The Duke USA PPO plan is a second medical insurance option for out-of-state employees that does not require you to select a PCP. Duke USA has a national network of physicians and hospitals and a network of international hospitals, so if you or a family member travels often or lives elsewhere, you may want to consider this plan.

If you use a network provider, you will be responsible for a lower portion of the bill than you would if you used an out-of-network provider. Routine, preventive services such as annual physicals, ob/gyn exams, immunizations, and well baby visits are covered with network providers under this plan. For more information, please see the following:

Comparing Health Plans

Each Duke medical care plan covers both pharmacy and behavioral health benefits. Please refer to the Medical Plans Comparison Chart and Monthly Medical Premiums for details. All of our medical plans will cover pre-existing conditions or covered services.

Need to Find a Provider?

An online directory of participating medical providers by medical plan is available here.

Contact Information

Contact Plan Provider

24 Hour Health Advice Line

By calling a health care advice line, faculty and staff can get confidential, up-to-date health information any time of the day or night. Professional staff are available to assist with almost any medical question, offer support, or help patients navigate the health care system.

  • Duke USA Members

    1-877-477-2424

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 copayYou pay 40% after deductible2$20 copayYou pay 30% after deductible2
Specialist$55 copayYou pay 40% after deductible2$55 copayYou pay 30% after deductible2
MRI, CT, PET ScanYou pay 20% after deductibleYou pay 40% after deductible2You pay 10% after deductibleYou pay 30% after deductible2
Lab & Other X-RayYou pay 20% after deductibleYou pay 40% after deductible2You pay 10% after deductibleYou pay 30% after deductible2
Annual Preventive VisitCovered in fullNot coveredCovered in fullNot covered
MammogramCovered in fullYou pay 40% after deductible2Covered in fullYou pay 30% after deductible2
ColonoscopyCovered in fullYou pay 40% after deductible2Covered in fullYou 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 ChildCovered in fullNot coveredCovered in fullNot covered
Maternity Care$25 copay primary care or $55 copay specialist first visit, then professional services covered in fullYou pay 40% after deductible2 for professional services$20 copay primary care or $55 copay specialist first visit, then professional services covered in fullYou 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
InpatientAfter $600 or $700 per admission copay3 and deductible, you pay 20% coinsuranceYou pay 40% after $900 per admission copay and deductible2After $600 or $700 per admission copay3 and deductible, you pay 10% coinsuranceYou pay 30% after $900 per admission copay and deductible2
OutpatientYou pay 20% after deductibleYou pay 40% after deductible2You pay 10% after deductibleYou 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
InfertilityDoes not include COH, IVF, or other types of artificial conception4Not coveredEmployees must have two years continuous fulltime service;5 limits apply4Not covered
Infertility Testing and Treatment, Subject to Precertification$25 copay primary care; $55 copay specialist; covered in full for testing4Not coveredPrecertification required; limits apply4,5Not covered
Skilled Nursing FacilityYou pay 20% after deductible when authorized after $250 per admission copay; 60-day annual maximumYou pay 40% after deductible2 when authorized after $250 per admission copay; 60-day annual maximumYou pay 10% after deductible when authorized after $250 per admission copay; 60-day annual maximumYou pay 30% after deductible2 when authorized after $250 per admission copay; 60-day annual maximum
Home Health CareYou pay 20% after deductible when authorized; 100 combined in- and out-of-network visits per calendar yearYou pay 40% after deductible2 when medically necessary; 100 combined in- and out-of- network visits per calendar yearYou pay 10% after deductible when authorized; 100 combined in- and out-of-network visits per calendar yearYou pay 30% after deductible2 when medically necessary; 100 combined in- and out-of- network visits per calendar year
Hospice CareYou pay 20% after deductibleYou pay 40% after deductible2You pay 10% after deductibleYou pay 30% after deductible2
Durable Medical EquipmentYou pay 20% after deductibleYou pay 40% after deductible2You pay 10% after deductibleYou pay 30% after deductible2
ProstheticsYou pay 20% after deductibleYou pay 40% after deductible2You pay 10% after deductibleYou 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- networkYou 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- network6You 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- network40% 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- networkYou pay 30% after deductible2 ; 40 visits per calendar year for combined PT, OT, and chiropractic in- and out-of-network
NutritionCovered in full up to 6 visits per calendar yearNot coveredCovered in full up to 6 visits per calendar yearNot covered
Speech Therapy$55 copay; 20 visits per calendar year for combined in- and out-of- network40% 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- network6You pay 30% after deductible2 ; 20 visits per calendar year for combined in- and out-of- network
Vision ExamNot CoveredNot covered$55 copay; limit 1 exam per calendar yearNot covered
Bariatric Surgery7Not CoveredNot covered$2,500 surgical copay7,8Not covered
Gender Affirmation SurgeryNot coveredNot coveredAfter $600 or $700 per admission copay3 and deductible, you pay 10% coinsuranceYou 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 therapyYou pay 40% after $6,000 annual deductible2$20 copay for individual/family therapyYou pay 30% after $650 annual deductible2; no visit limit applies
InpatientAfter $600 or $700 per admission copay3 and deductible, you pay 20% coinsuranceAfter $900 per admission copay and deductible, you pay 40% coinsurance2After $600 or $700 per admission copay3 and deductible, you pay 10% coinsuranceAfter $900 per admission copay and deductible, you pay 30% coinsurance2
  1. Deductible does not apply to office visits for primary care and specialist.
  2. All payments are based on the allowable charge. You are liable for charges over the allowable charge when receiving out-of-network services.
  3. $600 per admission co-pay for Duke Hospital, Duke Regional Hospital, and Duke Raleigh Hospital facilities and $700 for all others in-network.
  4. See the Member Guide and Summary of Benefits and Coverage for details.
  5. 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
  6. 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
  7. For qualified patients only. See Summary of Benefits and Coverage for details.
  8. 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 pharmacyThrough 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

Duke USA PPO – Frequently Asked Questions (FAQs)

What insurance is available if I relocate outside of North Carolina?

