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Policy POL-100
Standard PPO
Plan year 2026 · Annual deductible $1000.00· Out-of-pocket max $5000.00 The most a member pays out-of-pocket per year for covered services — enforced via the OOP accumulator.
$1000.00 annual deductible, $5000.00 out-of-pocket max. Cosmetic isn't covered; Diagnostic lab at 20% coinsurance (after deductible); Mri at 20% coinsurance (after deductible, needs review); Office visit at $30.00 copay; Physical therapy at 20% coinsurance (up to $2000.00/yr).
Coverage rules
These rules are stored as data and applied by the adjudication pipeline — every decision on a claim traces back to one of these rows.
| Service | Covered | Cost-share | Deductible | Annual limit | Review |
|---|---|---|---|---|---|
Cosmetic Cosmetic isn't covered. | — | — | — | — | |
Diagnostic lab Diagnostic lab at 20% coinsurance (after deductible). | 20% coinsurance | Yes | — | — | |
Mri Mri at 20% coinsurance (after deductible, needs review). | 20% coinsurance | Yes | — | Required | |
Office visit Office visit at $30.00 copay. | $30.00 copay | — | — | — | |
Physical therapy Physical therapy at 20% coinsurance (up to $2000.00/yr). | 20% coinsurance | — | $2000.00 | — |