PPO Deductibles and Medical Coinsurance Out-of-Pocket Maximums
This chart shows deductible amounts when you complete Call to Health — and when you do not. The medical coinsurance 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 Coinsurance 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 coinsurance 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 coinsurance 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 coinsurance out-of-pocket maximum for members enrolled in medical continuation coverage; for 2025 and 2026, the deductible and medical coinsurance out-of-pocket maximum are based on salary range 4 ($58,270–$63,024). The annual deductible and medical coinsurance out-of-pocket maximum amounts for seminary students are based on the lowest salary range.
**After the member reaches the medical coinsurance 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 network 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).