For benefits-eligible faculty and staff who have a permanent home zip code located outside of North Carolina
Effective July 1, 2023, Duke began offering a second medical insurance option for out-of-state employees called the Duke USA PPO plan that provides a monthly premium similar to Duke Select and access to the same national network of BlueCross BlueShield providers and facilities as Duke Options.
Beginning January 1, 2024, if you live outside of the Triangle Area (i.e., outside of a zip code beginning with 272, 273, 275, 276, or 277) and are ineligible for coverage in Duke’s Aetna plans, you will be eligible to participate in the Duke USA plan. For more information, please see the following:
Medical Comparison Charts
Deductibles and Limits
| Duke USA PPO In-Network | Duke USA PPO Out-of-Network | Duke Options PPO In-Network | Duke Options PPO Out-of-Network | |
|---|---|---|---|---|
| Annual Deductible1: Individual | $2,000 | $6,000 | $130 | $650 |
| Annual Deductible1: Family | $6,000 | $12,000 | $390 | $1,950 |
| Out of Pocket Limit: Individual | $6,800 | $13,600 | $3,000 | $6,000 |
| Out of Pocket Limit: Family | $13,600 | $27,200 | $6,000 | $12,000 |
Physician Office Visit
| Duke USA PPO In-Network | Duke USA PPO Out-of-Network | Duke Options PPO In-Network | Duke Options PPO Out-of-Network | |
|---|---|---|---|---|
| PCP | $25 copay | You pay 40% after deductible2 | $20 copay | You pay 30% after deductible2 |
| Specialist | $55 copay | You pay 40% after deductible2 | $55 copay | You pay 30% after deductible2 |
| MRI, CT, PET Scan | You pay 20% after deductible | You pay 40% after deductible2 | You pay 10% after deductible | You pay 30% after deductible2 |
| Lab & Other X-Ray | You pay 20% after deductible | You pay 40% after deductible2 | You pay 10% after deductible | You pay 30% after deductible2 |
| Annual Preventive Visit | Covered in full | Not covered | Covered in full | Not covered |
| Mammogram | Covered in full | You pay 40% after deductible2 | Covered in full | You pay 30% after deductible2 |
| Colonoscopy | Covered in full | You pay 40% after deductible2 | Covered in full | You pay 30% after deductible2 |
| OB/GYN Exams | $25 copay primary care
$55 copay specialist | Well visits not covered; you pay 40% after deductible2 for Pap smear, mammogram, and sick
visits | $20 copay primary care
$55 copay specialist | Well visits not covered; you pay 30% after deductible2 for Pap smear, mammogram, and sick
visits |
| Well Baby / Well Child | Covered in full | Not covered | Covered in full | Not covered |
| Maternity Care | $25 copay primary care or $55 copay specialist first visit, then professional services covered in full | You pay 40% after deductible2 for professional services | $20 copay primary care or $55 copay specialist first visit, then professional services covered in full | You pay 30% after deductible2 for professional services |
Hospital Care
| Duke USA PPO In-Network | Duke USA PPO Out-of-Network | Duke Options PPO In-Network | Duke Options PPO Out-of-Network | |
|---|---|---|---|---|
| Inpatient | After $600 or $700 per admission copay3 and deductible, you pay 20% coinsurance | You pay 40% after $900 per admission copay and deductible2 | After $600 or $700 per admission copay3 and deductible, you pay 10% coinsurance | You pay 30% after $900 per admission copay and deductible2 |
| Outpatient | You pay 20% after deductible | You pay 40% after deductible2 | You pay 10% after deductible | You pay 30% after deductible2 |
| Emergency Care | $250 copay, waived if admitted | $250 copay, waived if admitted | $250 copay, waived if admitted | $250 copay, waived if admitted |
| Urgent Care | $50 copay | $50 copay | $35 copay | $35 copay |
| Ambulance | $250 copay when medically necessary | $250 copay when medically necessary | $250 copay when medically necessary | $250 copay when medically necessary |
Other Services
| Duke USA PPO In-Network | Duke USA PPO Out-of-Network | Duke Options PPO In-Network | Duke Options PPO Out-of-Network | |
|---|---|---|---|---|
| Infertility | Does not include COH, IVF, or other types of artificial conception4 | Not covered | Employees must have two years continuous fulltime service;5 limits apply4 | Not covered |
| Infertility Testing and Treatment, Subject to Precertification | $25 copay primary care; $55 copay specialist; covered in full for testing4 | Not covered | Precertification required; limits apply4,5 | Not covered |
| Skilled Nursing Facility | You pay 20% after deductible when authorized after $250 per admission copay; 60-day annual maximum | You pay 40% after deductible2 when authorized after $250 per admission copay; 60-day annual maximum | You pay 10% after deductible when authorized after $250 per admission copay; 60-day annual maximum | You pay 30% after deductible2 when authorized after $250 per admission copay; 60-day annual maximum |
| Home Health Care | You pay 20% after deductible when authorized; 100 combined in- and out-of-network visits per calendar year | You pay 40% after deductible2when medically necessary; 100 combined in- and out-of- network visits per calendar year | You pay 10% after deductible when authorized; 100 combined in- and out-of-network visits per calendar year | You pay 30% after deductible2when medically necessary; 100 combined in- and out-of- network visits per calendar year |
