PPO

How the PPO Works

STEP 1: YOU PAY FOR CARE

You pay copays for doctor’s office visits and prescription drugs. You don’t have to meet the deductible for these services. Copays do not count toward your deductible but do count toward your out-of-pocket maximum.

STEP 2: SHARE COSTS WITH THE PPO

For other services, such as hospitalization, you must meet your deductible before the PPO shares costs.

STEP 3: THE PPO PAYS THE REST

If you reach your out-of-pocket maximum, the PPO will pay 100% of your eligible expenses for the rest of the calendar year.

Understanding the Medical Tiers

Wondering what the different tiers mean and how they work? This short video walks you through it.

Tier 1

Parkland Health Network
and Children’s Medical Center

Get the highest level of benefits and lowest copays.
You’ll pay a $20 copay for primary care office visits and a $30 copay for specialist office visits.
Tier 1 providers are doctors who provide your care at Parkland Health or Children’s Medical Center (Dallas and Plano). This includes UTSW physicians with Parkland privileges only when they treat you at a Parkland facility.
Tier 1 facilities include Parkland Hospital, the Employee Health Center (EHC), the Employee Women’s Wellness Center (EWWC), the COPC centers and Children’s Medical Center (Dallas and Plano).

Tier 2

Cigna Open Access Plus Network

You’ll pay higher copays and have to meet higher deductibles and out-of-pocket maximums compared to Tier 1.
You’ll have a $35 copay for PCP office visits and a $50 copay for specialist office visits.
Tier 2 providers/facilities include those in the Cigna Open Access Plus Network. This includes UTSW when your services are provided at UTSW facilities and not at a Parkland Health facility.
UTSW/Aston, Cook Children’s Medical Center, Baylor Scott & White Health, Methodist Health System and THR (Texas Health Resources) facilities are also in Tier 2.

Tier 3

Out of Network

Use any provider/facility outside of Tiers 1 and 2 and receive out-of-network Tier 3 benefits.
This tier has the highest deductibles and out-of-pocket maximums.
After you meet the deductible, you pay 50% plus any charges over the reasonable and customary (R&C) amount.
In most cases, you’ll pay out of pocket and then file claims to be reimbursed.

If You See a Tier 1 Provider in the PPO

Be aware if you see a Tier 1 provider, your lab work, imaging or surgeries may be done by a Tier 2 provider or facility.

Frequently Asked Questions

Do I need to pick a primary care physician (PCP)?

You’re not required to choose a PCP, and you don’t need referrals to see a specialist. But choosing a PCP may still make sense. A PCP knows your medical history and can help coordinate your care. The amount you pay for office visits will be based on which tier your doctor is in.

Do all of my doctors need to be in the same tier?

No, you can see providers in any of the three tiers. For example, you might see your PCP who is a Tier 1 Parkland Health provider. Your allergist may be in Tier 2, and your dermatologist might be in Tier 3. What you pay for office visits will depend on which tier your doctor is in. Remember, Tier 1 providers offer the highest level of benefits and lowest copays. Log in to myCigna.com to see a list of providers in Tier 1 and Tier 2. (Prior to Jan. 1, 2024, search for doctors in the Cigna Open Access Plus Network at Cigna Health Care Provider Directory.) Providers not on this list would be considered Tier 3, and you will receive out-of-network benefits for those office visits.

Do I get a Health Savings Account (HSA) with the PPO?

No, the HSA is only available if you enroll in the HDHP. If you enroll in the PPO, you can contribute to the Health Care Flexible Spending Account (FSA).

Medical Benefits at a Glance (PPO)

Here’s a look at what you’ll pay when you need care under each of the three tiers. If a service is not provided by a Tier 1 provider or facility, you will need to receive the service from a Tier 2 or Tier 3 provider. Your benefit will be paid based on the tier of the provider that you use. If you reach the out-of-pocket maximum, the plan pays 100% of eligible charges for the remainder of the calendar year.

Use the search bar at the top of the chart to help you find how your service is covered.

For a full list of covered services, refer to the PEHP Plan Documents posted in the Legal Notices section.

To find a provider, contact Cigna, at mycigna.com or 800-247-4433. (Prior to Jan. 1, 2024, search for doctors in the Cigna Open Access Plus Network at Cigna Health Care Provider Directory.)

