Limited PPO (EPO Network) DTCEPO

Enrollees in the Limited PPO (EPO Network) Plan have access to all providers in the Freedom of Choice EPO Network.  All elective care must be rendered by an EPO Network provider to be considered in-network.  Exceptions to this rule which will be considered in-network include authorizations from Medical Management to receive services from non-EPO Network providers due to medical necessity as well as services received in an Emergency Room setting for emergency situations. 

Enrollees in the Limited PPO (EPO Network) Plan may also receive professional (not institutional) services from a non-EPO network provider at an in-network benefit level should there be no equivalent EPO Network provider within thirty (30) miles.  In such cases, the allowed reimbursement for claims received from the non-EPO Network provider will be limited to the EPO Network allowable for those services, and the non-EPO Network provider may in turn bill the enrollee for the balance.  The same reimbursement limit and potential for balance billing will apply to claims received from non-EPO Network providers with authorizations from Medical Management due to medical necessity as well as to claims for services received in an Emergency Room setting for emergency situations.

To find a Freedom of Choice EPO Network provider, select the link above.

The Executive PPO (Private Healthcare Systems Network) Plan DTCPPO

Enrollees in the Executive PPO (PHCS Network) Plan have access to all providers in the PHCS Network.  All elective care must be rendered by a PHCS Network provider to be considered in-network.  Exceptions to this rule which will be considered in-network include authorizations from Medical Management to receive services from non-PHCS Network providers due to medical necessity as well as services received in an Emergency Room setting for emergency situations. 

Enrollees in the Executive PPO (PHCS Network) Plan may also receive professional (not institutional) services from a non-PHCS network provider at an in-network benefit level should there be no equivalent PHCS Network provider within thirty (30) miles.  In such cases, the allowed reimbursement for claims received from the non-PHCS Network provider will be limited to the PHCS Network allowable for those services, and the non-PHCS Network provider may in turn bill the enrollee for the balance.  The same reimbursement limit and potential for balance billing will apply to claims received from non-PHCS Network providers with authorizations from Medical Management due to medical necessity as well as to claims for services received in an Emergency Room setting for emergency situations.

To find a PHCS Network provider, select the link above.