How does a Tiered Copay PPO Plan work?

Unlike a traditional PPO plan, our Tiered Copay PPO plans include the benefit of no deductible and no coinsurance when your employees see any of our in-network providers.* This makes it easier to understand what we cover and what they owe. Another difference from a traditional PPO plan is Tiered Copay plans include two provider tiers. When your employees visit a provider in Tier 2, they’ll pay their normal in-network copay. But when they visit a provider in Tier 1, their copay could be up to 85% less.

How do you determine provider tiers?

Providers in Tier 1 have scored higher than Tier 2 providers on national metrics for cost, quality and appropriateness of care. Members pay a lower copay when they see providers who scored well compared to their peers.

Are all provider specialties tiered?

No. Primary care providers (PCPs) and select specialties are tiered. All mental health providers are in Tier 1 for the lowest possible copay. All other services, including labs, imaging and durable medical equipment will have set copays.

How are Tiered Copay PPO plans good for employers?

These plans help save employers money by incentivizing members to choose more cost-efficient providers, facilities and services. And new opportunities to give employees more control over their care and its cost can improve their morale and satisfaction with the coverage you offer. You can offer Tiered Copay PPO plans alone, or as an option alongside traditional PPO and High-Deductible Health Plans to give your employees even more flexibility in choosing their coverage.

How are Tiered Copay PPO plans good for employees?

These plans give your employees more options than ever for their care. They have access to the same number of doctors as with our PPO and High-Deductible Health Plans. And when they get care, our fixed copays and no deductibles make it simple for them to know in advance how much they should expect to pay. Our easy-to-use Find Care and Cost Estimator tools will help your employees find which in-network doctors are in which tier, and how much they’ll owe for specific care and services. And we direct members to facilities with lower costs for care when appropriate, like surgical centers instead of hospitals. Each plan also prioritizes no-cost virtual care programs like Teladoc Health® and Hinge Health.

Nationwide Tiered Copay PPO Plans

More savings. More choices. More transparency.

That’s what you and your employees will get from our Tiered Copay PPO plans. They're a new type of health plan that give your employees more choices than ever while encouraging them to pick cost-effective care that saves you both money.

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Plan Design

Tiered Copay PPO plans: A new way to save

We’ve built these plans around four concepts: savings, choice, transparency and quality.

Cost savings

Each plan includes two tiers of in-network providers. Members can save the most by choosing Tier 1 providers, who accept lower copays.

Choices

Members have access to our broad provider networks and get to choose their providers based on what’s most important to them.

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Transparency

These plans include clear, fixed copays for providers and services. With no deductible for in-network care, members can easily see and plan for the cost of their care.*

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Quality

All providers in our networks have to meet our standards. However, Tier 1 providers have displayed exceptional performance in the areas of cost efficiency, clinical quality and appropriateness of care.

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Understanding Tiered Copay

More about Tiered Copay PPO plans

Before you decide whether a Tiered Copay PPO plan is right for your employees, read below for more information on how these plans work.

How does a Tiered Copay PPO Plan work?
Unlike a traditional PPO plan, our Tiered Copay PPO plans include the benefit of no deductible and no coinsurance when your employees see any of our in-network providers.* This makes it easier to understand what we cover and what they owe.
Another difference from a traditional PPO plan is Tiered Copay plans include two provider tiers. When your employees visit a provider in Tier 2, they’ll pay their normal in-network copay. But when they visit a provider in Tier 1, their copay could be up to 85% less.
Here’s an example of how these plans save money**:
Mary visits a Tier 1 Provider
Mary sees an Orthopedist in Tier 1
She needs shoulder replacement
Her surgery is scheduled at ambulatory surgical center
She uses Hinge Health for physical therapy
Total out-of-pocket costs $350
Tina visits a Tier 2 Provider
Tina sees an Orthopedist in Tier 2
She needs a shoulder replacement
Her surgery is scheduled at an outpatient hospital
She uses a brick and mortar site for physical therapy
Total out-of-pocket costs $2,400
Betty visits an Out-of-Network Provider
Betty sees an Out-of-Network Orthopedist
Betty needs a shoulder replacement
Her surgery is scheduled at an out-of-network outpatient hospital
She uses a brick and mortar site for physical therapy
Total out-of-pocket costs are $5,000
How do you determine provider tiers?
Are all provider specialties tiered?
No.
Primary care providers (PCPs) and select specialties are tiered.
All mental health providers are in Tier 1 for the lowest possible copay.
All other services, including labs, imaging and durable medical equipment will have set copays.
How are Tiered Copay PPO plans good for employers?
These plans help save employers money by incentivizing members to choose more cost-efficient providers, facilities and services. And new opportunities to give employees more control over their care and its cost can improve their morale and satisfaction with the coverage you offer.   
You can offer Tiered Copay PPO plans alone, or as an option alongside traditional PPO and High-Deductible Health Plans to give your employees even more flexibility in choosing their coverage.
How are Tiered Copay PPO plans good for employees?
These plans give your employees more options than ever for their care. They have access to the same number of doctors as with our PPO and High-Deductible Health Plans. And when they get care, our fixed copays and no deductibles make it simple for them to know in advance how much they should expect to pay.
Our easy-to-use Find Care and Cost Estimator tools will help your employees find which in-network doctors are in which tier, and how much they’ll owe for specific care and services. And we direct members to facilities with lower costs for care when appropriate, like surgical centers instead of hospitals. Each plan also prioritizes no-cost virtual care programs like Teladoc Health® and Hinge Health.

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Flexible Plan Designs

With 25 possible plan options, we can design a plan to fit your needs

Tiered Copay PPO plans include a flexible plan design, with prescription coverage and other attractive options that you can mix-and-match to meet your needs.

In network
out-of-pocket options.

Distinct copay packages.

$5k-$10k

Range of out-of-pocket max options.

10+

Choose from all standard prescription drug options.