Tier 1
Tier 2
Tier 3

	TIER 1: Parkland Health Network and Children's Medical Center	TIER 2: Cigna Open Access Plus Network	TIER 3: Out of Network
Calendar-Year Deductible (Amount you must pay before the plan pays for some services. Amounts you pay towards the deductible count toward your out-of-pocket maximum.)
Per PersonDeductible	$500 (applies to coinsurance only)	$1,500 (applies to coinsurance only)	$3,000
Per FamilyDeductible	$1,000 (applies to coinsurance only)	$4,500 (applies to coinsurance only)	$18,000
Calendar-Year Out-of-Pocket Maximum¹ (Maximum amount you will pay out of pocket for the calendar year. If you reach this limit, the plan will pay 100% of your covered expenses for the rest of the calendar year.)
Per PersonOut-of-Pocket Maximum	$2,500	$6,000	$15,000
Per FamilyOut-of-Pocket Maximum	$6,000	$13,000	$48,000
Lifetime Maximum
Per PersonLifetime Maximum	Unlimited	Unlimited	Unlimited
What You Pay
Preventive Care²rowlabel
Routine health assessments and immunizationsPreventive Care	$0 copay³	$0 copay³	50% after deductible
Physician Services (office or virtual visits)rowlabel
Primary carePhysician Services (for 2024)	$20 copay	$35 copay	50% after deductible
SpecialistPhysician Services (for 2024)	$30 copay	$50 copay	50% after deductible
Convenience Care (walk-in clinics located in retail stores, supermarkets and pharmacies that treat uncomplicated minor illnesses and provide preventive health care services)rowlabel
Convenience care clinic	N/A	$35 copay	50% after deductible
Emergency Carerowlabel
Hospital emergency room visit (for 2024)	$350 copay	$350 copay	$350 copay
Hospital admission from emergency room⁴	10% after deductible	30% after deductible	50% after deductible
Urgent care	$35 copay	$50 copay	50% after deductible
Ground ambulance services Emergency Care	N/A	$0 copay	$0 copay
Inpatient Hospitalrowlabel
Per admissionInpatient Hospital	10% after deductible	30% after deductible	50% after deductible
Outpatient Medicalrowlabel
Outpatient facility servicesOutpatient Medical and outpatient professional services (surgeon, radiologist, pathologist and anesthesiologist)	10% after deductible	30% after deductible	50% after deductible
Labrowlabel
Office visitLab and X-ray	$0	$0	50% after deductible
Independent lab or outpatient facility	$0	30% after deductible	50% after deductible
Mental Health and Substance Abuse Treatmentrowlabel
Outpatient Mental Health Substance Abuse Treatment	$20 copay	$20 copay	50% after deductible
Inpatient Mental Health Substance Abuse Treatment	10% after deductible	30% after deductible	50% after deductible
Maternity Carerowlabelpregnancy
Initial visit to confirm pregnancymaternity care	$20 or $30 copay (based on provider)	$35 or $50 copay (based on provider)	50% after deductible
Subsequent physician services including deliverymaternity carepregnancy	10% after deductible	30% after deductible	50% after deductible
Hospitalization (per admission)maternity carepregnancy	10% after deductible	30% after deductible	50% after deductible
X-raysrowlabel
Physician's services/office visit	10% after deductible	30% after deductible	50% after deductible
Outpatient facility radiology	No deductible/coinsurance for radiology services at Parkland Health	30% after deductible	50% after deductible
Advanced Radiological Imaging (includes MRI, MRA, CAT scan, PET scan, etc.)rowlabel
Outpatient facility	No deductible/coinsurance for radiology services at Parkland Health	30% after deductible	50% after deductible
Physician's services/office visit	$20 or $30 copay (based on provider)	$35 or $50 copay (based on provider)	50% after deductible
Durable Medical Equipmentrowlabel
Durable medical equipment services	10% after deductible	10% after deductible	Not covered
Skilled Nursing Care in Facility⁵rowlabel
Up to 60 days/year instead of acute hospital careskilled nursing	10% after deductible	10% after deductible	50% after deductible
Home Health Carerowlabel
Home nursing visits prescribed by a doctorhome health care	10% after deductible	10% after deductible	50% after deductible
Hospice Carerowlabel
If pre-authorizedhospice	10% after deductible	10% after deductible	50% after deductible
Rehabilitation Services⁵rowlabel
Outpatient (up to 60 days/year)rehabilitation	$20 or $30 copay (based on provider)	$35 or $50 copay (based on provider)	50% after deductible
Inpatient (up to 60 days/year)rehabilitation	10% after deductible	10% after deductible	50% after deductible
Family Planningrowlabel
Infertilityinfertility ($20,000 lifetime medical maximum benefit; integrated with pharmacy)	10% after deductible	30% after deductible	50% after deductible
Hearing Aidsrowlabel
Up to $2,000 every 36 months for each devicehearing	$0 copay	$0 copay	Not covered
Allergy Testing and Evaluationrowlabel
Testing and physician visitsallergy	$20 or $30 copay (based on provider)	$35 or $50 copay (based on provider)	50% after deductible

