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 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 deductible2when 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 deductible2when 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 per calendar year; 30% lens and frame discount at point of purchase; 15% disposable contacts discount at point of purchaseNot 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 $650 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