PPO Deductibles and Medical Out-of-Pocket Maximums
This chart shows deductible amounts when you complete Call to Health Level 1 — and when you do not. The medical out-of-pocket maximum is the most you will pay in the form of coinsurance for covered medical expenses in a year. This amount plus your deductible* offers a good idea of your potential out-of-pocket expense.
These deductibles and out-of-pocket maximums are for covered inpatient and outpatient medically necessary services; they do not include prescription drug costs or required copays (e.g., a $25 copay applies for each network doctor’s office visit). A separate out-of-pocket maximum applies for prescription drugs.
If you have questions, call Quantum Health at 855-497-1237 or log on to
myqhealthpcusa.org. You may also contact the Board of Pensions at 800-PRESPLAN (800-773-7752) (TTY: 711).
| Salary Range | Network Deductible* | Out-of-Network Deductible* | Medical Out-of-Pocket Maximum** | ||||
|---|---|---|---|---|---|---|---|
|
Without Call to Health |
With Call to Health |
|
Network |
Out of Network | |||
| 1 | up to | $48,759 | $660 | $440 | $1,100 | $2,200 | $6,600 |
| 2 | $48,760 | $53,514 | $735 | $490 | $1,220 | $2,440 | $7,320 |
| 3 | $53,515 | $58,269 | $805 | $540 | $1,340 | $2,680 | $8,040 |
| 4 | $58,270 | $63,024 | $875 | $585 | $1,460 | $2,915 | $8,745 |
| 5 | $63,025 | $67,779 | $950 | $635 | $1,580 | $3,155 | $9,465 |
| 6 | $67,780 | $72,534 | $1,020 | $680 | $1,695 | $3,390 | $10,170 |
| 7 | $72,535 | $77,289 | $1,090 | $730 | $1,815 | $3,630 | $10,890 |
| 8 | $77,290 | $82,044 | $1,160 | $775 | $1,935 | $3,865 | $11,595 |
| 9 | $82,045 | $86,799 | $1,235 | $825 | $2,055 | $4,105 | $12,315 |
| 10 | $86,800 or more | $1,305 | $870 | $2,170 | $4,340 | $13,020 | |
*Members with covered family members are responsible for two deductibles, one for the member and one for all other family members combined. Deductibles do not count toward the medical out-of-pocket maximum. Deductibles for the following plan year may be reduced by completing Call to Health for the current program year. The annual deductible and medical out-of-pocket maximum for a disabled member and their eligible family is based on the lowest salary range. The Board may, in its sole discretion, establish the deductible and medical out-of-pocket maximum for members enrolled in medical continuation coverage; for 2024 and 2025, the deductible and medical out-of-pocket maximum are based on salary range 4 ($58,270–$63,024). The annual deductible and medical out-of-pocket maximum amounts for seminary students are based on the lowest salary range.
**After the member reaches the medical out-of-pocket maximum, the Medical Plan pays 100% of eligible expenses (up to the plan allowance) for the rest of the year, except for any required copays (e.g., a $25 copay applies for primary care doctor’s office visits). Total out-of-pocket expenses for covered network services, including deductibles and coinsurance, copays, and prescription drug costs (except for non-formulary brand names and certain nonessential specialty pharmacy drugs) are capped at annual limits of $5,000 (member) and $10,000 (family).