¹ Calendar-year out-of-pocket maximum includes amounts you pay toward the deductible. It does not include copays, amounts over plan limits and penalties.

² Routine health assessments include routine physicals, such as well-adult checkups, well-woman care and well-baby/well-child care.

³ These preventive services are covered at a $0 copay if billed by a separate facility: routine adult/child lab and X-rays, annual mammogram (including 3D), PSA (prostate-specific antigen) and Pap smear.

⁴ If admitted to hospital from the emergency room.

⁵ 60 days combined maximum per calendar year for skilled nursing facility, rehabilitation (inpatient and outpatient) and sub-acute facilities.

Free-Standing Emergency Room Visits

The PEHP does not cover visits to out-of-network, free-standing emergency rooms, which are facilities that:

Provide emergency medical services at a place outside of a regular hospital campus, and
Are not attached to a hospital or even located near one.

Pregnant Couple On Sofa At Home Looking At Baby Clothes

Save on Maternity Care

The PPO in the Parkland Employee Health Plan will waive deductibles and coinsurance for all routine obstetric office visits related to your prenatal care if you participate in the Maternity Care Program through the Cigna Healthy Pregnancies/Healthy Babies Program during your first or second trimester.

Delivering at Parkland?

If you participate in the program, go to the Employee Women’s Wellness Center for routine doctor’s visits during pregnancy and deliver at Parkland, you’ll pay $0 for all services, including anesthesiology and facility charges.
If you participate in the program, go to a doctor who is not at the new Employee Women’s Wellness Center for routine doctor’s visits during pregnancy and deliver at Parkland, you will pay a $500 copay for the birth.

To be eligible for these incentives, you must enroll in the Healthy Pregnancies/Healthy Babies Program during your first or second trimester and continue to participate in the program each trimester of your pregnancy.

Learn more

Infertility Benefit To Help You on Your Parenting Journey

Parkland offers a generous infertility benefit covering a wide range of treatments and services. The infertility benefit is integrated with your pharmacy benefits. Employees enrolled in the PPO have up to a $20,000 lifetime maximum for infertility benefits. You must first meet the deductible before the PPO will begin paying benefits based on the tier of the provider that you use.

Your 2024 Medical Biweekly Benefit Deductions (PPO)

For full-time employees, deductions are based on annual wages as shown in the chart below.

	Full-Time Employees Whose Annual Wages Are						Part-Time Employees With Benefits
Wagesrowlabel	Under $35,000	$35,000–$45,000	$45,001–$65,000	$65,001–$100,000	Over $100,000	All Hourly Rates
Coverage Category
Employee Only	$33.92	$48.95	$63.00	$78.99	$82.38	$130.95
Employee Plus Children	$92.08	$128.42	$162.83	$199.18	$233.10	$343.58
Employee Plus Spouse	$112.92	$157.02	$201.60	$246.67	$283.98	$418.52
Employee Plus Family	$157.02	$217.59	$278.17	$337.78	$391.57	$595.66

Note: If your salary increases between Open Enrollment and Jan. 1, 2024, the increase may move you into a higher benefit premium salary tier than what you are in during Open Enrollment. This situation especially applies if your current salary level is close to the top of one of the salary tiers.

Covering Your Spouse

If your spouse has access to health care coverage through his/her own employer, you will pay a surcharge to cover them under the PEHP. The surcharge will be $75 per pay period. Watch your mailbox for a packet containing next steps on the Working Spouse Health Coverage verification process. Failure to complete the verification process by the deadline means Parkland will apply the surcharge. You must repeat this process every year.