If you move outside of North Carolina and wish to have a medical plan through Duke, you will need to enroll in the Duke Options PPO or Duke USA PPO, administered by BlueCross BlueShield of North Carolina. Duke Options and Duke USA provide comprehensive medical coverage outside of North Carolina.

What if I need international coverage?

Duke Options and Duke USA are the plans offered by Duke that provides medical coverage outside of the United States.

How does the annual deductible work for in-network care?

The annual deductible is the amount you are responsible for paying before your insurance plan begins to pay for covered services. Under the Duke USA plan, when you have an MRI, CT, PET scan, lab work, or X-rays; or you receive maternity care, inpatient hospitalization services, outpatient services, ambulance services, durable medical equipment, skilled nursing, home health care, or other services that are subject to the annual deductible, you are responsible for the first $2,000 of costs each year.

What are out of pocket limits?

The plan's out of pocket limit is the maximum dollar amount that a member or family could pay in a year for covered services before the plan pays 100%. Any deductible, copayment, and coinsurance amounts that you pay count towards the out of pocket limit. Under the Duke USA plan, the individual out of pocket limit for in-network services is $6,800 per calendar year and the family out of pocket limit for in-network services is $13,600 per calendar year.

What services have copayments?

Like other medical plans, Duke USA in-network services that are subject to copayments include provider office visits (PCP, specialist, and OB/Gyn exams), mental health/substance abuse, physical and occupational therapy (including speech therapy), chiropractic care, urgent care, emergency care, vision exams, inpatient hospitalization, outpatient services, and other services listed in the Member Guide.

Do copayments apply for preventive care services?

As long as you see an in-network primary care provider and your doctor files the visit as a preventive care visit, your visit will be covered at 100% (no copayment applied). Each member will have one annual visit covered at no charge, unless your provider diagnoses a health problem or provides medical treatment. If that occurs, your visit would be considered diagnostic and a copayment would apply. Preventive care services are not covered if you see an out-of-network provider.

Services, such as diagnostic lab tests, that may be delivered with preventive care service are not considered preventive care. Consult the Member Guide for more details or contact BlueCross BlueShield of North Carolina Member Services at (877) 275-9787 if you have questions related to preventive care services.

When does coinsurance apply?

Under the Duke Options PPO plan, coinsurance (the percentage of costs that you pay for a service after you meet your benefit period deductible) applies when you receive the following in-network services: MRIs, CTs, PET scans, lab work, X-rays, maternity care, inpatient hospitalization, outpatient services, ambulance services, durable medical equipment, skilled nursing, home health care, and other services listed in the Member Guide. For example, if you have an X-ray at an in-network provider, you will be billed your $2,000 deductible (if it has not yet been met) and 20% of the remaining cost (the in-network coinsurance).

Most out-of-network care is also subject to coinsurance.

What services require prior review and certification?

Certain services and medications require prior review and certification in order to be covered. These services include inpatient hospital services (including surgeries and transplants), outpatient surgeries, radiology imaging (such as MRI, CT, and PET scans), residential treatment centers, rehabilitation facility services, skilled nursing, applied behavioral therapy (ABT), durable medical equipment (including hearing aids and prosthetics), dental services, certain tests (such as EEGs, ECGs, genetic testing, sleep studies), home health care, infusion services, radiation therapy, non-emergency air ambulance services, private duty nursing, and other services listed in the Member Guide. If you see a provider outside of North Carolina or go to an out-of-network provider in North Carolina, you are responsible for ensuring that you or your provider requests prior review by BlueCross BlueShield of North Carolina.

If you are not certain if a service requires prior review and certification, consult your Member Guide or contact BlueCross BlueShield of North Carolina Member Services at (877) 275-9787.

Who is responsible for obtaining prior review and certification?

If you are seeing an in-network provider in North Carolina, the provider is responsible for obtaining prior review and certification. If you are seeing an out-of-network provider in North Carolina, or any provider (either in- or out-of-network) outside the state of North Carolina, you are responsible for making sure that prior review and certification is obtained. Review your Member Guide or the back of your Duke Options ID card for details.

What happens if I do not obtain prior review and certification?

Failure to request prior review and receive certification will result in full denial of benefits.

What if I disagree with a decision my insurance company makes?

If you disagree with a decision by BlueCross BlueShield of North Carolina regarding a benefit or claim, you may be able to file an appeal. Information about the appeals process can be found in the Member Guide.

What is the difference between an in-network and out-of-network provider?

In-network providers are providers, facilities, and suppliers with whom BlueCross BlueShield contracts to provide health care services. Providers, facilities, and suppliers who do not participate in the BlueCross BlueShield network are considered out-of-network providers.

Who should I contact if I believe I have been incorrectly billed for a service?

If you believe you have been wrongly billed by a provider, you should contact BlueCross BlueShield of North Carolina Member Services at (877) 275-9787 for more information.

Who may I contact if I have additional questions about my Duke Options coverage?

For additional information regarding benefits provided under the Duke USA PPO plan, contact Duke's HR Information Center at (919) 684-5600 or BlueCross BlueShield of North Carolina Member Services at (877) 275-9787.