and mental health and chemical dependency treatment. There is also a $40 copayment for each office visit to a specialist.
Out-of-Network Coverage
Most other covered services are reimbursed at 70% of the reasonable and customary costs, after you meet the annual deductible.
Important Note: You are responsible for all out of-network charges above the reasonable and customary limits, even if you have reached the out-of-pocket maximum.