Benefits Guide | 2027

VDHP/Traditional PPO with Ortho/Massachusetts

Medical Plans Comparison

Option 1: VDHP Medical Plan Option 2: PPO Medical Plan
    In-Network Out-of-Network
Deductible*    
Employee $0 $1,500 $3,000
Employee + Spouse or Child $0 $3,000 $6,000
Family or Employee + Children $0 $4,500 $9,000
Coinsurance 0% 80% 30%
Teladoc $0 $0
Office Visit Copay    
Copay PCP/Specialist $30/$35 $35/$45 Deductible/Coinsurance
Preventive Care 100% 100% Deductible/Coinsurance
Durable Medical Equipment $100 – Copay for each rental month/each device Deductible/Coinsurance Deductible/Coinsurance
Urgent Care Copay $40 $50 Deductible/Coinsurance
ER Copay $250 emergency $250 emergency,
then Deductible and Coinsurance
Outpatient Services $600 80% after Deductible Deductible/Coinsurance
Inpatient Hospital $1,200 80% after Deductible Deductible/Coinsurance
Chiropractic   80% after Deductible 30% after Deductible
Max per Visit $35 $45 – Copay then CPC covers up to $20
Visit Limit 26 visits/calendar year 26 visits/calendar year
Out-of-Pocket Max      
Employee $5,000 $6,600 Unlimited
Employee + Spouse or Child $10,000 $13,200
Family or Employee + Children $10,000 $13,200
Prescription Drug Coverage—
Preferred Walgreens Retail 		     
Annual Deductible $75 (Brand-Name Drugs Only) $75 (Brand-Name Drugs Only) Use of a non-participating pharmacy requires payment for the prescription upfront.
Tier 1: Generic Drugs $10 Copay $10 Copay
Tier 2: Preferred Brand-Name Drugs 30% with a minimum of $20; max of $100 30% with a minimum of $20; max of $100
Tier 3: Nonpreferred Brand-Name Drugs 40% with a minimum of $35; max of $150 40% with a minimum of $35; max of $150
Prescription Drug Coverage—
Retail 		     
Annual Deductible $75 (Brand-Name Drugs Only) $75 (Brand-Name Drugs Only) Use of a non-participating pharmacy requires payment for the prescription upfront.
Tier 1: Generic Drugs $15 Copay $15 Copay
Tier 2: Preferred Brand-Name Drugs 30% with a minimum of $25; max of $100 30% with a minimum of $25; max of $100
Tier 3: Nonpreferred Brand-Name Drugs 40% with a minimum of $40; max of $150 40% with a minimum of $40; max of $150
Prescription Drug Coverage—Mail      
Annual Deductible $75 (Brand-Name Drugs Only) $75 (Brand-Name Drugs Only) Not applicable
Tier 1: Generic Drugs $25 Copay $25 Copay
Tier 2: Preferred Brand-Name Drugs 20% with a minimum of $45; max of $200 20% with a minimum of $45; max of $200
Tier 3: Nonpreferred Brand-Name Drugs 30% with a minimum of $75; max of $250 30% with a minimum of $75; max of $250
Specialty Prescription Drug Coverage    
Annual Deductible $500 $500 Not applicable
Tier 4: Specialty Drugs 50% with a minimum of $150; max of $1,500 50% with a minimum of $150; max of $1,500

*Deductibles and out-of-pocket maximums are 2 x for Employee + Spouse and Employee + Child. The limit is 3 x for Employee + Children and Family.

Please note: In accordance with Massachusetts state law, pregnancy-related services for a covered dependent daughter are eligible for coverage when the member resides in Massachusetts. Covered services include medically necessary prenatal care, labor and delivery, postpartum care, and related pregnancy complications, subject to plan provisions, network requirements, and applicable cost sharing.

For members residing outside of Massachusetts, pregnancy expenses for a dependent daughter are generally not covered unless specifically required by applicable state law or outlined in the plan document. The newborn child of a dependent daughter is not considered an eligible dependent under the plan unless otherwise specified.

Contact Benefit Specialists at (800) 941-7089 for questions or assistance.

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