PPO Plan
Ketjen offers two medical plan options through UnitedHealthcare for 2027.
PPO Plan
Plan Details
- Carrier
- UnitedHealthcare
- Plan Type
- PPO
- HSA Eligible
- No
- FSA Eligible
- Yes
- HRA Eligible
- Yes
Premiums
Bi-Weekly premiums
| Coverage tier | Employee Contributions | Ketjen Contribution |
|---|---|---|
| Employee Only | $58.62 | $386.41 |
| Employee + Spouse | $144.00 | $879.54 |
| Employee + Child(ren) | $126.92 | $730.92 |
| Employee + Family | $219.23 | $1,218.18 |
Employee Only
- Employee Contributions
- $58.62
- Ketjen Contribution
- $386.41
Employee + Spouse
- Employee Contributions
- $144.00
- Ketjen Contribution
- $879.54
Employee + Child(ren)
- Employee Contributions
- $126.92
- Ketjen Contribution
- $730.92
Employee + Family
- Employee Contributions
- $219.23
- Ketjen Contribution
- $1,218.18
Employer Contributions
| Coverage tier | Employer Contribution |
|---|---|
| Employee - Employee / Family | $0 |
| Family - Employee / Family | $0 |
| Employee - Wellness Incentives Employee / Employee + Spouse or Partner | $750 |
| Family - Wellness Incentives Employee / Employee + Spouse or Partner | $1,500 |
Employee - Employee / Family
- Employer Contribution
- $0
Family - Employee / Family
- Employer Contribution
- $0
Employee - Wellness Incentives Employee / Employee + Spouse or Partner
- Employer Contribution
- $750
Family - Wellness Incentives Employee / Employee + Spouse or Partner
- Employer Contribution
- $1,500
Deductible and Out-of-Pocket Limits
| Feature | In-Network | Out-of-Network |
|---|---|---|
| Annual Deductible (Combined Medical / Rx) - Employee Only Coverage | $1,500 | $3,000 |
| Annual Deductible (Combined Medical / Rx) - Employee + Dependent Coverage' | $3,000 | $6,000 |
| Out-of-Pocket Max (Combined Medical / Rx)² - Employee Only Coverage | $5,000 | $10,000 |
| Out-of-Pocket Max (Combined Medical / Rx)² - Employee + Dependent Coverage' | $10,000 | $20,000 |
Annual Deductible (Combined Medical / Rx) - Employee Only Coverage
- In-Network
- $1,500
- Out-of-Network
- $3,000
Annual Deductible (Combined Medical / Rx) - Employee + Dependent Coverage'
- In-Network
- $3,000
- Out-of-Network
- $6,000
Out-of-Pocket Max (Combined Medical / Rx)² - Employee Only Coverage
- In-Network
- $5,000
- Out-of-Network
- $10,000
Out-of-Pocket Max (Combined Medical / Rx)² - Employee + Dependent Coverage'
- In-Network
- $10,000
- Out-of-Network
- $20,000
- ¹ Employee + Dependent Coverage includes Employee + Spouse, Employee + Child(ren), and Employee + Family
- ² Includes Deductible and Co-insurance.
Medical Services
| Services | In-Network | Out-of-Network |
|---|---|---|
| Preventive Care | No copay | Not covered |
| Primary physician office visit | $30 copay | 50% after ded. |
| Specialist office visit | $60 copay | 50% after ded. |
| Telehealth | 20% after ded. | 50% after ded. |
| Inpatient hospital services | 20% after ded. | 50% after ded. |
| Outpatient hospital services (lab, x-ray, diagnostic) | 20% after ded. | 50% after ded. |
| Advanced diagnostics | 20% after ded. | 50% after ded. |
| Urgent Care | 20% after ded. | 50% after ded. |
| Emergency room care | 20% after ded. | 20% after ded. |
| Other | In Vitro Fertilization Services; GLP-1 Medication | — |
Preventive Care
- In-Network
- No copay
- Out-of-Network
- Not covered
Primary physician office visit
- In-Network
- $30 copay
- Out-of-Network
- 50% after ded.
Specialist office visit
- In-Network
- $60 copay
- Out-of-Network
- 50% after ded.
Telehealth
- In-Network
- 20% after ded.
- Out-of-Network
- 50% after ded.
Inpatient hospital services
- In-Network
- 20% after ded.
- Out-of-Network
- 50% after ded.
Outpatient hospital services (lab, x-ray, diagnostic)
- In-Network
- 20% after ded.
- Out-of-Network
- 50% after ded.
Advanced diagnostics
- In-Network
- 20% after ded.
- Out-of-Network
- 50% after ded.
Urgent Care
- In-Network
- 20% after ded.
- Out-of-Network
- 50% after ded.
Emergency room care
- In-Network
- 20% after ded.
- Out-of-Network
- 20% after ded.
Other
- In-Network
- In Vitro Fertilization Services; GLP-1 Medication
- Out-of-Network
- —
Retail (30-day supply)
| Tier | In-Network | Out-of-Network |
|---|---|---|
| Generic | 20% after ded. | 50% after ded. |
| Brand preferred | 20% after ded. | 50% after ded. |
| Brand non-preferred | 20% after ded. | 50% after ded. |
Generic
- In-Network
- 20% after ded.
- Out-of-Network
- 50% after ded.
Brand preferred
- In-Network
- 20% after ded.
- Out-of-Network
- 50% after ded.
Brand non-preferred
- In-Network
- 20% after ded.
- Out-of-Network
- 50% after ded.
Mail order (90-day supply)
| Tier | In-Network | Out-of-Network |
|---|---|---|
| Generic | 2.5x MO | 50% after ded. |
| Brand preferred | 2.5x MO | 50% after ded. |
| Brand non-preferred | 2.5x MO | 50% after ded. |
Generic
- In-Network
- 2.5x MO
- Out-of-Network
- 50% after ded.
Brand preferred
- In-Network
- 2.5x MO
- Out-of-Network
- 50% after ded.
Brand non-preferred
- In-Network
- 2.5x MO
- Out-of-Network
- 50% after ded.
Plan Notes
- Pay a higher monthly premium for a lower deductible and get transparent copays on primary and specialty care visits.
- This is a summary of coverage, please refer to your summary plan description for the full scope of coverage. In-network services are based on negotiated charges. Out-of-network services are based on a percentage of Medicare charges.