If you have a PPO plan, then you need to know this!
In network simply refers to the list of doctors, hospitals, labs, pharmacies and other ancillary providers that are members of your PPO. Out of network refers to any one of the above named providers who are not a member of your PPO network.
Why does it matter? If you see an in network provider, then all medical expenses you incur will be billed at the in network rate which is normally about 30-50% less than what you would pay if you’re out of network. Basically, out of network would not entitle you to any price breaks whatsoever.
Also, if you have a plan that has doctor co pays, as long as you stay within the PPO network, then you only pay the co pay for the office charge and the insurance carrier picks up the remainder of the cost for the office visit. If you have a co pay plan and decide to visit a physician who is outside of your network, then you pay full price and are subject to whatever the doctor wants t charge you. Your co pay doesn’t apply if you go out of network.
The same scenario can apply if you go to an out of network pharmacy. Normally have a co pay for prescriptions with an in network pharmacist, well not this time. Out of network pharmacies will charge you full price for the medications and your insurance won’t do you too much good.
It gets even worse: All PPO plans have both an in network deductible and an out of network deductible. Guess which one is higher? Correct – out of network deductibles are usually at least twice the amount of the in network deductible.
I hope you’re catching on. Basically, only use doctors, hospitals, pharmacies, etc that are in the PPO network of your Texas health insurance plan. One of the worst things you can do is have a surgical procedure or a hospital stay out of network. You’ll end up paying 2-3 times what you would have paid if you stayed in network.
If you have any questions about your network, please call us at 866.270.6209.