| Hospice Care | You pay 20% after deductible | You pay 40% after deductible2 | You pay 10% after deductible | You pay 30% after deductible2 |
| Durable Medical Equipment | You pay 20% after deductible | You pay 40% after deductible2 | You pay 10% after deductible | You pay 30% after deductible2 |
| Prosthetics | You pay 20% after deductible | You pay 40% after deductible2 | You pay 10% after deductible | You pay 30% after deductible2 |
| Physical Therapy (PT) & Occupational Therapy (OT) | $55 copay; 40 visits per calendar year for combined PT, OT, and chiropractic in- and out-of- network | You pay 40% after deductible; 40 visits per calendar year for combined PT, OT, and chiropractic in- and out-of-network2 | $55 copay; 40 visits per calendar year for combined PT, OT, and chiropractic in- and out-of- network6 | You pay 30% after deductible; 40 visits per calendar year for combined PT, OT, and chiropractic in- and out-of-network2 |
| Chiropractic Care | $55 copay; 40 visits per calendar year for combined PT, OT, and chiropractic in- and out-of- network | 40% after deductible2; 40 visits per calendar year for combined PT, OT, and chiropractic in- and out-of-network | $55 copay; 40 visits per calendar year for combined PT, OT, and chiropractic in- and out-of- network | You pay 30% after deductible2; 40 visits per calendar year for combined PT, OT, and chiropractic in- and out-of-network |
| Nutrition | Covered in full up to 6 visits per calendar year | Not covered | Covered in full up to 6 visits per calendar year | Not covered |
| Speech Therapy | $55 copay; 20 visits per calendar year for combined in- and out-of- network | 40% after deductible2; 20 visits per calendar year for combined in- and out-of-network | $55 copay; 20 visits per calendar year for combined in- and out-of- network6 | You pay 30% after deductible2; 20 visits per calendar year for combined in- and out-of- network |
| Vision Exam | Not Covered | Not covered | $55 copay; limit 1 exam per calendar year | Not covered |
| Bariatric Surgery7 | Not Covered | Not covered | $2,500 surgical copay7,8 | Not covered |
| Gender Affirmation Surgery | Not covered | Not covered | After $600 or $700 per admission copay3 and deductible, you pay 10% coinsurance | You pay 30% after $900 per admission copay and deductible2 |
Behavioral Health and Substance Abuse
| Duke USA PPO In-Network | Duke USA PPO Out-of-Network | Duke Options PPO In-Network | Duke Options PPO Out-of-Network | |
|---|---|---|---|---|
| Outpatient | $25 copay for individual/family therapy | You pay 40% after $6,000 annual deductible2 | $20 copay for individual/family therapy | You pay 30% after $650 annual deductible2; no visit limit applies |
| Inpatient | After $600 or $700 per admission copay3 and deductible, you pay 20% coinsurance | After $900 per admission copay and deductible, you pay 40% coinsurance2 | After $600 or $700 per admission copay3 and deductible, you pay 10% coinsurance | After $900 per admission copay and deductible, you pay 30% coinsurance2 |
- Deductible does not apply to office visits for primary care and specialist.
- All payments are based on the allowable charge. You are liable for charges over the allowable charge when receiving out-of-network services.
- $600 per admission co-pay for Duke Hospital, Duke Regional Hospital, and Duke Raleigh Hospital facilities and $700 for all others in-network.
- See the Member Guide and Summary of Benefits and Coverage for details.
- For members with a permanent home address outside of the state of North Carolina, access to a provider other than a Duke Fertility provider is covered, as long as the member meets the eligibility requirements and medical policy criteria. Prior
- For children under 18 with significant disability, the plan will pay 100 percent for in-network benefits after appropriate copay per visit to an annual maximum of $10,000 in charges for employees hired prior to January 1, 1997. After $10,000 in
- For qualified patients only. See Summary of Benefits and Coverage for details.
- For members with a permanent home address outside of the state of North Carolina, access to a provider other than a Duke provider is covered, as long as the member meets the eligibility requirements and medical policy criteria. Prior
Pharmacy Benefits (through Express Scripts)
| At a participating retail pharmacy | Through the Express Scripts Mail Order Pharmacy or Participating On-site Duke Pharmacies | |
|---|---|---|
| Generic (No deductible applies.) | First three purchases (any medication): $15 (or cost of drug if less) After third purchase (long-term medication): 50% (cost of drug to max. $30) | No Deductible $25 (or cost of drug if less) |
| Brand (Annual $100 per person deductible applies at retail pharmacies.) | First three purchases (any medication): $50 After third purchase (long-term medication): 50% (min. $70, max. $165) | No Deductible $130 |
| Non-Formulary (Annual $100 per person deductible applies at retail pharmacies.) | First three purchases (any medication): $70 After third purchase (long-term medication): 50% (min. $85, max. $180) | No Deductible $180 |